The MoCA with a double threshold 5 113 5.1 Introduction More diagnostic effort is recommended by the Alzheimer’s society because early recognition of dementia allows for timely interventions and better quality of life for the patients (Borson et al., 2013;). However, the (clinical) reality has its limitations. The diagnosis of patients with suspected mild dementia (MD) is challenging, and the number of patients continues to rise. It is difficult to differentiate who has MD based on anamnesis alone. Subjective complaints and reports from informants often do not correspond to objective impairments (Schouws et al., 2012; Pendlebury et al., 2015; Ryu et al., 2020). Specialised diagnostic facilities are needed but will become overloaded by the number of referred patients in the near future. Most countries already have diagnostic challenges (Alzheimer’s Disease International, 2018), including a lack of financial or staff resources for a time-consuming comprehensive neuropsychological assessment (NPA). An accurate short screening test to identify patients with a (high) risk of MD, i.e., those in need of an NPA, is therefore necessary. A difficulty is who is to be considered at risk as definitions for disease (e.g., MD) do not always define health at the same time and thereby create subthreshold disorders (Helmchen and Linden, 2000). Cognitive functioning is a state on a continuumwith dementia on one end and no cognitive impairment (NoCI) on the other end of the extremes. Classifications define these states, therefore creating double thresholds. In-between, there is an area in which the patient is in an intermediate state and at risk, e.g., mild cognitive impairment (MCI), of which approximately 40% worsens 40% stabilises and 20% recovers (Gauthier et al., 2006; Julayanont et al., 2014; Canevelli et al., 2016). Given the wide range of outcomes of MCI and the large numbers involved, it is essential to be able to differentiate patients with MCI from those with MD and NoCI (Gauthier et al., 2006). In particular, in an old age psychiatry setting, there is a high correlation between psychiatric conditions (American Psychiatric Association, 2013) (including psychotropic medication and substance abuse) and MCI that does not necessarily worsen over time (Julayanont et al., 2014). TheseMCI cases deserve their own policy. An elaborate diagnostic route (including biomarkers/MRI) is often not yet necessary, but they should not be discharged either. A NPA comes to mind as a compromise. However, limited resources warrant the restraint of false positive (FP) referrals for an NPA to avoid potential harm due to unnecessary emotional and financial burden (Borson et al., 2013; Burn et al., 2018; Davis et al., 2015). Although early identification of neurocognitive disorders is advocated
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