The MoCA with a double threshold 5 115 regardless of whether these are disorders in their own right or are merely (minor) forms of major disorders (Batelaan et al., 2007). Either way MCI is not (yet) dementia. A double-threshold MoCA offers the possibility to distinguish clinical and subclinical states according to their appropriate domain and thus to implement different policies. Previous studies have shown that almost no patients with MD or even MCI will score ≥ 26, the originally proposed cut-off of the MoCA, therefore indicating health (i.e., NoCI) (Nasreddine et al., 2005; Davis et al., 2015; Carson et al., 2018; Dautzenberg et al., 2020, 2021; Korsnes, 2020). The number of FPs below this cut-off is too large to have a full workup. ‘Reducing the risk of FP is important (Davis et al., 2015). In a memory clinic setting, half of the depressed patients scored below 26 (Blair et al., 2016; Dautzenberg et al., 2021). Other studies showed that the majority of patients with affective- psychotic- or neurotic disorders scored between 20-26 on the MoCA, while the majority of the organic disorders scored <19 (Gierus and Mosiolek, 2015; Dautzenberg et al., 2021; Korsnes, 2020). By using a lower (second) cut-off for referral (using the highest Youden index for MD in this cohort; <21) (Dautzenberg et al., 2020), FPs will decrease, but this will also increase the false negatives (FNs). This could be compensated for by actively monitoring all these patients with a score from 21 to 26, reducing unnecessary referrals (FP), but still allowing those patients at high risk of MD to be monitored (FN). A recent study by Landsheer demonstrated that using a double threshold for the MoCA improves clinical classification and that using an uncertainty interval (21 to 26) reduces the effect of prevalence on MoCA performance (Landsheer, 2020). Other studies on double thresholds aimed to improve classification accuracy by stratifying the population based on normative data (Oren et al., 2014; Tan et al., 2014; Borland et al., 2017) or stratifying the outcome, of certain or uncertain test results (Swartz et al., 2016; Landsheer, 2020; Thomann et al., 2020). They do not separate the three distinct cognitive states, i.e., MD versus MCI versus NoCI. In our study, however, wewanted to introduce three policies, matching the three diagnostic entities of cognitive functioning, to improve the MoCA’s potential as a triaging tool. Although the use of the MoCA in this way feels intuitive, to our knowledge, no results have been presented before on the MoCA with a double threshold separating all three distinct stages and analysing the consequences of subsequent policies. Especially in old-age psychiatry there are many inconclusive MoCA scores due to age (60+) and psychiatric comorbidities (including psychotropic medication), i.e., from 21
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