Chapter 5 116 to 26. Therefore, we studied the policy of ‘active monitoring’ in this population as an intermediate option. We used data from our cohort of an old age psychiatric setting (Dautzenberg et al., 2020, 2021), where referrals, at least in the Netherlands, include patients with cognitive, behavioural and psychiatric symptoms that may result from neurodegenerative diseases, but also from other psychiatric disorders. The standard is that after an initial assessment, it is decided who could benefit from an extensive cognitive diagnostic route at our memory clinic. We aim to demonstrate the advantages of using a double-threshold MoCA to triage patients in need of an NPA. Therefore, we compare different selection strategies, including the double threshold, to efficiently select patients in need of an NPA (i.e., MD), those who are not (NoCI) and patients who should be actively monitored (MCI). We rate the strategies according to their accuracy and the number of referrals for an NPA that result in as few false negatives (FNs) as possible. The compared selection strategies for referral to an NPA are as follows:; an initial assessment only (without the use of an objective test, i.e., the MoCA), the MoCA as a stand-alone (i.e., without clinical judgement), or the MoCA as an add-on after the initial assessment (i.e., as a two-stage screener). The MoCA strategies are compared when using single and double thresholds. 5.2 Methods 5.2.1 Study sample The cohort (n=693) was taken from a previously reported validation study of the MoCA for patients referred to an old age psychiatric service in Utrecht, the Netherlands, as described in detail elsewhere (Dautzenberg et al., 2020). In short, all newly referred patients to our clinic were eligible for the study if they were capable of giving written informed consent. Therefore, patients with severe dementia (Global Deterioration Scale (GDS) ≥6) (Reisberg et al., 1982), and Behavioral and Psychological Symptoms of Dementia (BPSD) as a reason for referral and compulsory referrals were not eligible (n=1337). To resemble a clinical screening population, Standards for Reporting Diagnostic Accuracy (STARD/STARDdem) (Noel-Storr et al., 2014; Bossuyt et al., 2015) require we excluded patients with an obvious diagnosis of dementia (GDS ≥5), a recent history of substance abuse (<1 year), delirium (<6 months), or acquired brain injury including CVA
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