The MoCA with a double threshold 5 125 Using a double threshold with scores <21 identifying patients suitable for an NPA and ≥26 for discharging patients, i.e., indicating patients do not need an NPA or reassessment, not only gave the best results but also achieved two goals simultaneously. Not only compensating for the increase in FNs by monitoring most of the missed MDs but also at-risk intermediate state patients (MCIs), without increasing the number of referrals. How to classify the different strategic selection outcomes for the accuracy calculations can be debated and depends on the setting and its target disease. Introducing a double threshold together with an intermediate state raises the dilemma of what is to be considered TP/FP or TN/FN. As these cells only exist in a 2x2 classification table, in our study, we created a 3x3 table (table 4b,c,d). In addition to this theoretical classification problem, there is a clinical classification dilemma. There are multiple reasons to advocate (TP) or to be cautious (FP) with early MCI referrals and the debate is ongoing. Because of limited access to NPAs in most countries or rural areas and because MCI can also consist of aetiologies fromwhich a patient can recover, we considered MCI an FP when a patient was referred for a comprehensive diagnostic route (therefore, MCI automatically became a TN for observation and discharging). Even though we understand that, with unlimited resources, one could consider (some of) the MCIpatients as TP when referred, as quality of life can improve by cognitive testing (Janssen et al., 2019). Identifying this intermediate state to actively monitor MCI without giving them this demanding diagnostic route is another justification for using a double threshold. Intuitively, we would consider 21≤MCI<26 as TP (for monitoring); however, technically this is not possible, as MCI is already labelled as an FP when a patient has a score <21. For dementia, a short assessment that differentiates MD from MCI with certainty would be preferred, but such a test is still not available. This is also true for the MoCA, as our results showed that our best PPV is still too low (52%) for a conclusive classification. Selecting those patients in need without missing one MD in the best way possible, without referring too many who are not (yet) in need of a memory clinic, is essential, i.e., triaging. These requirements were translated into our evaluation criteria of low absolute referral rates while still maintaining the highest possible sensitivity, i.e., no FNs and low FPs. Therefore, we judged the strategies by these values. Of the strategies selecting MD, the double threshold add-on not only gave the highest accuracy (89%), PPV (53%), NPV (99%) and the lowest FPs with still acceptable FNs, it also creates the opportunity to monitor MCI and seems the preferred selection route (table 3, column F).
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