The MoCA with a double threshold 5 129 5.5 Conclusion To conclude, the optimal strategy for NPA referral is a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26) and whose course should be monitored actively as they are at risk (21<26). This strategy not only gives the best results (accuracy, PPV, NPV) by referring most MD patients and reduces unnecessary FP referrals by 65%. It also identifies most MCIs whose intermediate state justifies active monitoring. By introducing a second cutoff, the clinical value of the MoCA improved.
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