Chapter 7 164 controls, a matter of consideration should be that we used as a reference group a lot of ‘unrealistic’ patients, as the majority did not have subjective cognitive complaints. This is true in a sense, but at our old age psychiatry clinic, almost all referred patients will receive a MoCA during the initial interview, as we consider them at risk, now, or in the near future. Therefore, we wanted and needed to know the MoCA’s accuracy in this situation. There is another methodological concern that needs to be addressed that arises from ‘not everyone who participated in the study receiving the same diagnostic tests’. This counts for the group that was not suspected of cognitive impairment by an old age psychiatrist. If they would receive the same diagnostic test as all other participants, they would receive an extensive follow-up assessment only to confirm the clinical view of no-cognitive impairment. Although this would be important for detecting false negatives by using the gold standard, it was ethically and socially unjustifiable. The cost, in addition to the time investment of patients, would not be proportional, especially because false negatives can also be detected by other means, although with less certainty. This was done by following up on those who were not referred for an extensive neuropsychological examination to determine if cognitive complaints would develop over time. In addition, when in doubt, referrals were made by the practitioners, as is often the case in practice, resulting in a few false negatives after the initial interview. In the study using the CANE (second chapter), we included the MINI (Sheehan et al., 1998) assessment to standardise the DSM-IV diagnosis. We did not include this in the MoCA study. The main reason for this was that we considered the diagnostic route advised by international criteria as the gold standard. One of the inclusion, or in fact, exclusion criteria, that may be critically evaluated was the timeframe in which the MoCA had to be taken after the initial interview. We set this to three months (100 days). You want the MoCA to have been conducted in the period in which the other parameters were also collected, such as the diagnosis and the GAF or GDS15 score. Although cognitive impairment is often not assumed to change rapidly, it can do so. Especially in geriatric psychiatry, there are situations in which this is precisely what can occur. One might think of medication or a mania, as the cause of cognitive symptoms. Again, the difference between the study design and clinical practice comes into play. Whereas in clinical practice a cognitive test is often delayed until acute affective or psychotic symptoms have diminished, for this study, one wants them to coincide. Without going into the benefits of whether the decline in MoCA and the primary complaint coincide, it is important to be aware of them. This has implications for the interpretation
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