Summary and general discussion 7 171 7.3.2 Considerations of Section C: The MoCA in clinical practice In this section, we highlight the practical possibilities of the MoCA. This is based on our findings, as described in Chapters 5 and 6. In the daily use of the MoCA, many clinical users always interpret it with a margin of uncertainty. This involves, if all goes well, the clinical history of the patient, as assessed by the examiner. In doing so, a great deal of subjectivity is influential. In a positive sense, this subjectivity is referred to as the clinical view. However, this ‘subjective’ clinical view can help make the right decisions when the interpretation of a dichotomous result is not as certain despite what the cut-off situation may make apparent. As argued earlier, subjectivity is desirable in practice, of course within limits, but not in scientific studies. We have translated the clinical and intuitive use of the MoCA, where a margin of uncertainty or error is often used, into a study design. The seemingly intuitive ‘double cut-off point’ introduced in clinical practice consists of a score where the examiner is not sure how to interpret the score, that is, a grey area. This automatically creates two states on either side of the grey area: one area where the examiner is certain of the negative result from the test (no cognitive impairment), and one area where the examiner is certain of the need for a neurocognitive evaluation based on a positive MoCA test. Our double-threshold study shows that a grey area does not only mean bad things. This can also bring about benefits. We examined the range within which this grey area should be located with a higher certainty of the outcome of the MoCA compared with a single cut-off point. Our results, combined with results presented in the existing literature, show that even patients with a false positive test (i.e. MCI below 21) are more prone to develop dementia sooner than patients with MCI who score above this cut-off. Therefore, even though these MCI patients are to be rated as false positives, one could consider these true positives for an elaborate neurocognitive assessment. This can be considered a correct referral for various reasons, with an early diagnosis being one of them. These two chapters provide seemingly opposing advice. On the one hand, we show the risk of using the MoCA as a standalone or ‘blind’ screener (e.g., false positives) and confirm the added value of using the MoCA when used as an add-on, that is, triaging (Chapter 5). On the other hand, the case report in Chapter 6 demonstrates well how the MoCA can be of great clinical significance, even in the presence of a good result (during routine collection or screening). The add-on strategy, meaning using the MoCA after clinical judgment, clearly shows better results in terms of accuracy, PPV, and reduction of referrals compared to using the MoCA without any clinical judgment (standalone). This seems to advocate against screening and only for triaging, but it actually shows that the
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