Chapter 1 34 Wilson and Jungner’s Criterion 5: A reliable detection method must exist and criteria 9: The cost of detection, diagnosis and treatment must be in an acceptable proportion to the cost of health care as a whole. If we focus on cognitive impairment in the older adult psychiatry population, these two criteria together with criteria 6 (The detection method must be acceptable to the public) can conflict with each other, especially, but not solely, in old age psychiatry. This is because a comprehensive neurocognitive assessment has the highest reliability, but is next to being invasive for patients and exacting with respect to resources, to say nothing of the near future with a growing older adult population. In the paragraphs above, we explained that an increasing number of people have cognitive complaints (e.g. MCI or dementia); they are mentioned and examined earlier in the process, which interferes with regular (psychiatric) treatments and diagnostics owing to increasing overlapping symptom presentation. A validated short test, which allows for a good interpretation of scores, can help identify or exclude mild cognitive impairment. The MoCA is becoming the standard in the world of short cognitive screening tests, rather than the MMSE. Internationally, the MoCA has been well validated. However, this is not the case with respect to Dutch. In addition, data on the MoCA in psychiatry and geriatric psychiatry, in particular, are lacking. Although cognitive complaints are a core feature of many referral reasons encountered in old age psychiatry, it often remains unseen by patient delay or doctor delay, but it has a major impact on treatment, functional recovery, and quality of life. We introduced the MoCA during the initial history interview to determine the patients’ cognitive state. Therefore, we need to study the MoCA and its criterion validity for screening for MCI and mild dementia in an old age psychiatric setting. In chapter three, Diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) for cognitive screening in old age psychiatry: Determining cutoff scores in clinical practice. Avoiding spectrum bias caused by healthy controls. We address the reliability of this short bedside test, the MoCA, which is cheaper, faster, and less demanding for patients and staff. However, is it reliable for screening all referred patients in an old age psychiatric setting? The population or setting in which the test is used can significantly influence the performance of this test. As explained earlier, using healthy controls as comparisons improves the discriminating ability of the test. The opposite is true as well: by using comparisons that resemble the impaired, it will be harder for a test to discriminate. However, it will better represent the clinical reality. In chapter four, Clinical value of the MoCA in patients suspected of cognitive impairment in old age psychiatry. Using the MoCA for triaging to a memory clinic, we describe the reliability of the MoCA for triaging to a
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