Validating the MoCA for screening 3 79 with or without MCI. One may argue the latter should have been diagnosed with MCI due to their psychiatric conditions. However, it was the clinical opinion of the team, after IADL investigation, that their presentation was not persistent and did not justify a diagnosis of MCI, as the MoCA score was not taken into account. There is a risk, including in this study, of a subjective decision whether MCI is diagnosed or not when a psychiatric disorder explains its etiology, despite the criteria for MCI beingmet. We minimized this by including a Neuropsychological assessment during the diagnostic work-up when there was suspicion of persistent impaired cognitive functioning. In the future the MoCA would make it easier and more objective to select these possible MCIs and identify those in need of a further work-up. False positives (i.e. a low MoCA score) due to unrecognized neurodegenerative MCI can be excluded in our study, as progression to any DSM IV diagnosis of cognitive impairment was monitored with a mean follow-up of 3.5 years. This study shows it is safe to use a threshold of ≥26 to indicate normal-cognition (95% sensitivity for CI), taking specific situations, like a university degree or FTD, into account. While the MoCA detects most MD (<21; 90% sensitivity) and MCI (<26; 94% sensitivity) below these cut-off scores, making it fit for screening, it is not suitable for diagnosing MD or MCI in our study population, as the PPV for MD and MCI are still only fair (31% and 33% PPV respectively). The proportion of referred psychiatric patients scoring below these cut-off scores is too high for diagnostic purposes (22% and 63% of NoCI, respectively). The MoCA is suitable for excluding dementia (≥21; NPV 92-98%) and MCI (≥26; NPV 94%), if used to assess patients referred to an old age psychiatry setting. This, combined with the high sensitivity at these cut-offs, makes the MoCA a useful screening tool. In the case of a positive test result, further work-up is usually necessary; the absolute amount of false-positives is substantial, since the majority of referred patients do not suffer from mild dementia. Using our study cohort as an example, applying a MoCA cut-off of <21 to screen 100 referred patients would lead to 33 patients receiving specialized diagnostic tests, of whom 14.7 would be NoCI, 8.2 MCI, and 10.5 correctly identified MD. One patient (1.15) with MD would not be detected using this cut-off score. This confirms that screening comes with its price, also in old age psychiatry. We recommend further research to findmethods that increase the specificity and improve selection of those in need of a specialized diagnostic pathway. The aforementioned
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