Chapter 4 88 especially with MD (Carson et al., 2018; Davis et al., 2015; Elkana et al., 2020; Gil et al., 2015; Larner, 2012; Lee et al., 2008; O’Caoimh et al., 2016; Pugh et al., 2018; Rossetti et al., 2011; Waldron-Perrine & Axelrod, 2012). A test needs to be validated in its corresponding clinical setting (Noel-Storr et al., 2014), as the prevalence of the index disorder and the clinical setting influences results of the validation of tests. Our aim was to test the criterion validity of the MoCA for MD after initial assessment in old age psychiatry, in order to examine the added value of the MoCA for triaging patients for further specialized work-up. These patients were suspected of cognitive problems on clinical judgment without a cognitive test. To our knowledge, this is the first time the MoCA has been validated for this use in old age psychiatry. Our reference standard consisted of a consensus-based diagnosis adhering to international criteria resulting in patient groups with MCI, MD, and patients suspected of MCI/MD -but ruled out of having cognitive impairment (SNoCI) from the same cohort. 4.2 Methods 4.2.1 Study samples All newly referred patients for diagnostic purposes from the North-West part of Utrecht (the Netherlands) to our old age psychiatry memory clinic between 2008 and 2018 were eligible for the study if they were capable of giving written informed consent. This clinic offers services to 57.000 inhabitants of 60+ in the North-West side of the city and its rural surroundings and is one out of four memory clinics in the bigger metropolitan area. Therefore, patients with severe dementia (Global Deterioration Scale (GDS) ≥6) (Reisberg et al., 1982) or Behavioral and Psychological Symptoms of Dementia (BPSD) as a reason for referral, as well as compulsory referrals, were not eligible (n=1337). Exclusion criteria included patients with a diagnosis of severe mid-stage dementia (GDS ≥5) to prevent inclusion of the extreme of the spectrum – as this could lead to spectrum bias (NoelStorr et al., 2014) –, or other obvious causes of CI, such as; a recent history of substance abuse (<2 years), a delirium (<6 months), or an acquired brain injury including CVA or TIA (n=174). Only those patients that were referred to our memory clinic after the initial assessment at our old age psychiatric service were included (n=292) (figure 1). All of these patients followed a comprehensive cognitive diagnostic route for CI using a consensus based diagnosis following international criteria as a reference standard with a
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