The Montreal Cognitive Assessment (MoCA) with a double threshold: improving the MoCA for triaging patients in need of a neuropsychological assessment
ABSTRACT Objectives: Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cu...
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Published in | International psychogeriatrics Vol. 34; no. 6; pp. 571 - 583 |
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Main Authors | , , |
Format | Journal Article |
Language | English |
Published |
Cambridge
Cambridge University Press
01.06.2022
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Subjects | |
Online Access | Get full text |
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Abstract | ABSTRACT
Objectives:
Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cutoff <26 for MD, but results in too many false-positive (FP) referrals in clinical practice (low specificity). A cutoff that finds all patients at high risk of MD without referring to many patients not (yet) in need of an NPA is needed. A difficulty is who is to be considered at risk, as definitions for disease (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders.
Design:
In this study, we compared different selection strategies to efficiently identify patients in need of an NPA. Using the MoCA with a double threshold tackles the dilemma of increasing the specificity without decreasing the sensitivity and creates the opportunity to distinguish the clinical (MD) and subclinical (MCI) state and hence to get their appropriate policy.
Setting/participants:
Patients referred to old-age psychiatry suspected of cognitive impairment that could benefit from an NPA (
n
= 693).
Results:
The optimal strategy was a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26), and who’s course should be monitored actively as they are at increased risk (21<26).
Conclusion:
By using two cutoffs, the clinical value of the MoCA improved for triaging. A double-threshold MoCA not only gave the best results; accuracy, PPV, NPV, and reducing FP referrals by 65%, still correctly triaging most MD patients. It also identified most MCIs whose intermediate state justifies active monitoring. |
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AbstractList | ABSTRACT
Objectives:
Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cutoff <26 for MD, but results in too many false-positive (FP) referrals in clinical practice (low specificity). A cutoff that finds all patients at high risk of MD without referring to many patients not (yet) in need of an NPA is needed. A difficulty is who is to be considered at risk, as definitions for disease (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders.
Design:
In this study, we compared different selection strategies to efficiently identify patients in need of an NPA. Using the MoCA with a double threshold tackles the dilemma of increasing the specificity without decreasing the sensitivity and creates the opportunity to distinguish the clinical (MD) and subclinical (MCI) state and hence to get their appropriate policy.
Setting/participants:
Patients referred to old-age psychiatry suspected of cognitive impairment that could benefit from an NPA (
n
= 693).
Results:
The optimal strategy was a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26), and who’s course should be monitored actively as they are at increased risk (21<26).
Conclusion:
By using two cutoffs, the clinical value of the MoCA improved for triaging. A double-threshold MoCA not only gave the best results; accuracy, PPV, NPV, and reducing FP referrals by 65%, still correctly triaging most MD patients. It also identified most MCIs whose intermediate state justifies active monitoring. OBJECTIVESDiagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cutoff <26 for MD, but results in too many false-positive (FP) referrals in clinical practice (low specificity). A cutoff that finds all patients at high risk of MD without referring to many patients not (yet) in need of an NPA is needed. A difficulty is who is to be considered at risk, as definitions for disease (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders. DESIGNIn this study, we compared different selection strategies to efficiently identify patients in need of an NPA. Using the MoCA with a double threshold tackles the dilemma of increasing the specificity without decreasing the sensitivity and creates the opportunity to distinguish the clinical (MD) and subclinical (MCI) state and hence to get their appropriate policy. SETTING/PARTICIPANTSPatients referred to old-age psychiatry suspected of cognitive impairment that could benefit from an NPA (n = 693). RESULTSThe optimal strategy was a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26), and who's course should be monitored actively as they are at increased risk (21<26). CONCLUSIONBy using two cutoffs, the clinical value of the MoCA improved for triaging. A double-threshold MoCA not only gave the best results; accuracy, PPV, NPV, and reducing FP referrals by 65%, still correctly triaging most MD patients. It also identified most MCIs whose intermediate state justifies active monitoring. Objectives:Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of a neuropsychological assessment (NPA) is welcome. The Montreal cognitive assessment (MoCA) has high sensitivity at the original cutoff <26 for MD, but results in too many false-positive (FP) referrals in clinical practice (low specificity). A cutoff that finds all patients at high risk of MD without referring to many patients not (yet) in need of an NPA is needed. A difficulty is who is to be considered at risk, as definitions for disease (e.g. MD) do not always define health at the same time and thereby create subthreshold disorders.Design:In this study, we compared different selection strategies to efficiently identify patients in need of an NPA. Using the MoCA with a double threshold tackles the dilemma of increasing the specificity without decreasing the sensitivity and creates the opportunity to distinguish the clinical (MD) and subclinical (MCI) state and hence to get their appropriate policy.Setting/participants:Patients referred to old-age psychiatry suspected of cognitive impairment that could benefit from an NPA (n = 693).Results:The optimal strategy was a two-stage selection process using the MoCA with a double threshold as an add-on after initial assessment. By selecting who is likely to have dementia and should be assessed further (MoCA<21), who should be discharged (≥26), and who’s course should be monitored actively as they are at increased risk (21<26).Conclusion:By using two cutoffs, the clinical value of the MoCA improved for triaging. A double-threshold MoCA not only gave the best results; accuracy, PPV, NPV, and reducing FP referrals by 65%, still correctly triaging most MD patients. It also identified most MCIs whose intermediate state justifies active monitoring. |
Author | Lijmer, Jeroen G. Beekman, Aartjan T. F. Dautzenberg, Géraud M. F. C. |
Author_xml | – sequence: 1 givenname: Géraud M. F. C. orcidid: 0000-0001-8943-200X surname: Dautzenberg fullname: Dautzenberg, Géraud M. F. C. – sequence: 2 givenname: Jeroen G. surname: Lijmer fullname: Lijmer, Jeroen G. – sequence: 3 givenname: Aartjan T. F. surname: Beekman fullname: Beekman, Aartjan T. F. |
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CitedBy_id | crossref_primary_10_3389_fnagi_2023_1068708 crossref_primary_10_1186_s12877_023_04281_7 crossref_primary_10_1097_MD_0000000000037393 crossref_primary_10_1017_S104161022200031X |
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Snippet | ABSTRACT
Objectives:
Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients... Objectives:Diagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of... OBJECTIVESDiagnosis of patients suspected of mild dementia (MD) is a challenge and patient numbers continue to rise. A short test triaging patients in need of... |
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SubjectTerms | Age Alzheimer's disease Clinical medicine Cognitive ability Cognitive impairment Dementia Drug abuse False positive results High risk Medical diagnosis Medical referrals Memory Mental disorders Neuropsychological assessment Neuropsychology Psychiatry Psychotropic drugs |
Title | The Montreal Cognitive Assessment (MoCA) with a double threshold: improving the MoCA for triaging patients in need of a neuropsychological assessment |
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