Altrecht Institute for Mental Health Care, Old Age Psychiatry, Soestwetering 1, 3543AZ Utrecht, The Netherlands.
Department of Psychiatry, Amsterdam UMC, location VUmc and GGZ inGeest, Oldenaller 1, 1081 HJ, Amsterdam, The Netherlands.
Int Psychogeriatr. 2022 Jun;34(6):571-583. doi: 10.1017/S1041610221000612. Epub 2021 Aug 31.
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.
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 ( = 693).
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).
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.
诊断疑似轻度痴呆（MD）的患者是一个挑战，且此类患者人数持续增加。因此，我们欢迎一种简短的测试方法来对需要神经心理评估（NPA）的患者进行分诊。蒙特利尔认知评估（MoCA）在原始截断值<26 时对 MD 具有较高的敏感性，但在临床实践中导致太多的假阳性（FP）转诊（特异性低）。需要找到一种截断值，它可以找到所有患有 MD 高风险的患者，而不会转诊太多尚未需要 NPA 的患者。一个困难是，谁应该被认为有风险，因为疾病的定义（例如 MD）并不总是在同一时间定义健康，从而产生亚阈值障碍。
在这项研究中，我们比较了不同的选择策略，以有效地识别需要 NPA 的患者。使用 MoCA 的双阈值来解决提高特异性而不降低敏感性的难题，并创造机会来区分临床（MD）和亚临床（MCI）状态，从而为他们制定相应的政策。
设置/参与者：被转介到老年精神病学就诊的疑似认知障碍患者，这些患者可能受益于 NPA（=693）。
最佳策略是使用 MoCA 的两阶段选择过程，作为初始评估后的附加测试。通过选择哪些患者可能患有痴呆症，应进一步评估（MoCA<21），哪些患者应出院（≥26），以及哪些患者的病情应积极监测，因为他们的风险增加（21<26）。
通过使用两个截断值，MoCA 的临床价值得到了提高，可以进行分诊。双阈值 MoCA 不仅提供了最佳的结果，而且具有准确性、PPV、NPV，并且减少了 65%的 FP 转诊，仍然可以正确地对大多数 MD 患者进行分诊。它还可以识别大多数 MCI 患者，因为他们的中间状态需要积极监测。
