Géraud Dautzenberg

Summary and general discussion

7.3.4 Implications for clinical practice and health policy, and recommendations for future scientific research

In the foregoing discussion, we recapitulated what we presented in this dissertation, but what are its implications for clinical practice, and what evidence is still missing? How could we close that gap in knowledge so that a better health policy can be formulated? Theclinical implicationsof thevalidationof theMoCA inoldagepsychiatryare, inourhumble opinion, numerous. Different advocacy groups recommend making more diagnostic efforts. This was accompanied by public campaigns. More people seek reassurance for minor complaints, but subjective complaints do not always correspond with objective impairment, whether it is reported by a next of kin or by the patient himself (Pendlebury et al. , 2015; Ryu et al. , 2020). This dissertation shows that the MoCA is very useful for ruling out cognitive complaints. Even though one can argue that the use of the MoCA was already implemented in old age psychiatry, we added scientific proof that it does what we think, or hope it does. More importantly, we now better understand how to use it and how to interpret the total score in old age psychiatry. The advantages and disadvantages of using the MoCA, instead of the widely used MMSE, are presented in this dissertation and seem evident. However, even during this research, policymakers still argued for restarting the use of the MMSE instead of the MoCA. The MoCA is proven to be a useful screening test in old age psychiatry for unseen cognitive impairment, excluding cognitive impairment during subjective cognitive impairment that is often experienced in old age psychiatry by patients as it can rise due to age, psychiatric diseases, or psychotropic medication. In addition, the side effects of pharmacotherapy can be evaluated by the MoCA, as these complaints are a major reason for therapy discontinuation, whether they truly exist or only subjectively do so (Gitlin, Cochran and Jamison, 1989). The MMSE is not up for that task, as it not only has a low sensitivity for MCI it also has a low credibility according to the patients to disprove cognitive impairment (Kerwin, 2009). In addition to screening, it is of great significance to triage who is and who is not in need of a scarce NPA. This is of great importance as the number of referrals is large and will continue to rise in the near future. It is expensive, scarce, time-consuming, and burdensome for the patient to perform this procedure in specialised outpatient clinics by means of an extensive cognitive examination, and sometimes includes an MRI, EEG and spinal fluid puncture. Therefore, a validated bedside test before a referral is desirable. This should meet the requirements of a short acquisition time, test multiple cognitive domains, and have good sensitivity and specificity for MCI. The MoCA meets all these requirements. For general practitioners (in the Netherlands), the MoCA is advised to be part of the diagnostic algorithm (Janssen et al. ,

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