Géraud Dautzenberg

Chapter 7

10 The process of detection must be a continuous process and not a one-time project. This criterion is, of course, part of a bigger debate and is alsomentioned in this dissertation. This criterion combined with criterion 9, ‘the cost must be in proportion’, is of importance that the cost must not outweigh the benefits. This is especially true if one considers the use of a test not only for indication, that is, triaging, but continuously (i.e. as a screener). As often when there is a debate, the disagreement is often about the grey area between the two opposite views and where to draw the line: ‘screening versus on indication only’, ‘general population versus high-risk population’. However, as is so often the case, ‘who or how to screen’ must first be a part of the topic for the problem to be solved. Thinking of screening for cognitive impairment and considering the above, the criteria ‘the how’ and ‘the who’ make a difference, that is, respectively, what test is used and the prevalence of cognitive impairment. Even though advocacy groups encourage more screening as they want to lower the number of missed cases of dementias, there is critical literature with different motivations related to this wish. Spending resources wisely being one of them. To solve these dilemmas, it helps to start at the extreme ends at either side of the grey area, where there is less doubt about the necessity to assess cognitive function. When starting this dilemma from one side of the population. i.e., prevalence, all the high-risk populations should indeed be assessed. Moving down in risk or prevalence, the relevance of criterion 9 will increase. This is where not only ‘the who’ but also ‘the how’ becomes important as the cost and yield differ per test. In general, with cognitive assessments, the more concise the test is, often implying to be cheaper, the less accurate it will be. To meet criterion 10, including criterion 9, one must consider how the inevitable interaction between ‘who’ and ‘how’ is tested. This interaction takes place between the continuum of ‘the who’: ‘high risk population (e.g., with subjective complaints) through the old age psychiatry patients to the general elderly population’ and continuum of the how: ‘extended testing with an elaborated assessment, through the MoCA towards the MMSE’. In this dissertation, we show the advantages of the MoCA that will help bring these contrasting black or white views, to screen or not to screen, closer together and even merge, by adding more colours (i.e. a double cut-off) to the grey area. As motivated in this dissertation, we showed that the MoCA is a valuable tool for the continuous screening of a population at an increased risk for cognitive disorders.

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