title: Optimising the cutoffs of cognitive screening instruments in pragmatic diagnostic accuracy studies: maximising accuracy or the Youden index?
abstract: OBJECTIVE
  The optimal method of establishing test cutoffs or cutpoints for cognitive screening instruments (CSIs) is uncertain. Of the available methods, two base cutoffs on either the maximal test accuracy or the maximal Youden index. The aim of this study was to compare the effects of using these alternative methods of establishing cutoffs.
  
  
  METHODS
  Datasets from three pragmatic diagnostic accuracy studies which examined the Mini-Mental State Examination (MMSE), the Addenbrooke's Cognitive Examination-Revised (ACE-R), the Montreal Cognitive Assessment (MoCA), and the Test Your Memory (TYM) test were analysed to calculate test sensitivity and specificity using cutoffs based on either maximal test accuracy or the maximal Youden index.
  
  
  RESULTS
  For ACE-R, MoCA, and TYM, optimal cutoffs for dementia diagnosis differed from those in index studies when defined using either the maximal accuracy or the maximal Youden index method. Optimal cutoffs were higher for MMSE, MoCA, and TYM when using the maximal Youden index method and consequently more sensitive.
  
  
  CONCLUSIONS
  Revision of the cutoffs for CSIs established in index studies may be required to optimise performance in pragmatic diagnostic test accuracy studies which more closely resemble clinical practice.
authors.affiliation: Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Liverpool, UK.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Larner
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000544:Alzheimer Disease / Q000145:classification / Q000175:diagnosis*; D003704:Dementia / Q000145:classification / Q000175:diagnosis*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009483:Neuropsychological Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D055815:Young Adult