{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T20:08:44Z","timestamp":1782936524530,"version":"3.54.5"},"reference-count":49,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2025,12,10]],"date-time":"2025-12-10T00:00:00Z","timestamp":1765324800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medical Sciences"],"abstract":"<jats:p>Background: Interpretation of cognitive performance in older patients with depression is challenging considering the association between late-life depression and (early-stage) neurodegenerative disease. The Montreal Cognitive Assessment (MoCA) is widely used to screen for mild cognitive impairment in community-dwelling older adults. Objective: The aim of the present study was to examine the need for and to develop dedicated MoCA norms for older people with depressive disorder. Methods: We used data from the Routine Outcome Monitoring for Geriatric Psychiatry &amp; Science (ROM-GPS) study and the Advanced Neuropsychological Diagnostics Infrastructure (ANDI) database, which consisted of 859 patients with a depressive disorder according to DSM-5 criteria and 320 healthy controls, aged \u226560 years. Linear regression was used to examine the relationship between late-life depression and MoCA scores, adjusted for age, sex, and education. Results: The presence of a depressive disorder was associated with lower MoCA scores, and this effect was larger for persons with 12 years or less of education than for those with more education (B = \u22120.76 [95% CI \u22120.61; \u22120.91] vs. \u22120.53 [\u22120.36; \u22120.70]). Among depressed patients, depressive symptom severity was not associated with the MoCA score. Regression-based normative data for the MoCA were computed and adjusted for age, education, sex, and type of depressive disorder. Conclusions: Our findings demonstrate that depressive disorder, but not symptom severity within depression, is associated with lower MoCA scores. Clinical interpretation of MoCA scores in depressed older persons can be facilitated by using MoCA reference tables stratified by age, sex and level of education.<\/jats:p>","DOI":"10.3390\/medsci13040312","type":"journal-article","created":{"date-parts":[[2025,12,10]],"date-time":"2025-12-10T14:22:40Z","timestamp":1765376560000},"page":"312","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Montreal Cognitive Assessment (MoCA) Norms for Older Patients with a Depressive Disorder"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4596-4618","authenticated-orcid":false,"given":"Myrthe E.","family":"Scheenen","sequence":"first","affiliation":[{"name":"Department of Neurology & Alzheimer Center Groningen, University Medical Center Groningen, 9700 RB Groningen, The Netherlands"},{"name":"Department of Psychiatry, University Medical Center Groningen, University of Groningen, 9700 AB Groningen, The Netherlands"},{"name":"Department of Geriatric Medicine, University Medical Center Groningen, 9700 RB Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5895-0840","authenticated-orcid":false,"given":"Rob H. S.","family":"van den Brink","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, University Medical Center Groningen, University of Groningen, 9700 AB Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Styliani","family":"Konstantinidou","sequence":"additional","affiliation":[{"name":"Graduate School of Medical Sciences, University of Groningen, 9700 AB Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3971-6068","authenticated-orcid":false,"given":"Astrid","family":"Lugtenburg","sequence":"additional","affiliation":[{"name":"Department of Geriatric Psychiatry, GGZ Drenthe Mental Health Institute, 9401 LA Assen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-3981-7276","authenticated-orcid":false,"given":"Jasmijn","family":"Spit","sequence":"additional","affiliation":[{"name":"Department of Geriatric Psychiatry Enschede, Mediant Mental Health Institute, 7546 RD Enschede, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5529-3275","authenticated-orcid":false,"given":"Gert-Jan","family":"Hendriks","sequence":"additional","affiliation":[{"name":"Pro Persona, Institute for Integrated Mental Health Care, 6500 HB Nijmegen, The Netherlands"},{"name":"Behavioural Science Institute, Radboud University, 6525 XZ Nijmegen, The Netherlands"},{"name":"Department of Psychiatry, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5617-0311","authenticated-orcid":false,"given":"Paul","family":"Naarding","sequence":"additional","affiliation":[{"name":"GGNet Apeldoorn, Department of Geriatric Psychiatry, 6525 CG Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathalie R.","family":"de Vent","sequence":"additional","affiliation":[{"name":"Department of Psychology, University of Amsterdam, 1012 WX Amsterdam, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9500-9793","authenticated-orcid":false,"given":"Roy P. C.","family":"Kessels","sequence":"additional","affiliation":[{"name":"Donders Institute for Brain Cognition and Behaviour, Radboud University, 6525 AJ Nijmegen, The Netherlands"},{"name":"Vincent van Gogh Institute for Psychiatry, 5802 EH Venray, The Netherlands"},{"name":"Radboudumc Alzheimer Center, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1501-4774","authenticated-orcid":false,"given":"Richard C.","family":"Oude Voshaar","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, University Medical Center Groningen, University of Groningen, 9700 AB Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0131-0735","authenticated-orcid":false,"given":"Hans W.","family":"Jeuring","sequence":"additional","affiliation":[{"name":"Department of Psychiatry, University Medical Center Groningen, University of Groningen, 9700 AB Groningen, The Netherlands"},{"name":"Department of Geriatric Medicine, University Medical Center Groningen, 9700 RB Groningen, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"499","DOI":"10.1016\/j.pop.2017.04.007","article-title":"Depression in Older Adults: A Treatable Medical Condition Depression Antidepressants Electroconvulsive therapy","volume":"44","author":"Casey","year":"2017","journal-title":"Prim. Care Clin. Off. Pract."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1016\/j.jad.2010.11.033","article-title":"Age- and gender-specific prevalence of depression in latest-life\u2014Systematic review and meta-analysis","volume":"136","author":"Luppa","year":"2012","journal-title":"J. Affect. Disord."},{"key":"ref_3","unstructured":"APA (2014). Handboek voor de classificatie van psychische stoornissen (DSM-5). Nederlandse Vertaling van Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association. [5th ed.]."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"227","DOI":"10.1080\/13651501.2020.1757116","article-title":"Duration of untreated illness and depression severity are associated with cognitive impairment in mood disorders","volume":"24","author":"Galimberti","year":"2020","journal-title":"Int. J. Psychiatry Clin. Pract."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Guzm\u00e1n-Esquivel, J., Becerra-Galindo, B.S., Hern\u00e1ndez-Fuentes, G.A., Ramos-Rojas, M.A., Delgado-Enciso, O.G., Guzm\u00e1n-Sol\u00f3rzano, H.P., Diaz-Martinez, J., Guzm\u00e1n-Sandoval, V.M., Sanchez-Ramirez, C.A., and Melnikov, V. (2025). Depression and Hypomagnesemia as Independent and Synergistic Predictors of Cognitive Impairment in Older Adults Post-COVID-19: A Prospective Cohort Study. Med. Sci., 13.","DOI":"10.3390\/medsci13030114"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"953","DOI":"10.1017\/S1041610214000155","article-title":"Heterogeneity of late-life depression: Relationship with cognitive functioning","volume":"26","author":"Korten","year":"2014","journal-title":"Int. Psychogeriatr."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1002\/gps.5227","article-title":"Diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) for cognitive screening in old age psychiatry: Determining cutoff scores in clinical practice. Avoiding spectrum bias caused by healthy controls","volume":"35","author":"Dautzenberg","year":"2020","journal-title":"Int. J. Geriatr. Psychiatry"},{"key":"ref_8","unstructured":"Brunet, M.D., McCartney, M., Heath, I., Tomlinson, J., Gordon, P., Cosgrove, J., Deveson, P., Gordon, S., Marciano, S.A., and Colvin, D. (2013). There is no evidence base for proposed dementia screening. BMJ, 346."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Chambers, L.W., Sivananthan, S., and Brayne, C. (2017). Is Dementia Screening of Apparently Healthy Individuals Justified?. Adv. Prev. Med., 2017.","DOI":"10.1155\/2017\/9708413"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1016\/j.cger.2013.07.003","article-title":"Classification and Epidemiology of MCI","volume":"29","author":"Roberts","year":"2013","journal-title":"Clin. Geriatr. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/0022-3956(75)90026-6","article-title":"\u201cMini-mental state\u201d. A practical method for grading the cognitive state of patients for the clinician","volume":"12","author":"Folstein","year":"1975","journal-title":"J. Psychiatr. Res."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"695","DOI":"10.1111\/j.1532-5415.2005.53221.x","article-title":"The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment","volume":"53","author":"Nasreddine","year":"2005","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Jia, X., Wang, Z., Huang, F., Su, C., Du, W., Jiang, H., Wang, H., Wang, J., Wang, F., and Su, W. (2021). A comparison of the Mini-Mental State Examination (MMSE) with the Montreal Cognitive Assessment (MoCA) for mild cognitive impairment screening in Chinese middle-aged and older population: A cross-sectional study. BMC Psychiatry, 21.","DOI":"10.1186\/s12888-021-03495-6"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Davis, D., Creavin, S., Yip, J., Noel-Storr, A., and Cullum, S. (2015). Montreal Cognitive Assessment for the diagnosis of Alzheimer\u2019s disease and other dementias. Cochrane Database Syst. Rev. Montr., 2015.","DOI":"10.1002\/14651858.CD010775.pub2"},{"key":"ref_15","first-page":"139","article-title":"Effects of Normative Adjustments to the Montreal Cognitive Assessment","volume":"176","author":"Pugh","year":"2019","journal-title":"Physiol. Behav."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Kessels, R.P.C., De Vent, N.R., Bruijnen, C.J.W.H., Jansen, M.G., De Jonghe, J.F.M., Dijkstra, B.A.G., and Oosterman, J.M. (2022). Regression-Based Normative Data for the Montreal Cognitive Assessment (MoCA) and Its Memory Index Score (MoCA-MIS) for Individuals Aged 18\u201391. J. Clin. Med., 11.","DOI":"10.3390\/jcm11144059"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1212\/01.wnl.0000413072.54070.a3","article-title":"Normative data for the montreal cognitive assessment (MOCA) in a population-based sample","volume":"78","author":"Rossetti","year":"2012","journal-title":"Neurology"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1016\/j.jad.2011.10.023","article-title":"A meta-analysis of cognitive de fi cits in fi rst-episode Major Depressive Disorder","volume":"140","author":"Lee","year":"2012","journal-title":"J. Affect. Disord."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1002\/da.22063","article-title":"Cognitive deficits and functional outcomes in major depressive disorder: Determinants, substrates, and treatment interventions","volume":"30","author":"McIntyre","year":"2013","journal-title":"Depress. Anxiety"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1097\/00019442-200508000-00007","article-title":"Effects of anxiety versus depression on cognition in later life","volume":"13","author":"Bierman","year":"2005","journal-title":"Am. J. Geriatr. Psychiatry"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"513","DOI":"10.1017\/cjn.2015.399","article-title":"Depressive Symptoms Negatively Impact Montreal Cognitive Assessment Performance: A Memory Clinic Experience","volume":"43","author":"Blair","year":"2016","journal-title":"Can. J. Neurol. Sci."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1016\/j.jalz.2016.06.2361","article-title":"Mild cognitive impairment and risk of depression and anxiety: A population-based study","volume":"13","author":"Mirza","year":"2017","journal-title":"Alzheimer\u2019s Dement."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"573","DOI":"10.1136\/jnnp-2024-334675","article-title":"Depression and dementia: Interrogating the causality of the relationship","volume":"96","author":"Paris","year":"2025","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1080\/03630242.2013.767301","article-title":"Depressive symptoms and neurocognitive performance among HIV-infected women","volume":"53","author":"Fialho","year":"2013","journal-title":"Women Health"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1111\/tmi.13699","article-title":"The influence of major depressive disorders on neurocognitive function among adults living with HIV\/AIDS in a regional referral hospital in Dodoma, Tanzania","volume":"27","author":"Nyundo","year":"2022","journal-title":"Trop. Med. Int. Health"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1879","DOI":"10.1007\/s10461-011-9973-3","article-title":"Depression and neurocognitive performance in portuguese patients infected with HIV","volume":"15","author":"Palha","year":"2011","journal-title":"AIDS Behav."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1001\/jamapsychiatry.2024.4305","article-title":"Depressive Symptoms and Amyloid Pathology","volume":"82","author":"Wiels","year":"2025","journal-title":"JAMA Psychiatry"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"755","DOI":"10.1080\/13825585.2015.1041449","article-title":"Age-and education-adjusted normative data for the Montreal Cognitive Assessment (MoCA) in older adults age 70\u201399","volume":"22","author":"Powell","year":"2015","journal-title":"Aging, Neuropsychol. Cogn."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Oude Voshaar, R.C., Dhondt, T.D.F., Fluiter, M., Naarding, P., Wassink, S., Smeets, M.M.J., Pelzers, L.P.R.M., Lugtenburg, A., Veenstra, M., and Marijnissen, R.M. (2019). Study design of the Routine Outcome Monitoring for Geriatric Psychiatry & Science (ROM-GPS) project; A cohort study of older patients with affective disorders referred for specialised geriatric mental health care. BMC Psychiatry, 19.","DOI":"10.1186\/s12888-019-2176-6"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"de Vent, N.R., van Rentergem, J.A.A., Schmand, B.A., Murre, J.M.J., and Huizenga, H.M. (2016). Advanced Neuropsychological Diagnostics Infrastructure (ANDI): A normative database created from control datasets. Front. Psychol., 7.","DOI":"10.3389\/fpsyg.2016.01601"},{"key":"ref_31","first-page":"393","article-title":"Het Mini Internationaal Neuropsychiatrisch Interview (MINI): Een kort gestructureerd diagnostisch psychiatrisch interview voor DSM-IV-en ICD-10-stoornissen","volume":"49","year":"2007","journal-title":"Tijdschr. Psychiatr."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1017\/S0033291700035558","article-title":"The Inventory of Depressive Symptomatology (IDS): Psychometric properties","volume":"26","author":"Rush","year":"1996","journal-title":"Psychol. Med."},{"key":"ref_33","unstructured":"Verhage, F. (1964). Intelligentie en Leeftijd: Onderzoek Bij Nederlanders van Twaalf Tot Zevenenzeventig Jaar, Van Gorcum."},{"key":"ref_34","unstructured":"Green, W.H. (1993). Econometric Analysis, Mcmillan Publishing Company Inc."},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Kang, J.M., Cho, Y.S., Park, S., Lee, B.H., Sohn, B.K., Choi, C.H., Choi, J.S., Jeong, H.Y., Cho, S.J., and Lee, J.H. (2018). Montreal cognitive assessment reflects cognitive reserve. BMC Geriatr., 18.","DOI":"10.1186\/s12877-018-0951-8"},{"key":"ref_36","first-page":"133","article-title":"Relationship of apathy with depressive symptom severity and cognitive functions in geriatric depression","volume":"56","author":"Topak","year":"2019","journal-title":"Noropsikiyatri Ars."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1084","DOI":"10.1016\/j.jagp.2016.06.005","article-title":"The Depressed Frail Phenotype: The Clinical Manifestation of Increased Biological Aging","volume":"24","author":"Brown","year":"2016","journal-title":"Am. J. Geriatr. Psychiatry"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"343","DOI":"10.1093\/gerona\/glw241","article-title":"Biological aging and the future of geriatric psychiatry","volume":"72","author":"Rutherford","year":"2017","journal-title":"J. Gerontol.\u2014Ser. A Biol. Sci. Med. Sci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"893","DOI":"10.1002\/gps.4866","article-title":"Normative data for the Montreal Cognitive Assessment (MoCA) and the Memory Index Score (MoCA-MIS) in Brazil: Adjusting the nonlinear effects of education with fractional polynomials","volume":"33","author":"Apolinario","year":"2018","journal-title":"Int. J. Geriatr. Psychiatry"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1159\/000494489","article-title":"Validation of the czech montreal cognitive assessment for mild cognitive impairment due to Alzheimer disease and czech norms in 1,552 elderly persons","volume":"46","author":"Bartos","year":"2019","journal-title":"Dement. Geriatr. Cogn. Disord."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"893","DOI":"10.3233\/JAD-170203","article-title":"The Montreal Cognitive Assessment: Normative Data from a Large Swedish Population-Based Cohort","volume":"59","author":"Borland","year":"2017","journal-title":"J. Alzheimer\u2019s Dis."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"775","DOI":"10.1590\/0004-282x20190130","article-title":"MoCA Test: Normative and diagnostic accuracy data for seniors with heterogeneous educational levels in Brazil","volume":"77","author":"Cesar","year":"2019","journal-title":"Arq. Neuropsiquiatr."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"1335","DOI":"10.3233\/JAD-215629","article-title":"Montreal Cognitive Assessment: Normative Data for Cognitively Healthy Swedish 80- to 94-Year-Olds","volume":"87","author":"Classon","year":"2022","journal-title":"J. Alzheimer\u2019s Dis."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"785","DOI":"10.1037\/bul0000197","article-title":"What did you do yesterday? A meta-analysis of sex differences in episodic memory","volume":"145","author":"Asperholm","year":"2019","journal-title":"Psychol. Bull."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1016\/j.jad.2018.10.358","article-title":"Course of depressive symptoms and associated factors in people aged 65+ in Europe: A two-year follow-up","volume":"245","year":"2019","journal-title":"J. Affect. Disord."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1477","DOI":"10.1080\/13607863.2017.1370688","article-title":"Factor structure of depressive symptoms using the EURO-D scale in the over-50s in Europe. Findings from the SHARE project","volume":"22","year":"2018","journal-title":"Aging Ment. Health"},{"key":"ref_47","first-page":"253","article-title":"Education bias in typical brief cognitive tests used for the detection of dementia in elderly population with low educational level: A critical review","volume":"32","year":"2022","journal-title":"Appl. Neuropsychol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1016\/j.jad.2018.09.068","article-title":"Persistent depressive disorder has long-term negative impacts on depression, anxiety, and somatic symptoms at 10-year follow-up among patients with major depressive disorder","volume":"243","author":"Hung","year":"2019","journal-title":"J. Affect. Disord."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Khan, G., Mirza, N., and Waheed, W. (2022). Developing guidelines for the translation and cultural adaptation of the Montreal Cognitive Assessment: Scoping review and qualitative synthesis. BJPsych Open, 8.","DOI":"10.1192\/bjo.2021.1067"}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/13\/4\/312\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,10]],"date-time":"2025-12-10T14:36:07Z","timestamp":1765377367000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/13\/4\/312"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,10]]},"references-count":49,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2025,12]]}},"alternative-id":["medsci13040312"],"URL":"https:\/\/doi.org\/10.3390\/medsci13040312","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,10]]}}}