General introduction 11 1 identifying mild cognitive impairments. Therefore, they still need to be easily applicable, accessible, and affordable. During a home visit consultation in 2008 regarding a patient with lithium intoxication, I also added routine cognitive screening. In this case a ‘new’ cognitive screener: the Montreal Cognitive Assessment (MoCA) was used (Nasreddine et al., 2005). This was more to gain experience with new cognitive screening instruments and which one to use from now on as I did not expected major abnormalities. This is partly because I had gone through an extensive complaint anamnesis with the patient, which was focused on her lithium use and its side effects. As it turned out, I overestimated that significant cognitive abnormalities would have been ‘à vue’ for me as an old age psychiatrist to notice. You are holding the result of that test in your hands in the form of this dissertation. Of course, this example could not be the only patient with unknown cognitive impairment, intervening with the treatment. In her case, there was a (lithium) intoxication as she forgot that she had already taken her lithium and therefore mostly likely doubled her dose by mistake. Not considering this would be a mistake and prone to more foreseeable mistakes. Being confronted withmy own shortcomings, even though the reason for the consultation had a different origin, I had fallen into a classical nicely put ‘doctors delay’ trap. I realised that the needs patients mention do not necessarily correspond with the needs the doctor hears, sees, or thinks should be met (by him or her). Furthermore, even those needs that the patients want or need to be met are not necessarily the ones they mention to be met, that is, ‘patients delay’. This can have multiple reasons, ranging from being unaware of their need to denial of their need, fear of being stigmatised, or thinking a doctor cannot help them with their particular needs. These “delays” result in the following question: When should we screen? 1.2 When The discussion above illustrates well the dilemma that doctors face on a daily basis. To what extent do they have to look for something that is not (yet) a problem, that is not seen or experienced as such (by the doctor or by the patient), or is not recognised as such. Or, when it is a problem but not (yet expressed as) a complaint? Does the patient always have the right to downplay or even ignore the problem? The COVID-19 pandemic is illustrative in that there is no obvious answer on second sight. This dilemma occurs also often with cognitive impairment, as many patients don’t want to have an elaborate
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