Chapter 7 160 In Chapter 6, we present a different topic. That topic is so important that we thought it was worth publishing. However, the presented case study stands for more than the clinical topic, as it also stands for the importance of the use of a cognitive screener in old age psychiatry, that is, the MoCA. Our patient was an extreme example of a misjudged intoxication. It did not remain unseen as it was so extreme in the end, but it is quite likely that many others would remain undiagnosed. By not measuring the correct blood concentration of valproic acid, that is, free fraction, unseen side effects can appear, including cognitive impairment. Especially when they start gradually and with increasing age, cognitive side effects are prone to be attributed to the reason why one takes valproic acid, age, or, in the case of more severe impairment, to a neurodegenerative aetiology. Even if one is aware of the side effects of valproic acid, and a blood sample to measure the total valproic acid concentration is taken, the result can be misleading when the free fraction is not known. As is still custom, in Europe, it only reports the total valproic acid concentration instead of the unbound concentration. This was the primary message of this chapter, but a secondary message is as follows. We want to emphasise that the routine use of the MoCA in old age psychiatry can make a difference. Even though the score was high or good at the beginning, without exaggeration, having an initial MoCA score saved the patient’s life. If it were not for the first (normal) MoCA score, the lower second MoCA score would have been attributed to the patients’ current functioning, including a recent lithium intoxication, and age and alarm bells would have sounded too late as a drop of 9 points on the MoCA would not have been noticed. This case report shows that not only is the MoCA score on indication is of value, but a baseline MoCA is of value as well. Especially in an old age psychiatric setting, due to age, medication, and comorbidity, the patients are at risk of developing cognitive impairment for various reasons now or in the near future. 7.2 Methodological reflections Wewant todiscussnot only theoutcomes and implicationsof our studybut also its limitations. This section focuses on the general methodological limitations of this dissertation. The specific limitations of each chapter are presented in the corresponding chapters. 7.2.1 Methodological reflections of Sections A: Unseen needs The question that needs to be clarified is whether elderly psychiatric patients differ from their younger equivalents in care needs, in general, and in certain diseases or domains, such as cognitive impairment, in particular. Do they only differ in quantity, that is, are they more of
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