Géraud Dautzenberg

General introduction 9 1 1.1 Why 1.1.1 Why this study? In old age psychiatry, one can encounter a broad variety of referrals, at least in the Netherlands. Predominantly patients with affective disorders, anxiety disorders, psychotic disorders, and cognitive disorders are referred. Very few of the symptoms of these disorders are specific to only one psychiatric disorder and even ‘typical’ complaints can mimic, different aetiologies (American Psychiatric Association, 2013). This increases with age, as patients tend to have complaints in more than one specific domain, and often the complaints cannot be attributed to just one cause (Bierman et al., 2007; Schouws et al., 2012; Baune and Renger, 2014; Bora and Pantelis, 2015). Giving up hobbies is often wrongly attributed to being too old or being socially isolated, but can (also) be due to an affective disorder, negative symptoms of (late-onset) schizophrenia, side effects of medication (ranging from a tremor to cognitive impairment), or a developing neurodegenerative disorder expressing itself in apathy. Therefore, in old age psychiatry, complaints can result from more than one of the ‘classical psychiatric diseases’, as encountered in textbooks (Ferri et al., 2005). Often, age, frailty, social isolation, mobility, polypharmacy, comorbidity, and neurodegenerative diseases contribute to the overall picture owing to its population. This is most prominent in cases of cognitive impairment. A simple but daily example is a patient of age that has limited mobility, is depressed, uses psychotropic medication, and experiences (subjective) cognitive decline, and (therefore) quits his bridge club, for example, because of the shame of not being able to play at their former level. Giving up this activity can find its origin in either of these causes. Of course, none of these factors could be significant enough to cause mild cognitive impairment (MCI) by itself, but when combined, they would be. Furthermore, it can of course be neither of the above but an emerging neurodegenerative process or social deprivation causing depressive symptoms with subjective cognitive impairment causing fear of embarrassing oneself. Disentangling the possible aetiologies seems simple in theory, but the clinical reality is harsh. Simply stopping the antidepressant that seemed effective, to see if it was indeed the presumed side effects that caused cognitive impairment, is easier said than done. Alternatively, could it be that depression was only partly in remission, and cognitive impairment is a remaining symptom? Waiting for depression to subside does not take into account that cognitive deficits can linger even after the clinical depression has subsided (Ahern and Semkovska, 2017; Riddle et al., 2017; Semkovska et al., 2019). Was there already a neurodegenerative process developing in the background as 15% of 70 years and older and increasing to over 30% of 85 years and older have dementia, and

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