When You Suspect Cognitive Impairment, Take Appropriate Action

When a lawyer (or investment counsel) is engaged in representing a client over time, there is an opportunity to develop a historical relationship. As a result, changes in client behavior may be observed. Something unexpected in the relationship, something out of the ordinary, may be perceived. For example, someone with strong math skills exhibited over the years becomes confused when it’s time to add a tip to a dinner tab. A perfectionist whose files and calendar are always organized cannot locate documents. A colleague receives notices of unpaid bills –unpaid due to forgetfulness, not carelessness.

When witnessing something that is out of character for a client, colleague, friend or family member, concern may lead to worry, and worry may lead to action. But what type of action? What is appropriate? And when is action called for? To prepare, we will review

Suspicion of Cognitive Impairment

The Need for a Diagnosis?

Diagnosis and Intervention

What’s Next Depends on the Circumstances

What If the Diagnosis Is Dementia?

Possible Benefits of Virtual Reality as an Intervention

Lessons from Successful Families

Resources

Suspicion of Cognitive Impairment

There are numerous studies that discuss the differences between normal or healthy aging and cognitive impairment, whether mild cognitive impairment (MCI) or advanced (Alzheimer’s disease (AD) or another form of dementia). (The differences are beyond the scope of this article, except to provide resources at the end.)

Suspicion of cognitive impairment can arise oh-so easily. Forgetfulness can be unsettling to the subject him- or herself and potentially irritating to family, friends, and colleagues. (“You’ve told me about that fishing trip 100 times, Dad, maybe more.”) Is that a reflection of healthy and normal aging or cognitive decline?

“The challenge to clinicians is to appreciate where the boundary between normal and abnormal is for a particular patient,” according to David Knopman MD and Ronald Petersen MD, (2014, p. 1454). “Forgetting is intrinsically human and increases with aging.”

Whether mild or severe, cognitive impairment involves these areas: “(1) learning and memory, (2) language, (3) visuospatial, (4) executive, and (5) psychomotor,” according to Knopman and Petersen (2014, p. 1454). “Mild cognitive impairment (MCI), calls for only one of these areas to be impaired and for substantial impairment, more than one. . .”

Because it is a challenge to experts themselves, lawyers, friends, and family need to refrain from drawing conclusions on their own. Instead, it is wise to make note of situations to prepare for informing the subject’s physician when the time is right. It is also important to understand that memory can be impacted by depression, stress, illness, medication, and many other influences that need to be factored into the equation by a physician, not a family member, friend, or colleague.

MCI is not universal among the elderly. However, of those diagnosed with MCI, the vast majority (80%) are later diagnosed with dementia (within 6 years) (Hwang and Lee, 2017, p. 1283).

Contrast that to normal (non-MCI) elderly, who are rarely (1-2%) diagnosed with dementia.

The elderly don’t necessarily move into MCI or advance into dementia, such as Alzheimer’s (AD). They could instead experience “healthy” aging, “normal” aging, or “age-related cognitive decline” (ARCD), “which is both independent of dementia and has an incidence 70% higher than dementia alone” (Juan and Adlard, 2019, p. 107).

Those who are diagnosed with MCI, however, experience “more substantial cognitive and memory decline than normal aging and represents a significant risk factor for the development of dementia” (Levey, et al., 2006, p. 1001).

It is yet unclear whether treatments can delay the “conversion from MCI to AD,” according to Levey, et al. (2006, p. 1001).

ABA Senior Lawyers Division

Julie Jason