Identifying and Responding to Potential Warning Signs of Cognitive Impairment

Article by Chip Glaze Featured Author

Posted March 2018

The Lawyer's Creed expresses the duties to which we, as attorneys, pledge our effort and fidelity. As its first sentence clearly indicates, a healthy mind is vital to our professional pursuits. Unfortunately, some of us and our colleagues will experience cognitive impairment, which may compromise the ability to effectively offer such service. As professionals, we are called to prepare for this possibility and to be ready to address it.

Some initial caveats should precede any discussion of signs and symptoms that you, a colleague, or a loved one may be experiencing cognitive impairment. The purpose of this article is NOT to diagnose or treat dementia. It is to identify signs that someone may be suffering with potential cognitive impairment. Further, its purpose is to prepare you to discuss your concerns with that person. The goal of such a conversation is, at a minimum, scheduling a thorough medical examination with a focus on these issues, either with their primary care physician or an assessment at the UMMC MIND Center. It is further important to note that the behavioral and other indicators described below are generally not malicious, or even volitional. Rather, these may be indicators of a medical issue. Additionally, the person may be completely unaware of the presence of these indicators. These indicators may also be entirely outside their ability to control. Finally, such symptomology may not always be associated with advanced age, so it is important that we can recognize these issues in ourselves and our colleagues regardless of age.

To my clients, I offer faithfulness, competence, diligence, and good judgment. I will strive to represent you as I would want to be represented and to be worthy of your trust.

All potential signs and symptoms should be considered in light of two key questions. Is the behavioral or physical indication a break from the norm? Is it an aberration? While continuation or exacerbation of pre-existing problematic conduct may be a concern, it is not necessarily indicative of cognitive impairment. Does the person seem to have a level of insight into signs which may be causing concern? A person's level of insight is key. Whether someone has insight into what is going on will greatly influence what actions may be necessary to address potential problems.

Changes in physical appearance and physiological symptomology that may also indicate potential cognitive impairment:

• Weight gain or loss
• Tremors
• Facial drooping
• Weakness
• Imbalance or unsteady gait
• Decreased energy
• Disheveled appearance
• Poor hygiene
• Dizziness
• Pain
• Headache
• Nausea
• Insomnia or narcolepsy
• Blurred vision

Behavioral indications that one might be experiencing cognitive impairment may include:

• Change in work focus, quality of work product, or timeliness
• Disorganization/misplacing things/missing appointments or hearings
• Decreased socialization at work and/or in community/family
• Other significant behavioral change

Cognitive impairment may also be evident in one's increased or reduced emotional expression:

• Impatience or lower frustration tolerance
• Increased emotional volatility
• Quick to anger
• Apathy
• Seems uncaring
• Doesn't seem to "get it"

Someone experiencing, or observing, mild cognitive impairment may wish to postpone or avoid a medical evaluation. People may be justifiably anxious when considering any discussion of potential cognitive impairment, fearing that such will open a Pandora's Box. Words like Alzheimer's, dementia, and incapacity may come to mind. Observation of symptoms does not necessarily indicate such diagnoses.

There are numerous other possibilities, including but not limited to:

• Depression/Anxiety
• Dehydration
• Infection
• Medication side effects
• Substance abuse
• Hearing loss
• Thyroid issue
• Vitamin deficiency
• Metabolic disturbances
• Nutrient deficiencies

If the foregoing may be ruled out by appropriate assessment, but symptoms continue, one may be tempted to avoid further inquiry, fearing once again "the worst." It is important to note that while individuals with mild cognitive impairment (cognitive changes serious enough to be noticed by the individual or other people, but not severe enough to necessarily interfere with daily life or independent function) have an increased risk of developing Alzheimer's or another dementia, but not all people with a mild cognitive impairment get worse; some get better.

It is also important to recognize that a medical evaluation may provide opportunities to address significant issues:

• Cause may be reversible or treatable; treatment/medication can begin when most beneficial
• Maintain/Preserve the individual's dignity and reputation
• Advance planning while the individual is competent (will, practice succession, powers of attorney, advance directives)
• Safety issues (e.g. driving, self care, supervision of others)
• Individual, family, and colleague stress and misunderstanding (blame, denial)
• Early education and support of the attorney, family and colleagues about how to help the individual (resources, engagement)

The Mississippi Bar Lawyers and Judges Assistance Program (LJAP) offers voluntary, confidential, free assistance to our colleagues who may be struggling, or may know someone who may be struggling with the issues described here. We have also gathered useful tools for assessing these situations as both a self-assessment, or for use as an observational checklist. The observational checklists can offer objective data to aid a potential conversation with a colleague or loved one. Further, these instruments can facilitate an accurate recitation of concerns at a medical evaluation. The checklists are available on The Mississippi Bar website. If you or someone you are concerned about appears to be exhibiting signs of cognitive impairment, you can always contact me at 601-948-4475 or cglaze@msbar.org.

1. Chip Glaze is the Director of the Lawyers and Judges Assistance Program for the Mississippi Bar Association. He may be reached at (601) 948-4475 or cglaze@msbar.org.