Cognitive Decline: What Every Lawyer Needs to Know About the Aging Brain [Webinar]

AMY LEVINE:  

All right, maybe, it’s 12:01, I know we have a lot to cover today so I will get started with the introduction. So, everybody, welcome to Lawyers Concerned for Lawyers’ webinar on Cognitive Decline: What Every Lawyer Needs to Know About the Aging Brain. We’re pleased to have you today. This is going to be the first presentation of a three-part series on exploring the impact of aging in the legal community. Please join us for future presentations, Preserving Integrity and Upholding Excellence: How Cognitive Decline Poses Ethical Complications for Lawyers, scheduled for February and Reimagine, Refocus or Retire: Second Acts for Lawyers, which is scheduled for March. We’re also going to offer two supplemental webinars as part of our Webinars for Busy Lawyers series on nutrition and cognitive wellness and succession planning. 

I’m going to introduce Dr. Tracey Meyers in just a moment, but first I want to remind people about LCL. We provide assessment and consultation for addiction, substance use challenges, and mental health concerns and law office practice management as well as well-being programs. Our services are confidential and free, our clinical staff are licensed professionals with many years of experience serving the legal community, our law office management assistance program is run by experienced law office advisors to assist attorneys with technology, ethics, and practice management and more.  

After Dr. Meyer’s webinar we’ll give you a chance to ask questions through the chat, and now I’d like to introduce our speaker for today, Dr Tracey Meyers. She is a licensed clinical psychologist, certified yoga instructor, and yoga therapist. She joined LCL in August of 2020 following her work for the state of Connecticut Department of Mental Health and Addiction Services where she spent over 15 years working in inpatient and outpatient mental health settings. She has a strong commitment to integrative medicine for mental health wellness and leads mindfulness and yoga programs for groups, individuals and professionals in the workplace, and she does run LCL Super Mom Support Group, Mindfulness for Busy Legal Professionals and Yoga for Busy Legal Professionals and without further ado I will hand it over to Tracey.  

 

DR. TRACEY MEYERS: 

All right, thanks, Amy. So nice to be here. So, my background, although we’re talking a lot about the yoga and the mindfulness, which certainly are um, strong areas of interest for me, but also my original background is in neuropsychology. So, I spent my original first years of graduate school in a memory disorders clinic learning about dementia, cognitive impairment, and subsequently went on to work in lots of different settings with people with different kinds of neurological and neurodegenerative conditions, so I have a real interest in cognitive decline. So, I’m really excited to talk about the information today that I’m going to share.  

So, this first presentation – and as Amy talked about we’re going to have three presentations in total and some supplemental ones – but this first one is really about: what is cognitive impairment? We often talk about it as maybe, ‘I’m not remembering things as well, or I can’t remember someone’s name, or I’m getting confused, I can’t manage new technology.’ So, we have kind of our myths and fears about what cognitive decline is, and much more about the science and the diagnosis that I’m going to cover today. So, we’re going to demystify what it is, talk about signs and symptoms, what happens in the brain, the spectrum of cognitive impairment, and then for lawyers, how to begin to approach if you or someone you work with is experiencing cognitive decline. All right, so I’m going to share my screen now. All right, excellent. 

Okay, so these are our topics we’re going to cover today. So, I wanted to start thinking about lawyers specifically with cognitive decline. Lawyers have to use their brains, right, especially things like memory, language, and attention and concentration, so even subtle changes when you feel like you’re not on top of your game can play a big a role in terms of work performance, right. And lawyers in general, and these are generalizations, are less likely to seek help for mental health and cognitive problems as compared to the regular population. Fear of stigma, loss of resources, shame, embarrassment, or lack of awareness, right. 

And then the other piece, as we talk about throughout the webinar today, [is] that lifestyle changes can make a big difference in terms of cognitive decline. And lawyers – again and I’m kind of lumping everyone together – but lawyers typically struggle with some of the lifestyle choices, right. So, cognitive decline is influenced by blood pressure, diabetes, medications, and so awareness of these risk factors can play a big role in mitigating some of the impact of cognitive decline. So, we’ll come back to the slide after I’ve gone through some of the definitions, prevalence rates, and a little bit more about what cognitive decline is.  

So, we’ll start first of all with cognition. So, we use these terms a lot like cognition, cognitive decline, cognitive impairment. What is it? So really cognition is thinking, right, and it encompasses the processes around thinking – our ability to reason, problem-solve, judge and analyze, express ourselves through language, and remember information. 

So, a little brain 101. This may bring you back to high school or college physiology/biology. But essentially, we have two hemispheres of the brain, the left hemisphere, and the right hemisphere. And information is processed uniquely in each hemisphere of the brain, and then there’s this communication network that goes across the corpus callosum, which are these fibers where information is shared. So, the left hemisphere of the brain is our more logical part of the brain; it controls the right side of our body, and it’s really language focused. So, speaking and understanding language, verbal memory, the ability to remember information presented verbally, sequencing and organizing, and even some of the emotion regulation skills that we need to be able to assess and calm ourselves down are left hemisphere located.  

And as lawyers, think about how much you rely on the left hemisphere, right. So, lawyers typically, if you were to do neuropsychological assessment, would have very high left hemisphere functioning, right, you do well on language and logic tasks. Now, that doesn’t mean you don’t do well on right hemisphere tasks, but right hemisphere is related to much more spatial, holistic learning, visuospatial perceptual skills, creativity and music perception, awareness of deficits (which we’ll talk about in a little while, but the ability to recognize if if you’re struggling with something), the big picture, kind of the gestalt, and visual memory, the ability to remember where you put things, how to get from one location to the other, right. That’s much more right hemisphere-based.  

And then so in addition to these two hemispheres, we have four main lobes of the brain. And each part of the each lobe has a right and left part to them, so we have the frontal lobes, left and right, the temporal lobes, left and right, parietal lobe, left and right, and occipital lobe, left and right. Now this has a lot of information on it, which might overload your frontal lobes, it does for me, but I just want to show you, just so you have a sense of how each part of the brain has different functions. Now, it’s important to consider that these skills are not limited just to one area. In fact, there [are] many, many connections that are happening between the frontal lobe and the temporal lobe, for example. And there’s also junctures right where these two lobes connect, which also has a lot of information. But in general, the frontal lobes are responsible for emotional control, verbal expression, problem solving, what we call executive functioning. Temporal lobe has a lot to do with memory organization, attention, receptive language, understanding language, language comprehension, and emotional responses. Parietal is much more visuospatial, organization, naming, eye-hand coordination. The motor cortex is right here so that’s why the parietal lobe has some of the motor components to it. Occipital lobe has less, it’s a small the smallest lobe and it involves visual stimuli, being able to process visual information. All right, that’s a lot of info, but I wanted you to kind of get the lay of the land with our brains.  

So, when we talk about cognitive domains, we’re talking about, these are the main ones: 

• Executive functioning (which is those frontal lobes, higher level problem solving skills),  

• Attention (also in the frontal lobes),  

• Memory (which is the temporal lobes),  

• Language (which is much more left hemisphere, frontal and temporal)  

• And then the visuospatial (which are the occipital and parietal lobes).  

Again, these are – these domains are not only limited to those areas, but by and large that is where most of the processing occurs…So, that’s kind of our healthy brain, right. This is where we think, problem-solve, remember information.  

Now let’s move toward talking about cognitive decline. So, cognitive decline is a concern or difficulty with a person’s thinking (remember cognition is how we think, and that especially involves memory concentration and other brain functioning) beyond what is expected due to aging. Now, here’s the tricky part, and probably you’re thinking this already; ‘I don’t know what’s expected due to aging,’ right? And this is where a lot of us can get fearful, because we don’t really know what is typical for aging and what is beyond that. So, we’re going to talk about that today because that’s actually a really important question.  

So, there are different kinds of cognitive decline if we think about cognitive decline is sort of this umbrella, underneath [is] subjective cognitive decline. And this is the number one thing I see when lawyers come in worried about their memory. It’s that that individual has a perception that their memory and thinking skills are worsening. How many of you have had that fear, right? Many of us. Independent of any testing, independent of anyone noticing or a physician diagnosing, it’s like, ‘Oh my brain’s not as sharp,’ right. So, about 10% of those over 45 report subjective cognitive decline. And the numbers go up as we age, right, we start to get to notice, ‘Oh yeah, I’m having trouble finding words or I’m noticing I’m not remembering information like I used to.’ So, it’s subjective – it’s not a diagnosis.  

Mild cognitive impairment (MCI which is how I’m going to refer to it today) is a diagnostic condition, so it’s an early stage of memory loss or of cognitive ability. We’re going to talk about different kinds of MCI; so, it’s not just memory. In individuals who are still independent and are able to perform most of their regular activities of daily living…about 20% of people 65 and older have some MCI (mild cognitive impairment).  

Now mild cognitive impairment can range, and we’re going to talk about that, but symptoms of mild cognitive impairment can lead to Alzheimer’s disease, so there’s a category called MCI due to Alzheimer’s disease, and it’s kind of a precursor to Alzheimer’s dementia. And it’s characteristic, these early symptoms, of what eventually can turn into Alzheimer’s disease. So, about 10% of those over 65 have MCI due to Alzheimer’s disease, so basically about half of the people that have some diagnosed MCI end up developing Alzheimer’s. About half, okay. That doesn’t mean, again, that all of these folks even have a diagnosable condition. So, I want to both reassure you, but also give you data.  

So, mild cognitive impairment is an early stage, again, a diagnosable early stage of memory loss or other cognitive ability, and you’re still able to perform most activities of daily living. The impairment, unlike the subjective cognitive decline where no one else notices, this is enough impairment so that people notice, right, work colleagues, family members, but it doesn’t affect the individual’s ability to carry out daily activities. Okay now, again, for lawyers, even small changes in cognition can impact work ability, but by and large people with MCI can still carry out their activities pretty well, including lawyers.  

MCI can develop into dementia, but not always, and we’re going to talk about that. About half, right, so there are many other reasons why people develop MCI that don’t go on to develop Alzheimer’s disease. In some cases, people can even go back to a normal cognition, or just keep that kind of mild decline level.  

Sometimes medications (and we’re going to talk about these factors) – medications, health factors – can reverse some of the MCI that someone might be experiencing. But that’s why it’s really important to get diagnosed and properly treated, especially if there are reversable causes. That’s why it’s really, really helpful to know if you are experiencing MCI.  

So, we’re talking about umbrellas and continuums today, so if you are diagnosed with cognitive impairment (again that’s a that’s a diagnosis), we can start with all the way to unimpaired to mild (which means it doesn’t really interfere with activities of daily living), but then eventually it moves more toward impairment of daily living – that is when we get into more of the mild, moderate, and then of course severe dementia. So, the delineation between mild cognitive impairment and mild dementia is really about, how much does it interfere with activities of daily living? Does it become harder and harder to be able to do activities that one could do independently? So, that’s really the criteria that we think about when we’re considering whether someone has a diagnosis of mild MCI to mild dementia.  

So, MCI is a known risk factor for dementia. We talked about, about half of folks that have MCI will go on to develop dementia, so everyone who experiences dementia has MCI at some point, but for many people, and especially lawyers who have a lot of cognitive reserve, it’s not always clear when that passing through happens. So, sometimes people don’t even realize they have cognitive decline until it’s already a more significant impairment, right, but not everyone who has MCI goes on to have dementia. So, that’s interesting to remember, not everyone who has MCI goes on to have dementia and when you can prevent a new case of MCI at the beginning or properly diagnose it, you’re preventing essentially…more dementia.  

So, dementia, just like cognitive impairment, is a syndrome, an umbrella term, and it can range from mild to severe. It’s a collection of symptoms related to cognitive decline, a worsening of cognition, that can lead to problems in daily living. It’s biological changes in the brain. Alzheimer’s is the most common, about 60 to 80% of dementias are Alzheimer’s. But often people have a mixed dementia, where they may have Alzheimer’s and something called Lewy Bodies – different brain abnormalities that can create different structural problems in the brain. Mixed dementia is very prevalent and some are reversible and are not truly dementia, so that’s…why again, diagnosis and proper treatment is really, really important.  

So, this is from the Alzheimer’s Association, if you ever had a chance to look at their materials, they’ve got amazing materials. If you have a loved one who’s experiencing dementia, or you’re a caregiver, [it’s] really helpful. But if you look at statistics, it’s pretty startling, right, if you think about more than six million people live with Alzheimer’s, over 11 million people provide care to people with Alzheimer’s, one in three seniors dies with Alzheimer’s, it kills more than breast cancer and prostate cancer combined. And I really wasn’t aware of this – the risk factors for women (we’re going to talk about this in a bit) are much higher than for men. Women live longer which is one reason also. And again, thinking about how often people don’t get help, so four in ten Americans talk to their doctors right away when they have cognitive loss, so six out of ten don’t. But seven in ten would want to know early if it could allow for earlier treatment, so the idea of having treatment helps people…overcome some of their fears about Alzheimer’s, and there is a lot of treatment coming, and that is already here as well.  

Again, a little bit of statistics for Alzheimer’s disease, you can see that the projected number of people in the population with Alzheimer’s dementia is going to grow over time especially as our population ages, right, so we want to make sure that we’re doing all we can to prevent that. So, just a little bit of the statistics of Alzheimer’s, about six million people have Alzheimer’s, you know, women significantly more at risk than men – 12% of women over the age of 65, 9% of men. Non-hispanic Black and Hispanic older adults are disproportionately more likely than white older adults to have Alzheimer’s or dementias and these prevalences are true for men and women. We know that there are disparities in marginalization of Black and Hispanic people and ultimately these disparities, in terms of healthcare access, play a big role, along with socio and economic indicators. So, structural racism plays a role in these high numbers and the disparities between white, Black, and Hispanic populations.  

So, what is the difference between normal aging and cognitive decline? And many of you are here for this part, right, it’s like, ‘Well how do I know if, what I’m experiencing, is this normal or even subjective cognitive impairment versus true decline?’ So, I’m going to kind of go through these, of course this doesn’t capture all of them, but I want to kind of go through them and you can see the nuances between them.  

So, normal aging. In normal aging we’re talking about age 45 and older, right, but you know typically we start to see this accelerating a little bit more by age 60-65. So, sometimes forgetting names or appointments but remembering them later, versus memory that disrupts daily life. And remembering that piece: does this disrupt my daily activities of living? That’s really the question. Normal aging [is] making occasional errors when managing finances or forgetting to pay a bill, versus challenges in planning or solving problems like no longer [being] able to get online and pay a bill or do your taxes if you’ve already always done your taxes. Number three, occasionally needing help to use microwave settings record a TV show – I’m laughing because this happens to me all the time now, my kids will grab the remote when I’m trying to do something – versus difficulty completing familiar tasks that we just do over and over again. Getting confused about the day of the week but then figuring it out, versus confusion, true confusion, and insistence that it is Monday, when it’s not Monday. Vision changes related to cataracts or changes in glaucoma versus trouble understanding visuospatial information, getting lost, getting confused, not recognizing faces. Sometimes having trouble finding the right word or the name of somebody, versus problems in speaking or communicating. Misplacing things from time to time and then being able to retrace the steps and find the item, versus misplacing things and can’t retrace the steps, like, ‘I have no idea where I was.’ Making a bad decision or a mistake and neglecting to change the oil [in your car], versus really poor judgment – driving on an empty tank of gas or going out in the middle of the night when the weather conditions are really poor to get an item that you don’t need that day. Feeling uninterested, some signs of maybe depression, versus withdrawal from work or social activities. Developing very specific ways of doing things, getting kind of ritualized, and can be irritable if people are bugging you or [if there’s] too much noise, versus changes in mood and personality – you’re not the same person or people are saying to you, you know, ‘What’s wrong?’ You know, really recognizing a change in your mood and affect. So, this isn’t all-inclusive, but I hope you’re getting from these differences that it’s the extent, right, so you know, even if memory is involved in what we would say is normal aging versus decline, it’s how much does it disrupt, how much…do other people notice, right, and how much do you then need assistance in these areas that you used to be able to do independently. So, it’s the level of independence, the level of disruption.  

There are two types of mild cognitive impairment. Again, this is a diagnostic condition. One is amnestic MCI, which is more of a memory issue so the symptoms in mild cognitive impairment are primarily memory-oriented versus non-amnestic MCI where it’s more about problem-solving skills, judgment, visual perception. And these are slightly, these impact different parts of the brain, so when we’re thinking about what dementia might be present, most typically for Alzheimer’s dementia we see more of the amnestic MCI. We see in other types of dementia like vascular dementia for example, we’ll sometimes see more of the non-amnestic MCI. Now it’s not always cut and dry that way, but that does help us understand, where the deficits start can lead into what potential challenges the person might be experiencing.  

Again, a little bit of statistics. About 12 to 18% of people aged 16 and over are living with MCI. An estimated 10 to 15% living with MCI develop dementia each year and then one third of people living with MCI due to Alzheimer’s develop…full dementia within five years. Now here, these last two are really important for me as a psychologist and an educator: 42% of Americans say they worry about developing MCI due to Alzheimer’s and that makes sense, right, of course, especially if you’ve had a family member or a loved one that you’ve cared for, it can be very, very frightening. And more than 80% of Americans know little or are not familiar with mild cognitive impairment, so most people are afraid of Alzheimer’s disease but they don’t understand what mild cognitive impairment is or how it could be a preventative condition or could be a stable condition if treated.  

So, this slide’s a little bit confusing, but cognitive impairment can be caused by a variety of things, not just dementia. So, we start here, the big four, right: Alzheimer’s, Vascular Lewy body, Parkinson’s, and frontotemporal dementia. So, that’s one cause of cognitive impairment, but it also could be drug-induced, it also can be a result of delirium – delirium can happen because of a urinary tract infection for example. It can be caused by depression and psychiatric issues, it can be caused by medical issues…B12 deficiencies, renal issues, liver issues. It can also be caused by neurodegenerative issues, trauma, tumor, etc. So, if someone has cognitive impairment, it doesn’t give us a window into any of this, it just tells us that they are having impairment. So, diagnosis is key. 

What are some common conditions that affect brain health? So, heart disease, high blood pressure, diabetes…Alzheimer’s of course, stroke, TBI, depression, and sleep problems. Okay, so some of these we don’t have control over, and some of them we do.  

So, heart disease and high blood pressure. Really interesting research that’s come out in the past five years around…reducing the risk of Alzheimer’s disease by reducing high blood pressure and heart disease. [It] can make a big difference. Of course, people that have chronic heart disease and high blood pressure can have strokes, blood vessel changes, and that can be related to dementia, so reducing risk is controlling cholesterol and high blood pressure, exercising, eating healthy foods, quitting smoking, and limiting the use of alcohol. 

Hypertension. We already talked about this, but what they found [in] the research (this is like really hot-off-the-presses research); the association is stronger with the non-amnestic type of MCI. And that’s more similar to the blood vessel changes which is more of a vascular type of dementia. So, prevention and treatment of hypertension, really important in lowering the risk of cognitive Impairment. So, these are some of the things we would want to check out if we’re having some cognitive Issues.  

Medicines and the brain. So, medicines can affect brain health and geriatricians and prescribers are much more aware of this than they were a decade ago, right, that there are some medications prescribed on a long-term basis and it really depends on the length of time you’re on the medication and the age and the polypharmacy (what other medications are you taking at the same time). So, most of us have probably used one or more of these medications, right. Benadryl, or a sleep med like Ambien. And the problem is not the use of it, the singular use or the use for a discreet period of time, but it’s the chronic use. So, Ambien was used extensively, you know, a decade or more ago as a good sleep aid. It’s a great sleep aid, but what researchers found was that it actually could enhance or create more cognitive impairment especially in older adults. So, when we think about the medicines we’re taking, we want to think about taking them for shorter periods. Some of them we can’t – so if you’re on anti-convulsants or anti-seizure meds, it’s going to be important to be on the lowest dose possible to maintain health, right. So, any of these medications short-term are likely not as impactful as long-term use, and the age you are, and how many in combination you’re taking. So, if someone is taking two anti-anxiety medications, that can be a problem. I used to work in inpatient settings, where clients would be on two or three or four different combinations of anti-anxiety, anti-seizure and anti-depressants, and their cognition was understandably slowed.  

Diabetes, another big risk factor for dementia. So, it can damage blood vessels throughout the body, increase the risk for stroke, and it can increase the risk for memory problems. And this is uncontrolled, so again…we may not be able to control having diabetes, but we can control the diabetes once we have it, and that’s why it’s so important to have early treatment.  

Other lifestyle factors: smoking, excessive use of alcohol, poor diet, insufficient sleep, lack of physical activity, and little social activity. Now for lawyers, some of this is a challenge, right. We know especially for excessive use of alcohol, diet, insufficient sleep and lack of physical activity, you know, if you’re working many, many hours, it can be really difficult to be able to incorporate healthy lifestyle activities. Interestingly, smoking of course, this is an ongoing area of research, but even regardless of other issues like hypertension and diabetes, cigarette smoking…is associated with worse cognitive impairment for people 60 and older, so another good reason to not smoke.  

Alcohol: slow or impaired communication among brain cells even with moderate use. And here’s the thing…doctors have really changed what [is considered] moderate use. Moderate use used to be maybe two to three drinks for men and one to two for women and now it’s actually much lower. So, women, moderate use is considered one or more and men, it’s two or more drinks. So, depending on metabolism, alcohol, even small amounts, on a daily basis can impact brain health. Of course, some of these things can happen with overuse, but even just chronic regular use can impact…brain health.  

Other reversible factors: Depression, sleep issues, fibroid problems, and vitamin deficiencies. Really important. And depression and anxiety and stress are big ones. I mean, I see this a lot when people are coming to LCL and asking to meet with one of the clinicians because they’re worried about mental health and cognition. You know, often that’s one of the things we can really look at, and if we can treat the depression, we can often see that some of the cognitive symptoms decrease, and if they don’t decrease that gives us a good indication that further testing for a cognitive impairment has to happen. So, depression, feelings of sadness, loss of interest. Not a normal part of aging, so it’s much more than, you know, what would be expected. Some medicines can cause depression, and sometimes depression, inattention, distractibility, grief, and loss can look like dementia, right, so that’s why we always want to treat it with traditional, you know, psychotherapy, sometimes medication, and see if we can ameliorate the depression, and see if some of the confusion and inattention gets better.  

Sleep apnea, another risk factor for problems later on with brain health, can lead to a higher level of blood pressure, can create more risk factors for stroke. And again, lifestyle kind of fits into what can cause sleep apnea; excessive weight, alcohol use, and smoking. So, Amy shared earlier we’re going to have some further webinars about reducing the risk, but healthy lifestyle choices – it’s not too late. You know, regular exercise is such a protective factor. I was just reading the most recent research – the New York Times has all these, you know, New Year’s informational pieces – and if doctors could recommend one thing to prevent cognitive decline, it’s exercise. So, no matter what else, we’ve got to really work on our exercise.  

And again, high blood pressure, reducing high blood pressure. New clinical trials have shown a significant reduction in the risk of developing mild cognitive impairment by treating high blood pressure. So, these are things that are doable for us, right.  

Alright, so what do we do if we are worried that we are experiencing cognitive decline, that subjective cognitive decline isn’t going away, and we want to know what to do? So, as I said before, it’s a diagnosis, so we want to get diagnosed properly, right, and then we can see what we’re actually working with. So, what’s the benefit of getting, you know, diagnosed? Well one, there could be a readily treatable cause – some of the degenerative dementias, even if someone does develop dementia, has symptoms, [there are] symptomatic pharmacotherapies, which means there’s medications to decrease the symptoms. There are new clinical breakthroughs, we’re going to talk about that in a moment, that are slowing down the progression of cognitive impairment. People want to know what they’re dealing with, right, and family members need to know. [Diagnosis] can help with long-term planning, research efforts, helps with advocacy, and for lawyers it can help save your career, right – we’ll talk about that too at the end.  

So, a full medical workup starts with your primary care doing a good history to look at risk factors, family history, looking at daily living activities. Like we were saying earlier, the biggest difference between mild cognitive impairment and dementia is the level of activities of daily living – if someone’s independent versus someone’s needing more and more assistance. So, we want to do an assessment. Sometimes this can be done by a physician, sometimes an occupational therapist or a neuropsychologist. Input from a family member or a trusted friend – that is really really important, because we’re not always aware ourselves of cognitive deficits, depending on where the deficits are, but often our family members and friends notice. And then we can move from primary care to a neurologist. So, typically, the primary care would be the first person, and then they may refer to a neurologist who would do a more full evaluation, potentially ordering imaging and blood tests as well. So, that’s kind of the core work of PCP evaluation; if there are some soft findings…and you know, ruling out out some of those other conditions like vitamin deficiencies, depression, etc.– and then a referral to a neurologist. So, cognitive screenings are helpful as a brief, kind of quick (we used to call it in our graduate school training, ‘a quick and dirty way’) to figure out if someone’s having some issues.  

Now, here’s the thing – lawyers are really a very very smart bunch, with a lot of intellectual capacity and cognitive reserve. So, what I have seen in my years of experience…the more a person has intellectual and cognitive reserve, the better they do on screenings, and even if someone does very well on a screening, that doesn’t mean they don’t have cognitive impairment. So, these are two common ones – the MoCA and the Mini-Mental Exam – and sometimes physicians or neurologists will give these, and even if you do fine on them, that doesn’t mean you may not still be experiencing some cognitive decline. So, they’re a brief kind of screen. A depression screening – this is called the geriatric depression scale or GDS – very simple, asking yes/no questions, and this helps, for clinicians and primary care providers, to see if there is a potential depression that is in the mix here that we’d want to look at and see if we need to treat, right, rather than, again, assuming that it is going to lead to a dementia. And some people have both, right. If someone has mild cognitive impairment and they are afraid, of course that could lead to some depression as well. So, it doesn’t mean that just because you have depression, you don’t have cognitive impairment, but it’s one of those things that we want to look at.  

So, neuropsychological testing is a full battery of tests, much more extensive than those screening measures that I showed you earlier. And why would you go for neuropsych testing? Well, if the work up from the neurologist and PCP is not clear, the doctor might want to have neuropsych testing done, especially for younger people under the age of 65 where it’s more unusual to have cognitive impairment, we want to see if, you know, to maybe do a full battery. Some of the screenings don’t always capture some of the deficits, and sometimes it’s helpful to get what we call baseline testing. So, with someone we do suspect has mild cognitive impairment, it’s going to be very helpful to be able to track if they are staying the same, getting worse, if they’re getting treatment, how does the treatment impact them? So, let’s say for example, someone gets diagnosed with mild cognitive impairment based on the testing that was done by the neuropsych and their physician, and then they get a medication, they make lifestyle changes. We might retest them in two years and see if what they have done has helped, right. And this also can help figure out what kind of treatment and strategies they may need. So, neuropsych testing helps us with… what kind of diagnosis, what potential progression might be happening, predicts when mild cognitive impairment might change to dementia… what the function level of the person is, treatment recommendations, competency – right, so, we’re thinking about ethics and competency to practice – and then research. These are all benefits of doing neuropsych testing. I don’t want to get too deep into this but basically when we do neuropsych testing, we’re comparing a person to norms or data that we expect. So, we’re not comparing a 65-year-old – let’s say you’re 65, and you’re getting a neuropsych eval, we’re not comparing your testing to a 20-year-old. We’re comparing your testing to a normal population, same age, right. And typically, the norms are based on age and education. And we’re looking at things like attention and concentration, sensory perception and psychomotor functioning, processing speed, language skills, visuospatial and constructional skills, learning and memory, IQ or intellectual achievement, executive functioning and personality testing.  

So, there’s a lot in an evaluation. A typical neuropsych assessment takes anywhere from like four to six hours. Some can be done you know, more, screenings, would be maybe a 2 hour, but typically neuropsychs are at least four hours. So, there are different kinds, right, there are manualized, where there’s a standard protocol and we’re also comparing them to data, and sometimes it’s more based on clinical interview, right, so typically if we’re going to be doing a neuropsych battery we do manualized procedures plus good clinical observations and clinical interviewing. And again, we’re comparing data to norms. So, if you’re going to have a neuropsych assessment, first it’s a record review, looking at your past medical record, assessments, imaging. And then clinical interview, which is really helpful to just hear from the person, observe, see about the history, looking at all those lifestyle factors. Family history can be really helpful, substance use. And then the actual testing. There’s different kinds of testing – again, about four to six hours – you try to tailor the testing to cover really what the person is needing assistance with.  

Overall, the testing produces recommendations. And it could be that the person’s needing more supervision, they may need more help to handle finances, there may be some safety or risk issues, they may make recommendations on using compensatory devices, right, so using different applications for the phone, or pen and pencil memory cues, accommodations, diet, sleep, exercise, which we’ve been talking about, and then psychotherapy. So, these are some of the recommendations that come out of the neuropsych eval.  

All right, so when we’re thinking about diagnosing – the screening measures, the neurology evaluation, the neuropsych testing. But now, lab work like blood work and imaging can shed light on a diagnosis. It used to be, especially with Alzheimer’s disease, that we could not diagnose someone with Alzheimer’s disease until they died – until there was literally a brain autopsy. That was the only way where pathologists could look at the actual brain and see the changes in the brain itself. Fortunately, there are huge advances over the last 10 or so years, where the diagnosis is clearer and clearer, earlier and earlier on. So, Alzheimer’s Association has lots of really good information, but essentially now it’s a totally different way of diagnosing. So, a typical diagnostic kind of picture would include brain imaging, usually MRIs, looking at blood and other fluids like cerebral spinal fluid. Spinal taps, right, can look at some of the tau proteins, some of the proteins in the in the cerebral spinal fluid that’s in the brain and the spinal cord. And then emerging genetic markers, right, so now [there are] a lot more ways to diagnose earlier and more effectively.  

So, there are blood tests, but they’re not out yet. There’s a race to find them, right, because they’re easiest, right, to be able to really detect if someone is developing an Alzheimer’s or other kind of dementia. So, this is coming within a short amount of time, and there are already some early blood tests that are being trialed.  

So, tau tangles and plaques. These you’re probably familiar with hearing about, but research shows that there’s a particular form of tau protein that is very specific to Alzheimer’s and can be measured in the blood, right, so this is where we’re moving toward in terms of blood work and blood tests. And these biomarkers can help differentiate Alzheimer’s from other types of dementia, diagnose the stage of disease, identify people appropriate for clinical trials, and show changes 20 years before dementia symptoms arise. Now there are all sorts of ethical issues of whether we want to know 20 years before we might emerge with the diagnosis, but remember how I said earlier on that if we know that there’s treatment, 7 out of 10 (70%) of us are willing to get tested, if we knew that there was treatment. It’s the fear that there’s no treatment that creates, I think, that resistance for many of us, myself included, right. So, blood tests are the wave of the future and are coming very soon. 

So, what are barriers? Why are we not getting tested, why are we afraid, what’s happening? So, basically most people are reluctant, we’re fearful, to see our doctor – especially with cognitive issues – and we wait until the symptoms are more noticeable. Again, these statistics: 4 in 10 Americans, only 4 in 10, would talk to their doctor right away if they were experiencing symptoms of MCI. And physicians aren’t great at this either, right. So, primary care physicians don’t often ask clients – patients. They, 97%, wait until the patient shares it, or the family member, right, so we’re sort of in this breakdown.  

People are fearful to talk to their doctors, and doctors don’t feel equipped to talk to patients, right. And how, especially now we’re in this era where treatments are available, so it’s really important to be able to have this discussion. This is exacerbated for certain racial and ethnic groups, so Black and Hispanic populations have higher rates of prevalence rates of dementia, but they’re also less likely to get a timely diagnosis and are likely to have more unmet needs, higher caregiving demands, and spend a higher share of family assets on dementia care. So, this is a big problem, right. So, that’s why awareness and getting folks properly treated earlier on is the name of the game. 

So, here’s kind of this journey. So, if you’re experiencing cognitive issues… this is the ideal scenario, right, this is where we’re going to be going hopefully in the next decade or so. And some of us have this available now. Especially in Massachusetts which, I’ll talk about in a little while, in the Boston area for example, we have this ability to kind of take this patient journey to get best evidence-based care. So, we have cognition issues, a person experiences memory and thinking problems, they talk to their primary care doctor in this medicare annual wellness visit, right. This is the ideal scenario: they talk to their PCP, PCP starts to do some testing… If they notice that there might be mild cognitive impairment, they refer to a dementia specialist which could be a geriatrician, a neurologic or geriatric psychiatrist, or a neuropsychologist. If the evaluation confirms mild cognitive impairment, then there’s biomarker testing, brain imaging, right. And then if the testing shows beta amyloid accumulation, the imaging is showing changes in the structure of the brain, that’s when treatment options can be discussed, right. And then, potentially going to treatment centers where they’re… enrolling them in clinical trials. So, this is the ideal scenario, right. And as we heard earlier, marginalized folks are not getting even this introduction early on, and many other people are afraid to go to their primary care doctor, so this whole chain can’t even begin.  

So, memory disorder clinics – that was where I started my training – have been around since the 1980s and they’re this very helpful worldwide vehicle to improve the care for dementia and neurological issues, because it’s a group of people with different disciplinary backgrounds (neurologists, psychiatrists, neuropsychs, RNs) that are specially trained in diagnosing memory issues. And so often these clinics have state-of-the-art clinical trials that are being run through them, or they can refer people to state-of-the-art facilities to get treatment. There are 11 – I was just looking to see what was the number in the Massachusetts area – 11 different memory clinics, and there may even be more, that you can get kind of one-stop shopping, which is really helpful when you’re overwhelmed and afraid, to be able to have a clinic kind of usher you through the different stages and steps. So, this is always my go-to when I’m working with clients who are really afraid, to be able to get properly diagnosed and then get treatment.

So, what are the treatments for cognitive impairment? So, the FDA has approved seven drugs for Alzheimer’s disease and five of these drugs – these are, these have been around, some of them, since the 1990s – have been really aimed at improving symptoms. So, improving symptoms by increasing the chemicals neurotransmitters in the brain to help the brain maximize its functioning. So, it doesn’t stop the progression, but it can improve some of the symptoms and essentially slow some of the impact on a daily basis.

But here’s the exciting breakthroughs. Many of you are probably familiar, there were two new FDA-approved drugs that are aimed at not just improving the symptoms, but changing the underlying biology of the disease, removing the beta amyloid from the brain and slowing the [progression] down in people, especially in early Alzheimer’s. And that’s where the research is right now. So, people that have MCI, which is what we’re talking about today, mild dementia, especially [since] half of those that are going to go on to develop Alzheimer’s disease, are going to potentially benefit from these new medications. And they’re available… I have folks that are already receiving some of these or are in the trials to, in the process of getting referred, so, that’s pretty exciting.

We’re going to be seeing radical shifts in the next decade, because, of course, there’s ongoing research. I thought was this was pretty helpful to think about – this is as of 2021, so this is three years ago now – phase one, there were 129 trials, phase 2 191, and phase 3, 62. So, this is getting closer to actually being… able to be used, so hopefully in the next decade we’re going to see many, many more medications coming.

All right, I want to go back to our lawyers part, right. This is, I know we only have a few minutes left, but I want to really focus on this part here. So, what are signs of cognitive decline in lawyers? Increasing memory loss, forgetting appointments, losing a train of thought in the middle of conversation, dodging questions about dates and events, telling tangentially related stories, failure to use technology, forgetting how to use technology, forgetting deadlines, hearings or important dates, missing dates or meetings or calls despite them being on the calendar, a decline in a lawyer’s writing or oral arguments and abilities. And then more of the like, living skills: arriving late or coming to work at odd hours, appearing disheveled, forgetting people’s names, irritability, changes in mood, falling (so motor issues), rapid weight loss or gain, more impulsivity (and this relates to more of the frontal lobe issues), overwhelmed by making decisions or understanding instructions.

Many lawyers are resistant. Not all. Many, many lawyers are willing to start to think about closing down their practice. But lawyers’ identities are so tied with their title, their position, their profession, and we’re going to talk about this much more in the in the next two panels over the next couple months, but being a lawyer is someone’s identity. It could be very scary to walk away. Many people are in denial if they’re having cognition issues, or they may not be aware because of the cognition issues, or they think that they can continue to practice. And then finally, the financial need. It could be devastating to close up a practice, and so sometimes we ignore cognitive decline until it’s too late, right, and then it can lead to ethics or malpractice issues. So, there are real genuine reasons why people are afraid to get diagnosed and treated.

All right, so we’re going to talk about this more extensively, but I wanted to end with this idea that noticing cognitive decline in colleagues is super tricky. It’s really uncomfortable. It’s sensitive. It’s easier if someone had a substance use problem, right, because we know, okay, if we get them help the problem will probably improve. But in this case, it could mean, it could end someone’s career, right. So, it’s important to consider how difficult it is and also how important it is. It’s really helpful not to scare someone with, ‘I think you have Alzheimer’s disease,’ right, but to begin to observe and maybe point out what are the changes you’re noticing in someone’s performance. Better to approach someone before it becomes a malpractice issue, of course.

So, we start with just helping someone get into their doctor. You know, we talked about, getting into the PCP is the beginning and often that can open the door to those other treatments that we talked about in that continuum. When someone has a diagnosis, it can help the person better organize, right, so the diagnosis helps to inform decision-making. Early diagnosis helps the attorney to really participate in succession planning, rather than waiting until, you know, someone else has to step in and intervene.

Limiting or starting to shut down the practice is really important once someone has a formal diagnosis. So, helping a colleague to do that, stepping in when they have a diagnosis, is really important. All right, so, I’m going to stop sharing here because that’s a lot of information. I know we have some questions. So, I know we don’t have a lot of time, but Amy, do you want to jump in, I know you’ve been looking at chat and stuff?  

 

AMY:

Yes… I mean, this was incredibly thorough. Hopefully it will give some folks some relief, and then some folks that say, ‘You know what…let me go to a doctor, let me get it checked out.’ So, I’m going to jump right into comments and questions: ‘Are women more likely than men to have cognitive decline due to menopause?’  

 

TRACEY:  

That’s a great question. There are – certainly the changes in estrogen can lead to some cognitive issues, but not necessarily MCI (mild cognitive decline). The study showing that women are more highly diagnosed with Alzheimer’s disease, have higher prevalence, is related to a couple of different factors. One, women live longer, so more women are over age 65. And also, some of the (especially in the 20th century) limitations in education and job opportunities and ways that are protective factors, can also impact the higher level of women getting Alzheimer’s. We’ll probably see a shift in that over the next several decades. But so, the answer is temporarily, changes in estrogen can affect cognitive functioning. But we’re not seeing it causing Alzheimer’s disease or some of the serious dementias.  

 

AMY:  

Next, thank you so much that was, again, so helpful. ‘I hope you will differentiate or mention the difference between developing MCI and increasing symptoms of ADHD, which can seem to – which can seem or feel the same, but the latter is not often diagnosed until adulthood, as when our instinctive coping skills become less effective, and the latter can be addressed with treatment, meds, and the development of new coping skills.’ And the person writes, ‘I don’t know if other MCI you just mentioned will cover this.’  

 

TRACEY:

Yeah, I mean, that’s the important thing about getting testing, and that’s why I love neuropsychological testing because it can actually look at things like Attention Deficit Disorder versus a true memory disorder. The testing is really sensitive to look at those different cognitive domains. And so if we see a pattern where it’s more attentionally based and memory skills are strong, we can do that rule out. Because subjectively, it may feel the same, right… If we’re having trouble paying attention, it can feel like it’s a memory issue, because we’re not getting the information in. So, a good differential diagnosis starts with an assessment.  

 

AMY:  

Yeah, excellent. Next is, ‘I heard that even seeking a baseline can impact health insurance costs. Is this true?’ This person’s grandmother had Alzheimer’s so she would like to have a baseline.  

 

TRACEY:

I don’t know, that’s a really good question. I haven’t heard that, but I actually don’t know, I mean, I think it would depend on… if your insurance had pre-existing conditions and if that would carry through. I mean, I think it’s super helpful to have baseline testing, not just for Alzheimer’s but to look at attention and concentration, to look at depression, some of those other things, so if especially if you have some concerns or there’s a family history risk, it’s a great idea, but I don’t know the answer to that.  

 

AMY:  

Yeah. Okay, next person asks: ‘Are there self-assessment tests which can be used for identifying MCI?’  

 

TRACEY:  

There are. There are a lot of self-assessment tests. I would say, how do I want to say this. Be really cautious. Because we can really scare ourselves. I’ve seen more people… that you know, that can scare themselves when they do self-report questionnaires, so I’m hesitant to say it’s the go-to, because we get a lot of false positives. So, I would talk to a professional. You know, come see one of us at LCL, come talk to your PCP. You can take a self [eval] – I mean, you can find them out there, but none are… That really falls into the subjective cognitive impairment realm, and like we talked about earlier that’s not a diagnosis. And so, what it means is, you’ll subjectively find out what you are already kind of experiencing. That, ‘I may I feel like I’m not functioning as well.’ So, it’s not a bad thing to do, but… it may create anxiety, and it may not give you an answer.  

 

AMY:  

Another barrier is that if a doctor’s office does not notice that a missed appointment might happen because of decreased cognition, then treatment is delayed.  

 

TRACEY:  

Really excellent point, right, so, [there’s] a missed appointment, right, and then the person doesn’t get seen for six or eight or nine months or more, or they haven’t seen their PCP in years. And that’s what happens to people, right. That’s… a really, really good point to make, how important it is to reinforce in all of us about going to our PCP appointments and not neglecting that. Because you’re right, a missed appointment absolutely could be a sign of cognitive impairment.  

 

AMY:  

Excellent, next question, ‘Is transcranial magnetic stimulation a treatment modality for MCI? Some of the providers market it as a focus or performance enhancer.’ 

 

TRACEY:  

Oh, good question, I don’t know. I mean, TMS is used widely for depression, and some for folks. I haven’t heard it used and I don’t think it’s being used traditionally in that way. What I would say is, it’s going to be really critical to do, again, a good clinical evaluation, because you wouldn’t want to do utilize a treatment like that if the person wasn’t properly diagnosed. So yeah, I haven’t heard it used for true cognitive impairment, no.  

 

AMY:  

Okay, and, ‘Why does depression and depression medications cause memory loss?’  

 

TRACEY:  

Yeah so – good question. Depression doesn’t necessarily cause memory loss, but the manifestations of depression can look like cognitive impairment; slowness in thinking, low energy, difficulty remembering and concentrating, difficulty focusing… The symptoms are similar. Also, we’re talking about the brain, and we’re talking about neurotransmitters in the brain. Depression is linked to decreased serotonin in the brain, and so with decreased serotonin we’re going to see less effective thinking and problem solving. The good news about depression is that it’s treatable, and often with anti-depressant treatment and other treatments like TMS, psychotherapy, we can essentially restore our brain’s chemistry to its normal functioning, and we see an improvement in symptoms. 

Some anti-depressant medication especially the older medications – like all of those medications I showed you in the presentation – overuse, chronic use, can affect the overall brain chemistry. The newer medications like Prozac, the SSRIs, Lexapro, don’t have that effect, so just to let you all know that. 

 

AMY:  

Sorry, these are rapid fire questions. There are so many… ‘Any connection between cannabis use and cognitive issues?’  

 

TRACEY:  

Yeah, there’s some early research coming out. And so you know, just – I think about cannabis as sort of a wild child. We don’t know, and now… we’ll know over the next several decades. There’s been studies showing some cognitive impairment in adolescents and teenagers with early use, later on, so we’re not sure. So, the issue, the answer, is preliminarily there is some impact, but we’re going to know more as cannabis has been legalized. We’re going to have more data and clinical trials. So, that’s a cautionary tale, right, just like tobacco was generations ago. It’s sort of like, we want to use moderation and be thoughtful about what we’re putting in our bodies, because anything that affects the brain chemistry, on a long-term basis, potentially could have an impact on cognition. And I worked in inpatient psychiatry for years, and patients that have been on multiple medications and substances over the years, their brains did not work as well as people that didn’t… So, it’s just important to, you know, to kind of think about [how] what we’re putting in is going to have some kind of impact.  

 

AMY:  

Excellent, and I know we’re just a minute over time. One more question where somebody says, ‘Great presentation, very practical and the whole process of diagnosis seems complex and overwhelming… Seems like it would discourage a lot of people. How can we help someone navigate this crucial part of the process?’  

 

TRACEY:  

Beautiful question. I agree, I agree with you. So, getting someone into the PCP and telling the primary care that they have some cognitive issues, that’s really the baseline. That, or, to find a memory disorder clinic in your area. Or ask your PCP, ‘Can you refer me to a… memory disorder clinic?’ Those are the simplest. I love memory disorder clinics because they streamline the process. You do an intake, they ask you questions, they do some of this preliminary screening work that we’re talking about today. And that simplifies it. Because you’re right, it can feel really complicated. But starting with your primary care doctor, and asking them what, you know, what resources they have available – that to me is the best starting place.  

 

AMY:  

Excellent. One other comment: ‘Cannabis is now much stronger and more potent than before.’  

 

TRACEY:  

Yeah, yeah, that’s the thing – we just don’t know. And so any chemical, whether it’s cannabis, antidepressant medication, sleep medications, any chemical that impacts the brain can impact our cognition. And how much? You know, we don’t know that yet.  

 

AMY:  

And another comment, ‘The presentation was incredible.’ I second that, thank you so much. And it looks like that is it for our questions. This has been extremely helpful, hopefully people got a lot out of it, I did put in the chat, hopefully people saw, some websites for the Alzheimer’s organization, a phone number that’s open 24 hours 7 days a week if you do have any urgent calls. We will also be sending out the presentation, the PowerPoint presentation for your references and this will also be posted on our website in a few days. 

 

TRACEY:  

Awesome, and I know we didn’t talk extensively about lawyer-specific issues and that’s why we really wanted to give you the overview today, and then talk more specifically with our panel next month. So, we’re excited for you to join us for that.  

 

AMY:  

Well, thank you again, this was truly, truly wonderful. Very informative and people are just saying, ‘Thank you,’ and again, ‘Wonderful presentation.’ So, thank you, Tracy. We are out of time so please people, stay tuned for our continuous coverage of this topic.  

 

TRACEY:  

Great, thanks.  

 

AMY:  

All right, thanks. Bye.