Clik here to view.
It’s no secret that the population of the United States is aging. The population of the United States over the age of 65 is expected to double from 46 million individuals currently to 98 million by 2060, and the number of individuals over the age of 85 is expected to triple during that same time frame.1 But, you don’t need to review statistics to see that the population is aging; you can simply glance at the clients in your reception area to notice the shift. Most older Americans are living longer with fewer health concerns and fewer disabilities than generations before. However, while heart disease-related deaths in the United States have declined by 9% between 2007 and 2017, deaths from dementia-related illnesses have increased 145%, and dementia becomes more prevalent with age. Studies show that dementia affects 5% of Americans between the ages of 71 and 79, but the occurrence increases to 37.4% of Americans over the age of 90.2 Professionals who haven’t already been affected in their practice by dementia are almost guaranteed to encounter clients with dementia in the next few years. Dementia comes at great cost as well. In 2019, it’s estimated that the cost of dementia in the United States will exceed $290 billion. The average cost of care for a dementia patient over his lifetime is more than $350,000.3
Ten Signs
As a professional advisor, being aware of the signs and symptoms of dementia is critical for a number of reasons. The Alzheimer’s Association has provided 10 signs of dementia that have become standard considerations.
Memory loss. Signs of dementia that may not be readily apparent to an advisor or professional who doesn’t have regular contact with a client include things like memory loss that disrupts daily life. Memory loss in this context is more than simply forgetting a name or an appointment and instead includes forgetting recently learned information, important dates or events or repeatedly asking for the same information. Often, it’s a spouse or other close friend who recognizes the memory loss because the loss wouldn’t necessarily be apparent to a casual acquaintance.
Planning challenges. Another symptom of a decline in cognition is displaying challenges in planning or problem solving. Examples include challenges in balancing a checkbook or coordinating a get together of friends. It isn’t uncommon for an individual with dementia to get lost while driving in familiar locations. While perhaps not immediately obvious to a professional, a client with dementia may find making decisions about investments difficult when making those decisions in the past had been easy, or the client may be unable to determine whom he would like to name as agents in various estate-planning documents when in the past, he would have made such a decision swiftly.
In addition, a client with dementia may have difficulty completing familiar tasks at home or work such as sending and saving an email or balancing a checkbook. A closely related symptom is misplacing objects. Not to be confused with simply forgetting one’s keys, misplacement is often characterized by placing items in an inappropriate location such as finding one’s keys in the freezer instead of on the counter or in a purse.
Visual impairment. Yet another unusual symptom that may not be apparent to a casual observer is vision impairment and difficulty contemplating visual images or spatial relationships. Vision often changes with age; however, the added challenge with a spatial relationship is common with dementia. Many outside observers may simply believe the individual is becoming clumsy. The individual with dementia may trip over curbs or area rugs or may perceive dark parts of carpet and a transition in pattern to be holes.4
Withdrawal from social activities. Withdrawal from social activities or settings is also a common early sign of dementia that can be difficult to observe. A client in early stages of dementia may no longer choose to participate in activities that he once enjoyed. This is often a result of the client finding it difficult to follow conversations or engage in activities requiring planning or critical thinking, such as playing cards with friends. This too is incredibly difficult to ascertain because it’s not unusual for an individual to choose not to participate due to being tired or otherwise unavailable. It’s hard to distinguish that individual from someone who chooses to skip activities because of changes in cognition.
Confusion with time or place. While a number of signs of dementia may be observed by friends and family members having regular interaction with the individual, different signs may be more apparent to a professional advisor who knows the individual but doesn’t see him on a daily basis. For example, a sign of dementia is confusion with time or place, such as believing appointments are on different days or confusing an appointment with a financial advisor with an appointment at an attorney’s office. Family members may not notice this small mix up, but advisors and staff will be aware of missed appointments or a client showing up for appointments on the wrong day.
Problems with words. New problems with words in speaking or writing are also a common sign of dementia. A professional may notice a client having difficulty following a conversation or finding the right word for an object or event. Instead of using an adjective or term, the individual may instead describe the item to which he’s referring.5
Decline in judgment. Professional advisors, particularly those who’ve worked with clients for many years, may be the first to notice a decline in judgment on their client’s part. Decreased or poor judgment is one of the most difficult symptoms of dementia to detect but is often one of the most unfortunate and disastrous. Decreased judgment often leads individuals to take action such as gifting sums of money when they otherwise wouldn’t do so or wiring money overseas to pay taxes on purported lottery winnings. This lack of judgment related to the early stages of dementia is what leads to many older adults becoming victims of fraud or abuse. A recent study from Rush University in Chicago analyzed whether decreased awareness of scams was an early indicator of dementia. The study included more than 900 seniors in their 70s and 80s and their ability to detect scams and fraud. Researchers then examined whether there was a link between susceptibility/awareness of scams and fraud to Alzheimer’s disease or other cognitive impairment. The seniors studied had no obvious signs of dementia or impairment at the outset. Of those studied, more than 400 later were diagnosed with Alzheimer’s disease or cognitive impairment.6 Impaired judgment is incredibly difficult to ascertain because the individuals appear to be completely capable of acting on their own behalf, and they take action without appearing confused or forgetful.
Changes in mood. These changes are a result of the loss of neurons, thus changing the basic brain structure. An individual with dementia may become easily upset, afraid, depressed or fearful, even when in a familiar setting. Common symptoms occurring in early stages of dementia are irritation and anxiety. Don’t confuse personality changes resulting from dementia with occasional irritation or a bad mood. To be signs of dementia, these changes would be manifested as regular occurrences for six months or more.7 In addition, individuals with dementia are often at risk of depression and should be evaluated if mood and personality are concerning.
Decline in executive function. Many of these symptoms can be considered to be changes or decline in executive function. Executive function is the group of skills needed to control and coordinate all cognitive ability and behavior. Executive function includes both organizational skills and regulatory skills, both of which are required to make sound, well-reasoned, decisions.8 When executive function is compromised or decreased, the resulting action or decision may be flawed.
Lesser known symptoms. In addition to the common signs of early dementia, there are some less well-known symptoms or indicators. A study from Massachusetts General Hospital in Boston found a link between failing sense of smell, or at least the inability to identify certain smells, and dementia. While the exact link isn’t clear, there’s a link between sleep disorders and dementia. For quite some time, it was assumed that dementia caused a sleep disorder; however, some now believe that sleep disorders are a risk factor for dementia. Finally, frequent falling is also a lesser known sign of dementia.9
Importance of Recognizing Dementia
Why is it that you should be concerned about recognizing dementia in a client? The answer is multifaceted. First, you typically care about your clients and don’t want to see harm come to them. If you notice early symptoms of dementia, you can be instrumental in assuring the client is protected. As alluded to above, an individual who may have no noticeable signs of impairment may easily fall victim to elder fraud or abuse. You may be able to prevent exploitation by alerting an appropriate individual of unusual activity, such as withdrawing large sums of money from an investment account or changing beneficiaries. One woman began online dating after her husband of almost 50 years died. She believed a man she met online, whom she later communicated with by telephone, was going to assist her with investing. Over a period of approximately one year, she wired almost $1 million to him. It was later discovered that the funds were being transferred to accounts overseas, and her new love interest was actually a 33-year-old scammer living in Texas. She had a financial advisor but she didn’t have a close relationship with him, so he was unable to stop her from wiring almost $873,000 in one day.10
Another reason to be aware of signs of dementia and impaired judgment is related to liability. Ultimately, you work at the discretion of the client. However, if a client directs an action that’s inappropriate due to an inability to ascertain risk, to what extent are you responsible? That question has yet to be answered by the courts, but some larger organizations are taking steps to develop procedures and policies for such an occurrence.
Attorneys’ Responsibilities
Attorneys are required to maintain a normal attorney-client relationship with a client with diminished capacity but, under Model Rule of Professional Conduct 1.14:
When the lawyer reasonably believes that the client has diminished capacity, is at risk of substantial physical, financial or other harm unless action is taken and cannot adequately act in the client’s own interest, the lawyer may take reasonably necessary protective action, including consulting with individuals or entities that have the ability to take action to protect the client and, in appropriate cases, seeking the appointment of a guardian ad litem, conservator or guardian.
In addition, attorneys have a duty to ensure that clients truly understand the nature and consequence of the legal documents that they may execute and may be admonished or disciplined for not appropriately assessing a client’s cognitive ability. One New York court admonished an attorney for meeting with a client for just a few minutes in a cramped office to execute a will and for failing to take even minimal steps to determine the size of the client’s estate, her family and social history and medical condition.11 Similarly, attorneys who fail to assess capacity are often witnesses in undue influence or lack of capacity cases challenging the validity of documents. Each attorney witness is most certainly contacting her malpractice carrier on notification of such events.
Employee Dementia
In addition to noticing signs of dementia in your clients, you should be vigilant for signs of dementia within your own office. If employees are exhibiting symptoms of dementia in the office, you need to take steps to ensure protection of the employee as well as clients. Such symptoms may include missing deadlines when timeliness has never before been an issue or failing to remember assignments. As an employer, you want to be sure to document such problems and communicate with the employee regarding the concerns. If there’s no improvement or change, then you’ll need to assess whether the employee should remain in his current position. While you should be careful not to ask about health conditions, you may address any condition that the employee has disclosed. If the employee hasn’t made any such disclosure, then you should gently express concerns about, and provide examples of, poor workplace performance. If an employee has openly communicated about cognitive impairment, then you should make reasonable accommodations for the employee as required by the Americans with Disabilities Act. Accommodations may be as simple as flexible working hours or software that provides adequate reminders and cues.12 One individual started using her Amazon Echo to remind her of appointments and deadlines.
Establish Procedure
Given the likelihood of encountering a client with dementia, it’s wise to develop processes and procedures now for how your relationship with the client will continue. Many industries have standards of confidentiality and prohibit professionals from sharing information with anyone other than the client. Therefore, given such professional restraints, it’s wise to speak with clients about with whom information can be shared in the event of a noticed decline. Encouraging clients to have up-to-date estate plans and to provide you and all professional advisors with a copy is also critical. In 2018, the Financial Industry Regulatory Authority (FINRA) released rules requiring firms to obtain contact information for a trusted person to be notified in the event that there’s concern about abuse, exploitation or neglect. In addition, FINRA allows members to freeze accounts if there’s reasonable belief of financial exploitation or neglect.13 Have clients identify a trusted contact and develop a procedure for how and when the client’s trusted contact should be approached. You may also wish to develop a checklist of warning signs, which, if exhibited, warrant a call to a trusted contact person or otherwise appointed agent. Similarly, there may be a checklist of transactions which, if requested, would trigger contact, an account freeze, a waiting period or even a request for a cognitive assessment.
If you believe that a client may have a cognitive impairment now, and you’re concerned about working with him, have a meeting to discuss your concerns and discuss how you can assist the client in accordance with his wishes. Listen to the client’s comments and get his participation in developing the plan. Cognitive impairment doesn’t mean the client is incompetent or otherwise unable to make decisions. You may need to alter your communication style to give the client the time to consider one issue at a time rather than overwhelming him with many questions at once. For example, you may wish to address the subject of financial power of attorney and agents at one meeting and leave discussion about trustees and health care agents to another meeting.
Cognitive Assessment
If you aren’t certain about a client’s cognitive ability, you may want to consider testing him. In some professions, the request for a cognitive assessment isn’t unusual. For example, attorneys will often request cognitive assessments if making changes to a client’s longstanding estate plan, particularly if the plan reduces or enlarges an individual’s inheritance. For some, the request for a cognitive assessment would result in termination of the advisor. For those professions (and clients), you may not want to request a pen and pencil test; however, you may want to do your own check. For example, have a conversation with a client and mention you went to a new restaurant last weekend. Rave about the steak, salad and ice cream, saying they were all great and that your client absolutely must try them. A few minutes later, ask the client what he absolutely must try when he goes to the new restaurant. Another simple, but not so subtle, test is to ask your client to draw a clock with a certain time. If the client is unable to accurately draw the clock, then you should consider what action to take next and how your relationship with the client will continue, particularly if you’re concerned about something that appears to be potentially harmful or risky for your client. Look first to company policy and internal resources on procedures as well as to state laws that may protect individuals with impairment. Notify the trusted contact person if such information is available. Some professionals are mandated reporters, which requires them to report any abuse or exploitation to appropriate authorities. Even if a professional isn’t a mandated reporter, each state has Adult Protective Services (APS), which is a social services program developed to investigate claims of abuse, exploitation or neglect of older adults and vulnerable individuals living in the community. APS then works with a network of service providers and law enforcement to ensure the protection of someone at risk.
Endnotes
1. www.prb.org/wp-content/uploads/2016/01/aging-us-population-bulletin-1.pdf.
2. www.ncbi.nlm.nih.gov/pmc/articles/PMC2705925/.
3. alz.org/alzheimers-dementia/facts-figures.
5.www.verywellhealth.com/alzheimers-disease-and-word-finding-difficulties-98554.
6. www.rush.edu/news/press-releases/scam-susceptibility-may-be-early-sign-dementia.
7. www.nytimes.com/2016/07/26/health/alzheimers-checklist-mild-behavioral-impairment.html.
8. memory.ucsf.edu/executive-functions.
9. www.pinnaclecare.com/highlights/blog/alzheimers-disease-symptoms/.
10. money.com/money/4718423/online-phony-boyfriend-scam/.
11. law.justia.com/cases/new-york/other-courts/2016/2016-ny-slip-op-50853-u.html.
12. www.shrm.org/hr-today/news/hr-magazine/pages/coping-with-cognitive-declines-at-work.aspx.
13. www.finra.org/sites/default/files/Regulatory-Notice-17-11.pdf.