Targeted Assessments May Help Identify Workers Experiencing Cognitive Impairment

“As the United States gears up for a likely presidential contest between an 81-year-old incumbent and a 78-year-old challenger, the dilemma of how to deal with the issue of older people in important positions who may be experiencing cognitive limitations is front and center in the public eye,” wrote psychiatrist and past APA President Paul Appelbaum, M.D., in a Law & Psychiatry column appearing today in Psychiatric Services.

According to 2022 data, nearly 58 million adults ages 65 and older live in the United States, accounting for about 17.3% of the nation’s population. This percentage is expected to keep growing.

“Encouraging workers to remain active beyond standard retirement ages will be important to satisfy demands for labor, especially in skilled positions,” noted Appelbaum, who is the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and the director of the Division of Law, Ethics, and Psychiatry at Columbia University. But some may experience challenges with cognitive impairment while still in the workforce. What can employers do to prepare for the future?

He described two federal laws that prohibit discrimination based on age—the Age Discrimination in Employment Act (ADEA) and the Americans With Disabilities Act (ADA)—before noting that under federal law, employers are permitted to conduct target assessments of employees who show signs of impairment. “Applying that rule in a fashion that is fair to employees, and protective of the interests of employers and the public, is the difficult, but vital, task ahead.”

Appelbaum described how new approaches might include routine assessments of worker performance throughout an organization that do not single out older employees for more intensive scrutiny and clear standards for determining when evidence of impairment warrants targeted assessments.

“The prevalence of the most widespread form of neurocognitive disorder, Alzheimer’s disease, increases with age from 3% between 65 and 74 years of age to 17% between ages 74 and 84, jumping to 32% for people 85 years or older—hence the urgency of understanding the current parameters for how workplaces can and cannot address concerns about the mental functioning of older workers,” Appelbaum wrote.

For related information, see the Psychiatric News article “Tools for Countering Burnout Mirror Those for Aging Well as a Physician.”

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Patient Asks You to Certify Emotional Support Animal: What Should You Do?

Multiple studies show the mental health benefits of pet ownership. What’s less clear from a small number of studies is the clinical benefits that emotional support animals offer for patients with psychiatric symptoms. An article in Psychiatric Services explores several factors psychiatrists should consider when asked by patients to write certification letters designating their pets as emotional support animals.

“ESAs [emotional support animals] are different from service animals and other disability-related assistance animals,” wrote past APA president Reneé Binder, M.D., of the University of California, San Francisco, and colleagues. Emotional support animals can be “animals of any species that alleviate symptoms of a person’s psychiatric disability through their companionship or presence but do not perform a specific task [as service animals do].” Also, unlike service animals, these animals are not protected by the Americans With Disabilities Act, but are regulated by various federal, state, and local laws, Binder and colleagues noted.

The authors described language in the following federal laws regarding emotional support animals:

• Americans With Disabilities Act
• Fair Housing Act
• Air Carrier Access Act
• Individuals With Disabilities Act

“Although federal statutes set minimum requirements protecting individuals with disabilities, state or local policies can require additional accommodations for people with disabilities,” the authors continued. “When assessing a patient’s eligibility for an ESA, clinicians must be aware of state and local laws that are constantly evolving and specific to a jurisdiction.”

More than one-third of mental health providers report feeling unqualified to determine whether to certify an emotional support animal, the authors continued. While there are few formal training opportunities for psychiatrists interested in ESA certification, “several authors have recently proposed practice guidelines for mental health providers to determine whether patients would benefit from an ESA,” they wrote. To start, they advised psychiatrists to do the following:

• Determine whether a patient has a chronic mental impairment caused by a psychiatric condition (as defined by the DSM-5-TR) that substantially limits functioning in one or more domains.
• Determine whether the ESA will alleviate such an impairment.

Additionally, they advised psychiatrists to consider a patient’s ability to care for an animal, as well as the animal’s ability to serve in the role as an emotional support animal.

Other topics explored in the article include ethical considerations, inappropriate ESA letters, and liability of the ESA letter writers.

“We recommend clinicians think about the evidence and considerations presented in this article before determining whether they want to complete an ESA letter for a patient. It is ethical and may be clinically indicated for clinicians to decline to write such letters,” the authors concluded.

For related news, see the Psychiatric News article “What to Do If Patients Want Service or Emotional Support Animals.”

(Image: iStock/vitapix)

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What’s Your Experience With Telepsychiatry? APA Wants to Know

APA is continuing to advocate for changes to improve the practice of psychiatry and we need to hear from you to better understand how you use telepsychiatry technologies. Unidentified aggregated data will be shared with the Centers for Medicare and Medicaid Services (CMS) as it promulgates rules that impact psychiatry.

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