Polished by years of corporate life, many an ageing executive can keep going even though his memory has become less reliable and his thinking less sharp. He is so embedded in the culture and so habituated to the rituals of office life that he can often move seamlessly through the day without these deficits showing.
Only those close to him know that his recall is not what it was and that he needs more and more support. One of his primary supports is usually his personal assistant who acts as his memory bank and frontal lobes, organising, filling gaps and ensuring his work world runs smoothly.
If he is fit and otherwise healthy, this man will pass his annual medical check-up because it is a physical examination and tests the parameters that could indirectly affect his decision-making capacity but does not test the capacity itself.
Testing his cognitive function would be almost unthinkable, even though he may be in a position of considerable responsibility, dealing with millions of dollars and making decisions that affect many people.
That he may be in the early stages of progressive cognitive impairment, which may damage his judgment and reduce his insight, doesn’t make testing any less of a taboo.
In our ageing society, there is a push for people to retire later and later, based on the sometimes flawed assumption that if the body is holding out, so is the brain.
David Ames, director of the National Ageing Research Institute in Victoria, says as people in positions of responsibility get older, there should be as much interest in their cognitive health as there is in their physical health.
“While they can run an organisation with significant arthritic damage, if their brain isn’t functioning properly, they won’t do a good job," he says.
Ames, who is also chief medical adviser of Alzheimer’s Australia, has floated the controversial idea of an external review process for older people occupying positions of responsibility.
He is aware that this would be contentious and require caution, but believes it is worthy of discussion, at least for professionals, executives and national leaders.
“Perhaps they should set up, in advance, some external process that allows them to be assessed to ensure they are functioning properly," Ames says.
Ames says addressing the mental capacity of a person in power is complex and difficult. “Ever since Ludwig ll of Bavaria was removed for what was said to be insanity, there has been debate about how to address a supreme leader and say ‘I’m afraid you are not up to the job’."
Although we don’t want to lose older people who are cognitively intact, have talent, experience and great ability, Ames says that, perhaps on an individual level, people could think of voluntarily putting in place a procedure by which colleagues arrange for them to be tested every year, once they reach a certain age, or if they have any problems earlier.
This could be tied in with their annual medical exam.
“You are far more likely to make a bad decision as a corporate executive because you have some form of degenerative brain disease than because you have angina or inflammatory bowel disease," Ames says.
Ames agrees there should be some mechanism by which to flag failing cognition of people in positions of responsibility, but Perminder Sachdev, professor of neuropsychiatry at the University of NSW, has hesitations about mandating an external review. “It’s a radical idea, with pros and cons," he says. “If a person, after doing a job for 15 to 20 years, had some reduction in memory, it may not compromise their ability to continue doing that job because their years of experience may compensate for the deficit."
In addition, he says memory loss does not necessarily mean a loss in analytical ability, judgment or reasoning. These can still be good. Another issue is that neuropsychological testing has limitations, Sachdev says.
“What happens in the laboratory doesn’t correspond completely with real-life functioning.
“We find some people do very well in testing but don’t function so well in real life, and vice versa. It is not the same as doing a brain scan or taking a blood test. These can provide objective results."
With neuropsychological testing, there is a degree of performance in the actual doing of the test and, as many factors influence performance, the results have a degree of subjectivity.
Mood can affect cognition and an older person being sent for an assessment of cognitive competence may, understandably, feel anxious at the prospect of a test and not perform well.
Moreover, an important cause of poor cognitive function is depression, which can be treated if properly diagnosed.
Sachdev says it is also important to consider how old is “old". From 65 to 70, he says, you don’t see a major decline in functioning, but after 70 you start seeing more deficits, although these may, again, be subtle. From 75, deficits often become much more apparent.
When asked how far we can push the retirement age, Sachdev usually answers 75. “That’s probably the threshold, when your biology has caught up with you and things are working against you," he says.
“But that said, I can think of senior professors in their 80s who are going very strong and not thinking of retirement. When you look at their performance, there is no reason they should retire as they beat people half their age in terms of productivity. To subject them to neuropsychological testing would be unfair."
With healthy ageing, in the absence of pathology, Sachdev says there is a gradual reduction in information processing speed.
“If you put older people through time-dependent tests, their reaction time is slower," he says. “If you assess their memory performance, that will be slowed too, but given enough time, they will perform well.
“Ageing affects performance, as in real life we are pressed for time – but there is another important dimension. Older people are able to look at the gestalt and come to conclusions quickly, whereas younger people tend to look at the minutiae and have to work their way through.
“In this way, as a result of their experience, older people are more efficient in coming to decisions and looking at the bigger picture.
“I believe putting them through a battery of cognition tests is can be counterproductive."
On a practical level, Sachdev suggests there could be a provision in a senior person’s contract for management to ask for a cognition test, if there were a suspicion about competence. There would have to be cues giving rise to the suspicion.
Although Sachdev has never had an executive referred for testing, he has assessed medical colleagues who had been referred to the Medical Board because of complaints by patients or co-workers. There is no obligatory age for doctors to retire but if a complaint is made to the board, the doctor is investigated.
“It is extremely difficult to come to an objective assessment unless there is clear evidence of decline of cognitive function," Sachdev says.
In some cases there may be early dementia but often he finds alcohol is the cause and says remedial action is possible.
Given its limitations, Sachdev says neuropsychological testing alone may not be enough to determine if the person is competent.
Some occupations require skills and a personal capacity that just can’t be measured in the laboratory and are not necessarily related to cognition.
“Anyway, to be a chief executive you don’t need to be the brightest of the bright; sometimes you just need common sense and experience," Sachdev says.
He has a suggestion for a possible way forward on this issue: “Perhaps at the age of 70, senior executives should have a neuropsychological assessment as a baseline," he says.
“They could then be reassessed if there is a concern based on poor performance, lapses or failings noted by those around them.
“If the repeat assessment shows a decline which is greater than would be expected with the ageing process, the person would be encouraged to retire."
He says there could also be a sunset clause.
The Australian Financial Review