A New Method of Evaluating Dementia and Other Neurocognitive Disorders in Social Security Disability Claims
On January 17, 2017, the new Mental Disorders Listings will go into effect. Southern Illinois Social Security disability attorneys are busy getting familiar with the changes. We are gleaning valuable insight from the public comments and the Agency’s explanations of the changes.
Many of the changes in the Mental Disorder Listings reflect changes in the recently published DSM-5. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.
The DSM-5 includes a subsection entitled neurocognitive disorders (NCDs) which replaces the DSM-IV category of delirium, dementia, and amnestic and other cognitive disorders category. Natalie Sachs-Ericsson & Dan G. Blazer (2015) The new DSM-5 diagnosis of mild neurocognitive disorder and its relation to research in mild cognitive impairment, Aging & Mental Health, 19:1, 2-12, DOI: 10.1080/13607863.2014.920303.
The new Listing 12.02 follows DSM-5; the criteria include deficits in complex attention, executive function, learning and memory, language, perceptual-motor, and social cognition.
The new Listing 12.02 fits perfectly within the framework of the Social Security Disability evaluation process because a significant decline in these functional areas interferes with a person’s ability to perform effectively in the workplace. POMS DI 25020.010 Mental Limitations.
Listing 12.02 is being completely rewritten.
This is the current Listing 12.02:
12.02 Organic Mental Disorders (effective until January 16, 2017):
Psychological or behavioral abnormalities associated with a dysfunction of the brain. History and physical examination or laboratory tests demonstrate the presence of a specific organic factor judged to be etiologically related to the abnormal mental state and loss of previously acquired functional abilities.
The required level of severity for these disorders is met when the requirements in both A and B are satisfied, or when the requirements in C are satisfied.
Demonstration of a loss of specific cognitive abilities or affective changes and the medically documented persistence of at least one of the following:
- Disorientation to time and place; or
- Memory impairment, either short-term (inability to learn new information), intermediate, or long-term (inability to remember information that was known sometime in the past); or
- Perceptual or thinking disturbances (e.g., hallucinations, delusions); or
- Change in personality; or
- Disturbance in mood; or
- Emotional lability (e.g., explosive temper outbursts, sudden crying, etc.) and impairment in impulse control; or
- Loss of measured intellectual ability of at least 15 I.Q. points from premorbid levels or overall impairment index clearly within the severely impaired range on neuropsychological testing, e.g., the Luria-Nebraska, Halstead-Reitan, etc;
Resulting in at least two of the following:
- Marked restriction of activities of daily living; or
- Marked difficulties in maintaining social functioning; or
- Marked difficulties in maintaining concentration, persistence, or pace; or
- Repeated episodes of decompensation, each of extended duration;
Medically documented history of a chronic organic mental disorder of at least 2 years’ duration that has caused more than a minimal limitation of ability to do basic work activities, with symptoms or signs currently attenuated by medication or psychosocial support, and one of the following:
- Repeated episodes of decompensation, each of extended duration; or
- A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental demands or change in the environment would be predicted to cause the individual to decompensate; or
- Current history of 1 or more years’ inability to function outside a highly supportive living arrangement, with an indication of continued need for such an arrangement.
This is the new Listing 12.02:
12.02 Neurocognitive Disorders (effective January 17, 2017).
(see 12.00B1), satisfied by A and B, or A and C:
Medical documentation of a significant cognitive decline from a prior level of functioning in one or more of the cognitive areas:
- Complex attention;
- Executive function;
- Learning and memory;
- Perceptual-motor; or
- Social cognition.
Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning (see 12.00F):
- Understand, remember, or apply information (see 12.00E1).
- Interact with others (see 12.00E2).
- Concentrate, persist, or maintain pace (see 12.00E3).
- Adapt or manage oneself (see 12.00E4).
Your mental disorder in this listing category is “serious and persistent;” that is, you have a medically documented history of the existence of the disorder over a period of at least 2 years, and there is evidence of both:
- Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of your mental disorder (see 12.00G2b); and
- Marginal adjustment, that is, you have minimal capacity to adapt to changes in your environment or to demands that are not already part of your daily life (see 12.00G2c).
The new 12.02 refers to the new 12.00B1 (reformatted to make it easier to read):
12.00B Which mental disorders do we evaluate under each listing category? (effective January 17, 2017.)
1. Neurocognitive disorders (12.02).
A. These disorders are characterized by a clinically significant decline in cognitive functioning. Symptoms and signs may include, but are not limited to, disturbances in
- executive functioning (that is, higher-level cognitive processes; for example, regulating attention, planning, inhibiting responses, decision-making),
- visual-spatial functioning,
- language and speech,
- judgment, and
- insensitivity to social standards.
B. Examples of disorders that we evaluate in this category include
- major neurocognitive disorder;
- dementia of the Alzheimer type;
- vascular dementia;
- dementia due to a medical condition such as
- a metabolic disease (for example, late-onset Tay-Sachs disease),
- human immunodeficiency virus infection,
- vascular malformation,
- progressive brain tumor,
- neurological disease (for example, multiple sclerosis, Parkinsonian syndrome, Huntington disease), or
- traumatic brain injury;
- or substance-induced cognitive disorder associated with drugs of abuse, medications, or toxins.
(We evaluate neurological disorders under that body system (see 11.00). We evaluate cognitive impairments that result from neurological disorders under 12.02 if they do not satisfy the requirements in 11.00 (see 11.00G).)
C. This category does not include the mental disorders that we evaluate under intellectual disorder (12.05), autism spectrum disorder (12.10), and neurodevelopmental disorders (12.11).
What is a clinically significant decline?
When a person is diagnosed with a neurocognitive disorder, it will be based on reports from the patient and family, clinical observations, and objective testing.
Unfortunately, the new listing 12.02 and preface 12.00B1 do not explain what is meant by “clinically significant decline.” This will be a challenge to Southern Illinois Disability attorneys who are helping clients with neurocognitive disorders.
In their article in the Aging & Mental Health Journal, Sachs-Ericsson and Blazer comment “Although DSM-5 does not identify the specific neurocognitive assessment to be used, it is noted that the deficit on a given test would be expected to be between 1 and 2 standard deviations below normal.”
Many people with pending Social Security disability claims will have a hearing under the new rules (beginning January 17, 2017) even though their cases were previously evaluated by consultative examiners and medical consultants under the old rules. The Agency delayed the effective date of the new rules to allow for training at every level in the adjudication process. The details of that training have not been made public.
The new listings provide an advantage for claimants who are suffering from neurocognitive disorders because the new listing 12.02 reflects the importance of cognitive functions that are essential in the workplace.
This advantage will be available to claimants with a representative who understands the criteria of the new listing and is prepared to make a compelling argument that his or her client is disabled.
Joni Beth Bailey is a Southern Illinois Social Security Disability representative.