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Q: What is the Legal Significance of Scores in Mental Status Exams?

Robert M. SlutskyA:  In a recent decision in a complicated and long-running guardianship case, an appellate court in Illinois highlights the tricky issue of how should courts value scores given by evaluators on mental status exams in guardianship cases.

The opinion in Estate of Koenen, issued August 31, 2015, described testimony from multiple witnesses about the mental status of a man in a plenary guardianship proceeding. In two reports, from physicians chosen by the individual, the medical experts opined he was capable of making his own personal and financial decisions. Another witness, a psychiatrist, was appointed by the court to evaluate the individual’s ability to make personal and financial decisions. Ultimately, the lower court concluded the individual was unable to manage his affairs.

On appeal, a central issue was the lower court’s reliance on the court-appointed expert. Part of the psychiatrist’s testimony was that the man scored 26 out of 30, at the low end of the normal range, on the Montreal Cognitive Assessment (MOCA) administered in January 2012, a test that was described by the court as a “twelve-minute test with standardized questions, as well as writing and ‘copying’ tests.” The psychiatrist also testified that in January 2013 he tested the man again with a score on the MOCA that was now 22 out of 30 which was “fully consistent with dementia.”

Ultimately, the appellate court affirmed the lower court’s decision, noting the extensive use of interviews and other data collection by the court-appointed physician to support the findings of incapacity. The appellate court seemed interested however, in the actual number scores, taking note that the court-appointed expert discounted scores reported by the individual’s preferred physicians on Folstein Mini-Mental examination on the grounds that the MOCA test was more sensitive for dementia.

Now the court mentions and focuses on the Montreal Cognitive Assessment which is similar to but not identical to the Folstein Mini Mental status exam that has been used for many years as an evaluation tool in determining the level of cognitive impairment. However, one has to understand that these two tests are considered by many in the eldercare field as a screens only. Have represented clients in over 300 guardianship proceedings I can tell you that I have seen many, many of these screens where someone scored in the high 20s on the test but were so impaired in their judgment and higher order thinking that they absolutely needed a guardian. Conversely, I have seen people who scored in the low 20s who recognized and acknowledged their impairment, sought assistance in managing their affairs and retained relatively good safety and health awareness and were not in need of a guardian because of their support systems. One must do more specific testing of abstract thinking and executive function to really determine if the person’s judgment is really impaired and how the impairment affects function rather than just blindly follow these scores on the screening tests.

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