Letters

Editor:

Edersheim et al.¹ provide a valuable commentary on cognitive impairment in the elderly. I have maintained a forensic practice specializing in guardianship evaluation. I offer some additional clinical perspectives. I have just reviewed 415 consecutive guardianship evaluations conducted by myself from August 9, 2008, through February 27, 2017. August 9, 2008, marked my adoption of the Montreal Cognitive Assessment (MoCA).² Evaluations of persons 64 and younger accounted for 150 evaluations. Evaluations for persons 65 and older accounted for 265 evaluations.

Edersheim et al. warn that the Mini-Mental Status Examination (also known as Folstein) has poor sensitivity. I strongly agree. Before adopting the MoCA, I administered Folstein. Situations would arise where I had evaluated persons with early dementia or mild cognitive impairment. They had made poor decisions, but tested in the normal range on the Folstein examination. Cross-examination became very treacherous. A disability was being asserted, but the test (the Folstein) results were “normal.”

The Folstein and the MoCA are both 30-point tests, but the MoCA is much more stringent. In the 415 evaluations, 299 MoCAs were administered. Some persons were either too disorganized to be engaged or refused to be tested. The average MoCA score for persons who were tested and were age 17 to 64 (n = 116) was 19.6, and the score for persons who were 65 or older (n = 183) was 14.2. Only 15 persons in the entire cohort attained a normal MoCA score of 26 or higher. Of these 15, only 3 were 65 or older. No one attained 30 points. The MoCA is a quick, 12- to 13-minute³ bedside test. It is easy to learn and is a free download (www.mocatest.org).

Some additional observations from the review of 415 evaluations that further complement the commentary of Drs. Edersheim et al.:

• Financial exploitation was suspected in 38 percent of evaluations in persons 65 or older.

• Gait impairment (bed, chair, wheel-chair confined, or use of an assistive device) was present in 55 percent of the 65 and older group. Lack of mobility is a factor that creates vulnerability to undue influence.

• Alzheimer dementia was the primary diagnosis in 70 percent of evaluations of persons 65 or older. None of the evaluations in the 64 and younger group found Alzheimer dementia. However, 63 percent of individuals in this younger group were diagnosed with intellectual disability, cognitive disorder, or dementia due to a nonprogressive cause (vascular, trauma, alcohol, and anoxia). Administration of the MoCA is important at all ages.

• As noted in the commentary, psychiatric comorbidity is frequent. Fifteen percent of the persons 65 and older who had a primary diagnosis of dementia were also psychotic or manic. Hoarding disorder was present in 19 percent of individuals 65 and older. Conducting evaluations on home visits is important for discovering hoarding and other home safety and habitation problems.

• Finally, there is a gender imbalance. For the 64-year-old and younger group, men predominated: 55 percent (n = 83) to 45 percent (n = 67). The gender distribution shifted markedly for evaluations of persons aged 65 and older: 35 percent men (n = 92) and 65 percent women (n = 173).

• © 2017 American Academy of Psychiatry and the Law