What is the Legal Significance of “Scores” in Mental Status Exams?

In a recent decision in a complicated and long-running guardianship case, an appellate court in Illinois highlights a topic I’m seeing more and more often: How should courts “value” scores given by evaluators on mental status exams, especially when addressing guardianship issues? 

The most recent 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 or ‘mini-mental’ examination[s]” on the grounds that the MOCA test was more sensitive “for dementia.” 

Reading this challenging case is a reminder of the ABA-APA Handbooks, for attorneys, psychologists, and judges, on assessing capacity of older adults.  The Handbook for Judges describes a host of cognitive and neuropsychological testing tools, although it appears neither the MOCA test or the Folstein test is described.  Is “standardization” of testing for purposes of legal capacity decisions needed?