Medical Certificate

The Medical Certificate:
Our evaluations result in a carefully prepared (and typed) seven page report, usually sent to the attorney within a week or two of the testing date. As the evaluation precedes completion of a Medical Certificate (MC), if the criteria are not met for guardianship/conservatorship, then the MC is not done and there is no charge for it. If the evaluation yields evidence supporting the need for a MC, then it is completed and typed up in a few days. The MC is submitted to the court with the report providing substantial documentation to a judge who is used to seeing only a medical doctor’s hastily scribbled notes on a handwritten Medical Certificate. Remember, of the 60,000 competency evaluations ordered by the courts, and only about 20% of them result in a finding of incapacity. Your MC is likely requested by a family member, not a judge, further reducing your odds of success. Since, we assess before capacity before completing an MC, we can advise an attorney when an MC is likely to be unsuccessful. Furthermore, since we treat the whole process seriously and document with many dementia tests (not just the MMSE), we have never had a petition for guardianship/conservatorship fail to be granted by a judge.

MCs are completed within days of the report, and Dr. Elovitz is sensitive to the fact that a patient must be seen/evaluated within 30 days of the hearing. Given most MC’s are on an emergent basis and result in a temporary guardianship/conservatorship he plans to re-see the patient within the next 90 days if a hearing for permanent status is needed. MC’s are typed and proof-read extensively; i.e., there is no scribbled handwriting. They reflect a dozen or more tests/procedures used and contacts/interviews with multiple people involved and (so far) have never been denied at hearing.

But wait, why all this fancy stuff. The patient had a screening test in his doctor's office, isn't that enough? No, in fact average doctor diagnoses dementia 3-5 years into the course of illness, when it is too late to take steps to try to slow its progression down, or do much in the way of Medicaid Estate Planning. Research has consistently shown that two factors, a patient's age and education, influence test scores–accounting for around 49% (e.g., on the MoCA) of the variability measures. Most screens used in the doctor's office do not account for that. The two most common screens are described below:

The Mini-Mental State Exam (MMSE):
The Mini-Mental State Exam (MMSE), especially when used without available normative data (as it almost always is), does not meet criteria as a “test.” The MMSE is nearly completely insensitive to diagnosing Mild Cognitive Impairment (MCI) and it is very weak at diagnosing first stage (early) dementia. It is a fair-to-good predictor of moderate and late dementia, but that degree of mental impairment is usually obvious to all. We use the MMSE at the Memory Center, but we don't use the typical cut-off scores to determine cognitive deficits, instead we compare a patient's score to thousands of similarly aged and educated people to determine if their scores are average or below. In other words, the MMSE becomes useful if one takes the time to use available normative data, which we never seen anyone doing.

The Montreal Cognitive Assessment (MoCA):
The Montreal Cognitive Assessment (MoCA) is a brief evaluation that got much attention in the media when Dr. Ronny Jackson declared that President Trump was "…mentally very sharp, very intact" because he scored 30/30 on this 10-minute test. The MoCA is more sensitive to Mild Cognitive Impairment and early dementia than the MMSE, but it does not measure judgment, complex reasoning or personality/emotional factors.

While the test has been translated into 60 languages and is popular, its basic normative sample (to whom a patient is compared) was limited to about 90 normal and 90 demented Canadians which is quite small. There are few memory items on it, which is where the most significant deficits all in early dementia. Overall, it is a good screening task, but not enough to base a guardianship on, removing a person’s rights. It has nothing to do with conservator-related skills. Dr. Elovitz once confronted a psychiatric expert who based his testimony entirely on the MoCA; however, when Dr. Elovitz pointed out the MoCA was the same (and only) test that found President Trump 100% A-OK (“stable genus”) the judge asked for no more information to rule against the expert.

Interesting Factoid:
Emerging research is showing one of the first signs of dementia is financial incapacity. Family often report noticing a patient’s susceptibility to scams, wasting money on the Shopping Channel, buying things like clothes and jewelry and leaving it all unopened in piles of packages before they see memory problems. What this means is conservatorship is often needed in the Mild Cognitive Impairment or early dementia ranges, to protect a person’s assets from dissipation. As noted above, the typical memory screens are not sensitive to MCI or early dementia–only a neuropsychological evaluation can detect these early precursor stages to full-blown dementia. This is when the most damage is often done (money given away to “boyfriends” or houses deeded to friendly neighbors, without the family being aware).

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