The relevance of Mini Mental State Examination (MMSE) use on demential interdiction exams in judicial proceedings

Objective: To highlight the important role of Mini Mental State Examination (MMSE) use on judicial interdiction assessments. Methods: On this paper, we present a case in which we have used the Mini mental state examination (MMSE) for screening an initial dementia diagnosis, suggested by clinical and mental state examination. Results: The relevance of using a screening test for demencial states on judicial interdictions assessments, as MMSE, in order to provide more objective findings to the court, has been demonstrated. Also, we review the current evidence for using MMSE on this setting and the importance of its use on demential interdiction exams in judicial proceedings. Conclusions: Judicial evidence is a critical element in decision making. Judicial interdiction assessment is usually performed by expert psychiatrists. As psychiatric diagnosis relies on clinical history and mental state examination, it is composed of subjective elements, varying also according to the examiner’s personal technical orientation and impressions. Neuroimaging exams are helpful on a minority of cases, in which specific findings are present. In such cases, clinical screening questionnaires play an important role - providing objective elements of neuropsychic functioning of an individual, thus limiting the subjective realm of the expert forensic report.


INTRODUCTION
Judicial evidence is a critical element in decision making.Although the judicial proceeding uses different evidence the expert analysis assumes a prevalent role due to its technical content regarding the matter it refers 1 .It is usually performed by an expert on the field, having the judge's confidence on the task.Therefore, the clearer the expert analysis report is, the better it will serve the court decision making.
Judicial interdiction assessment is usually performed by expert psychiatrists.The diagnosis in psychiatry relies on clinical history and on judicial mental state examination 2,3 .However, many of these findings will depend on the particular characteristics of the professional administering the exam, and the weight given by such professional to the elements found present on each individual assessment.Accordingly, the resulting conclusions for objectively similar situations may vary considerably.
Neuroradiologic exams are widely used to diagnose dementia based on anatomic/structural findings.Nevertheless, they poorly describe the patient's global mental functioning.In order to list more objective and reproducible elements concerting neurologic functional aspects, clinical screening tests for diseases can be used 2,3 .We have selected the Mini mental state examination (MMSE) 4 because of its easy accessibility and application, as well as its proven efficiency on the secondary role of identifying demential cases.
Important to observe that Brazilian Act n. 13.146 has altered the interdiction legal framework.This Act (the "Lei Brasileira de Inclusão da Pessoa com Deficiência -Estatuto da Pessoa com Deficiência") aims at promoting, and ensuring the exercise of, the rights conferred upon the mentally ill, with a view to the inclusion of such person in society, in all respects.The terms of this Act deny "interdição total" in Brazil: a mentally ill individual is entitled to maintain minimum rights to the administration of her assets and to exercise other routine actions in her civil capacity, to the full extent allowable, considered her mental condition 5 .
In this paper, we describe one of a serie of cases in which the MMSE was used as a complementary test to dementia screening on demential interdiction exams in judicial proceedings.Also, we review the current evidence for using MMSE on recent literature and on the former specific setting, demonstrating the importance of its use on demential interdiction exams in judicial proceedings.

Medical history and expert mental state examination
Just as in clinical practice, the interview is the most important of the diagnose activities 2,3 .From its elements, we can colect data regarding clinical and family histories of the evaluated individual, and perform the expert mental state examination 2,3 .From these assessments, it is possible to obtain the main elements for the psychiatric diagnosis and to evaluate the examinee's understanding ability.The latter is the main aspect to be considered on interdiction exams in judicial proceedings.
The interview and expert mental state examination should be registered in a very clear and technical way, respecting the visum et repertum 6 recommendation for such evaluations.As lined before, these exams vary according to the expert performing them, as they can be heavily influenced by the examiner's particular assessment.

The relevance of complimentary clinical testing in forensic evaluations
The importance of complementary clinical testing in forensic evaluations may provide enhanced elements to the conclusion reached in judicial proceedings, aiding the judges in the discharge of their duties.In this respect, it seems very important to add objective clinical elements to expert analysis 7 .With this procedure, it is also possible to avoid some of the most cited criticisms to the expert opinions: the subjective variability and the lack of reproducible methods 8 .
Only in limited circumstances, neuroimaging brain exams provide objective data regarding cerebral anatomic functioning 9 .In the relatively few incidences when their findings are conclusive, they serve as invaluable support to the expert forensic evaluations and judicial findings.They aid in the determination of the extent of an individual's brain functioning and discernment 10 .The lack of biomarkers that can unequivocally demonstrate the mental disorders stresses the importance of the imaging exams, especially when used in a secondary role in psychiatric evaluation 2,3 .On the other hand, however, complementary imaging exams in psychiatry are costly and controversial 11,12 , also delaying expert and processual conclusions.
The aim is to obtain the most objective evaluations possible on individual's impairment functioning assessment.On this setting, the application of already validated clinical tests to specific diseases screening (chosen by history and mental state examination findings) is important and welcomed in judicial proceedings 13 .

Non-diagnosed dementia prevalence on general population
The dementia detection rate on general population can be very low, mainly in adult subjects showing declines in memory and changes in brain activity.It is sometimes considered as part of aging 14 .In a recent metanalysis 15 , the mean prevalence of non-diagnosed dementia affected individuals in a certain general population was estimated as 61% (95% CI 55.0% to 68.0%).On studies in which MMSE was applied, the under diagnosis of dementia was even lower.

Mini Mental State Examination (MMSE) for dementia screening
Folstein's MMSE 4 is one of the earliest described questionnaires to screen demential states already validated for this purpose.As part of general medical training, physicians usually receive education for its application.It is the most widely used test 16 to evaluate cognitive function because of its short time duration (around ten minutes), its simplicity to perform, and its absence of specific material requirement.It should be used as a screening instrument, not as a substitute for a more detailed evaluation.Although it assesses several aspects, like space and time orientation, global memories, calculation, capacity to recognize objects, repetition, comprehension, writing and drawing, it does not serve as diagnostic test.On the other hand, it is a proper test for indicating mental functions that need further investigation.It is one of few tests validated and adapted for Brazilian population.
MMSE has shown to have good psychometric properties for dementia screening in primary care settings 17 .In secondary care, it can present lower sensibility than in the first one described, but its use is still recommended 17,18 .In a wide Cochrane review 18 , the authors still recommend MMSE use as part of dementia diagnostic evaluation, though it should not be solely used to exclude or to confirm the diagnosis.
In certain circumstances, where the clinical history suggests cognitive or functional loss (such as by reports provided by family members or other closely related individuals), a general screening cognitive test is usually administered.This is the case of MEEM, which may be sufficient to the diagnosis of "dementia."One of the most important aspects in this initial screening is to determine which areas are affected in the individual.Once the area of impairment is identified, the severity of such impairment must be assessed.In this respect, one of the most popular methods is the use of "Clinical Dementia Rating" (CDR), which is beyond the scope of this study.

CASE REPORT
An 86-year-old, widowed man, high school graduated, house-builder, born in Porto Alegre city, Brazil (the "Examinee"), was interviewed in connection with a demential interdiction exams ordered by a state judge.Three of the Examinee's four sons started the judicial process for interdiction, claiming waste of assets by their father.The Examinee argued against this proposition and contested the legal action.
During the psychiatric interview, he was found aware of the objectives of the evaluation, blaming the legal action to his offspring's greed.The Examinee lived alone, while the only son opposing the legal measures administers a company along with his father.In addition, this child assisted his father personally and professionally whenever necessary.
The Examinee reports having worked as a constructor at a federal state university during seventeen years, having later retired.He founded a construction company as part of his professional activities, from which he was able to amass a substantial number of assets.He reported ownerships of 13 apartments, estimated to be worth about 2 million reais, the Brazilian currency.The Examinee earned additional income from renting some of these buildings (estimating four thousand reais monthly) and also received certain retirement benefits.He used a hearing aid device, which he claimed to have acquired for twelve thousand reais.As to the Examinee's expenses, he reported bank loans that consumed a substantial part of his monthly income.He referred regularly paying a sum of money to his granddaughter -the daughter of his only son opposing the legal measures.The Examinee claimed to drive his own car, to vote and to hold a license to carry and using a firearm.
Although he exhibits some lapses of memory during his examination, the Examinee denied having health problems of any kind, including neurologic/psychiatric ones.He denied use of licit or illicit drugs of any kind, as well as of any medications.He objected to his interdiction and accused his former lawyer of colluding with his sons in order to get access his assets.The individual wasn't able to explain the reasons for, or the process resulting in, her personal debt, including his personal expenses, such as utility bills, as well as the substantial decrease in his assets occurred in the previous years.This inability is in sharp contrast to his performance of the same tasks in the past, evidencing a substantial loss in his mental capacity.
His eldest son was present during the psychiatric examination, after obtaining due permission from the parties involved.This individual informed that the Examinee was at the time responding to about a hundred judicial proceedings for delinquency in the payment of taxes regarding his buildings.Because of the Examinee's impulsive actions, he has incurred many debts, evidencing his inability to manage his affairs in the same way as performed in the past.As a result, claimed the son, the Examinee compromised a substantial amount of his assets.We asked the Examinee to perform a test for his memory, and he agreed to it.

Expert mental state examination
Established a direct, active, and productive interaction with the examiner.
General aspects: Good personal hygiene, tall and skinny body, simple and suitable clothes according to the occasion, presence of senile halo in both eyes.