Marc B. Hankin







TELEPHONE  (310) 204-8989

FAX  (310) 204-8985

























Dr. Jones, I requested that you be appointed as the independent medical expert to perform a psychiatric examination of Edward Smith because:

1.      I do not know you personally (and that was a condition required by opposing counsel),

2.      I understand that you are board certified in geriatric psychiatry, and

3.      Several of my colleagues and friends (Jim Spar, Stephen Read, Roland Jacobs) know you and have spoken well of you as a scientist, and as a treating psychiatrist.


As you know (much better than I), the competency assessment of a high functioning alleged dementia patient is a far more demanding task for the examiner, than the assessment of a severely and obviously impaired examinee.  Similarly, the examination and assessment of a high functioning examinee, who is alleged to be suffering from a labile psychosis or a labile mood disorder, requires far more historical and other background information, in order for the examiner to do his job properly.  I suspect that the examination of Edward Smith may be complicated for both of the foregoing reasons.



Albert asserts that his father, Edward Smith, is a high functioning dementia patient, who can dissemble well, and appear to be more high functioning than he is.  


A.  In cases involving an allegedly high functioning dementia patient who is alleged to be capable of masking his dementia, it is critical that:


1.  The examiner be equipped/armed with anecdotal information before commencing the examination, so that the examiner can query the patient about important factual background data, and


         2.  There be multiple examinations, to address liability.



As indicated in The Textbook of Geriatric Psychiatry, by Coffey and Cummings, (Year 2000 edition):

“[T]he caregiver must be an integral source of historical information.  * * *  The presence of impaired memory and insight may interfere with the gathering of the history to such an extent that the caregiver [is necessary to] provide [the examiner with] the essential collateral information [to conduct a reliable and effective examination].”


      (Page 110).


“Historical information, particularly a history of recent changes in behavior and cognition, must be organized in order to direct the focus of the mental status and physical examinations.  * * *    through an understanding of the functional neuroanatomy and neuropathology, the neuropsychiatrist will be able to clarify problems identified in the history and expand upon them through strategic use of bedside testing to arrive at a more complete understanding of the clinical problem.”


      (Page 113; emphasis supplied.)


As you know, dementia patients with a high pre-morbid level of intellectual function (which Albert asserts is the case here) often achieve misleadingly high scores on the Folstein MMSE test, and on many other standardized tests for cognition. 


Without adequate background information, supplied from anecdotal sources (such as Albert Smith, transcripts of legal proceedings in which Edward has testified, family members and long-term friends), even the most highly qualified examiners in the world can be “snookered”; and sometimes the person(s) manipulating the victim get away with it.   For example, Professor Robert Neshkes, M.D. will readily tell you about how he was recently deceived (for a period of time) by an examinee (Jerome K. Sayle) suffering from Lewy bodies dementia and borderline personality disorder.  If Dr. Neshkes had not had access to anecdotal information, he might have supported the wrong side. 


In another case, Professor James Spar was appointed as the independent medical in a petition for the appointment of conservator for Richard R. Hosenwald.   Dr. Spar, who ultimately supported a conservatorship for Richard R. Hosenwald, recalls with amusement [1] that Richard had initially persuaded Dr. Spar that he (Richard) was competent, and [2] how pleased Dr. Spar was that he took the time to do what he thought was obviously unnecessary, under the circumstances (because Richard had shown himself to be obviously competent), i.e., Dr. Spar took the time to verify Richard’s assertions with the family, and test their assertions later in a subsequent meeting with Richard.  Needless to say, Dr. Spar’s first meeting with Richard would have been far more productive, if Dr. Spar had been endowed with the relevant anecdotal information before Dr. Spar’s first meeting with Richard.  If Dr. Spar had not gotten the anecdotal information from family members, no conservatorship would have been established and the victimizer who had already depleted most of Richard’s estate, would have been able to dissipate the rest.


A manual “Assessment of Competency and Capacity of the Older Adults: a Practice Guide for Psychologists” prepared by a group of physicians and psychologists including Judith A. Salerno, M.D., M.S., Chief Consultant, Geriatrics and Extended Strategic Health Care Group, VA Headquarters, Thomas Horvath, M.D., Chief Consultant, Mental Health Strategic Health Care Group, VA headquarters, and including such renowned experts as Jennifer Moye, Ph.D. of Harvard and Larry Thompson of Stanford, made the following recommendation:


Assessment data should be obtained on a variety of sources including, when possible, family and staff in addition to the patient.  Serial evaluation sessions are preferable to single session evaluations[,] in that some patients manifest variable daily functioning (fluctuating capacity) which can only be discovered across several time periods.”


(Page 6.)    I will send this to you by e-mail, when I get your e-mail address.



A 1994 report to Congress by The Advisory Panel On Alzheimer’s Disease (in collaboration with the US Department of Health And Human Services, The Public Health Service, The National Institutes of Health, And the National Institute on Aging) discussed assessment protocols for mental health experts.  The panel, which included such renowned experts as Robert Kane, M.D. and Stanford Prof. Jerome Yesavage, M.D., asserted:


Current best medical opinion holds that clinical diagnoses of Alzheimer’s disease should be established through careful clinical evaluation at several different points in time.


That evaluation should include, but not be limited to (a) cognitive screening instruments (such as the MMSE); (b) NINDS/ADRDA Alzheimer’s screening criteria, including other neuropsychological assessment tools; (c) measures of practical aspects of functioning, such as occupational evaluations.


In addition, the assessment would be incomplete in the absence of historical evidence provided by the person in question or informed individuals, such as family and personal physician. (Emphasis added.)


(Page 26)    I will send this to you by e-mail, when I get your e-mail address.



Albert plans to provide you with a table/chart of information about which you could pose a probative/informative questions to Edward.  Albert is in the process of preparing that chart.



The Scope Of The Examination


It is obviously necessary that the scope of the inquiry and report(s) be clearly delineated, so that you may execute your task appropriately.  I look forward to talking with you about this, and coming to an agreement with both you and the other lawyers, so that we may all cooperate with you, and thereby enable you to carry out your task(s).



Kindest regards.



                                                                                     Marc B. Hankin