At what Montreal Cognitive Assessment (MOCA) score is it recommended to appoint a financial Power of Attorney (POA) for individuals with declining mental acuity due to dementia?

From the Guidelines

The appointment of a financial Power of Attorney (POA) for individuals with dementia should be considered as early as possible after diagnosis, ideally while the individual still has the capacity to understand and consent to the arrangement, rather than relying on a specific Montreal Cognitive Assessment (MOCA) score threshold. When considering the appointment of a financial POA, it is essential to assess the individual's capacity to make financial decisions, which can be evaluated through a combination of cognitive assessments, such as the MOCA, and functional evaluations of their financial decision-making abilities 1. The MOCA test, scored from 0-30, with scores below 26 suggesting cognitive impairment, can help track cognitive changes but should not be the sole determinant for appointing a POA 1. Some studies suggest that a MOCA score of 18 or lower (which corresponds to a score of approximately 25.5 on the 30-point MOCA) may indicate cognitive impairment, but this requires further validation 1. Key considerations for determining the appropriate timing of POA appointment include:

• The individual's unique circumstances and rate of cognitive decline
• Proactive planning with healthcare providers, legal advisors, and family members
• The importance of establishing a POA while the individual still has the capacity to understand and consent to the arrangement
• The potential for cognitive decline to diminish legal capacity, complicating the legal process It is crucial to prioritize the individual's autonomy and well-being while ensuring their financial security and safety, and to consider the appointment of a POA as part of a comprehensive care plan that addresses their evolving needs 1.

From the Research

Financial Power of Attorney and Declining Mental Acuity

• The decision to appoint a financial Power of Attorney (POA) for individuals with declining mental acuity due to dementia should be based on a comprehensive assessment of their cognitive abilities 2, 3.
• The Montreal Cognitive Assessment (MOCA) score can be used as a tool to evaluate cognitive impairment, but the optimal cutoff score for recommending a financial POA is not clearly established 3.

MOCA Score and Financial POA

• A study found that a MOCA score of 24 or lower may indicate mild cognitive impairment, while a score of 20 or lower may indicate dementia 3.
• However, another study suggested that thresholds lower than 26 may be more useful for optimal diagnostic accuracy of MOCA in dementia, but this requires confirmation in further studies 2.
• The MOCA index scores, including Memory, Executive Functioning, Attention, Language, Visuospatial, and Orientation, can provide valuable information on the function of each cognitive domain in patients with mild cognitive impairment and dementia 4, 5.

Recommendations

• A comprehensive assessment of cognitive abilities, including the MOCA score, should be conducted to determine the need for a financial POA 2, 3.
• The decision to appoint a financial POA should be based on individual circumstances and the level of cognitive impairment, rather than a single MOCA score threshold 6, 3.
• Healthcare professionals should consider the MOCA index scores and other diagnostic tools to evaluate cognitive impairment and make informed decisions about financial POA 4, 5.