I read the letter from Dr. David W. Tesar criticizing Dr. Hofmann for his opinions regarding the MMSE. Dr. Tesar was "concerned" that neurology residents might be "misled" by it.

I was a resident at the Palo Alto VA Hospital from 1966 to 1968 under the Stanford Program. Dr. Hofmann was chief of service. I would like to reassure Dr. Tesar that I was well trained.

Dr. Hofmann was skilled at taking a thorough history and getting a good feel for the patient's mental state while doing so. We learned not to just write that the patient was a "bad historian," but to evaluate why. When indicated, we applied parts of the MMSE.

If one reads the article regarding B-12 deficiency as a cause of dementia ("Dementia Insights," Vol. 8, No. 3, p. 14), one can see that Dr. Devere was able to take a good history from a patient with "fugue state" and realize that she had a dementia without applying the MMSE. To evaluate further, he then applied the Montreal Cognitive Assessment Test, which he felt was more sensitive than the MMSE.

In the same issue, I read with great interest the article about helping our patients obtain Social Security Disability ("Expert Opinion," p. 45). As a neurologist and independent contractor reviewer, I have some pointers to add to this excellent article.

Disability for epilepsy and migraine is dependent upon frequency of attacks and, in the case of seizures, description of the type of attack. If seizures are nocturnal, are there lingering effects the next morning?

Compliance with treatment is very important. The SSA is very interested in blood levels. Even though we may not ordinarily obtain serum levels with newer anti-convulsants, it would be helpful to your patient's cause if you did obtain levels. Of course, if serum levels are near zero, you may hinder your patient's application for benefits; but then you can better re-evaluate your management.

When asked to complete a functional analysis form, please do not exaggerate. It will not aid your patient's cause. For example, I recently saw an application from a lady with MS who was receiving injections of Avonex. She complained of fatigue. I was not the evaluator. Had I been, I would have believed her despite only mild neurological findings. Her treating neurologist wrote that this lady could never carry more than five pounds occasionally or one to two pounds frequently. The evaluating SSA physician, then, not only failed to believe the doctor but failed to believe the applicant.

— Jack Kundin, MD
San Mateo, CA

Dr. Kundin emphasizes that the opinions expressed above are solely his own and are not those of the SSA.

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