Abstract
The assessment of mental capacity to assist legal determinations of competency is potentially a growth area for neuropsychology, although to date neuropsychologists have published relatively little in this area. In this paper a systematic review of methods used to assess capacity is presented, including coverage of specialized tests and interviews used for this purpose. A neuropsychological model for conducting capacity assessments is proposed. This model involves comprehensive assessment of a wide range of cognitive abilities as well as assessment of specific skills and knowledge related to the type of capacity being assessed. The purpose of proposing this model is to stimulate further discussion and debate about the contribution neuropsychologists might make in this area.
Similar content being viewed by others
REFERENCES
Ambrose, M. (in press). Making an Advance Health Directive: The role of the neuropsychologist. In: Collier, B., Coyne, C., and Sullivan, K. (eds.), Mental Capacity in Powers of Attorney and Advance Health Directives: A Collection of Essays by Lawyers, Psychologists and Medical Practitioners, Federation Press, Annandale, NSW.
Anderer, S. J. (1990). A model for determining competency in guardian-ship proceedings. Ment. Phys. Disabil. Law Rep. 14(2): 107–114.
Backlar, P. (1996). Ethics in community mental health care: Assessing decision-making capacity: A slippery business. Community Ment. Health J. 32: 321–325.
Barton, C. D., Mallik, H. S., Orr, W. B., and Janofsky, J. S. (1996). Clinicians' judgment of capacity of nursing home patients to give informed consent. Psychiatr. Serv. 47(9): 956–960.
Bean, G., Nishisato, S., Rector, N. A., and Glancy, G. (1994). The psychometric properties of the Competency Interview Schedule. Can. J. Psychiatry—Revue Canadienne de Psychiatrie 39(8): 368–376.
Benesch, K. (1989). Legal issues in determining competence to make treatment decisions. New Dir. Ment. Health Serv. 41: 97–105.
Biegler, P., Stewart, C., Savulescu, J., and Skene, L. (2000). Determining the validity of advance directives. Med. J. Aust. 172(11): 545–548.
Bigler, E. D. (1986). Forensic issues in neuropsychology. In: Wedding, D., Horton, A. M., and Webster, J. (eds.), The Neuropsychol-ogy Handbook: Behavioral and Clinical Perspectives, Springer, New York, pp. 526–547.
Carpenter, W. T., Jr., Gold, J. M., Lahti, A. C., Queern, C. A., Conley, R. R., Bartko, J. J., et al. (2000). Decisional capacity for informed consent in schizophrenia research. Arch. Gen. Psychiatry 57(6): 533–538.
Christensen, K., Haroun, A., Schneiderman, L. J., and Jeste, D. V. (1995). Decision-making capacity for informed consent in the older popu-lation. Bull. Am. Acad. Psychiatry Law 23: 353–365.
Collier, B., Coyne, C., and Sullivan, K. A. (in press). Mental Capacity in Powers of Attorney and Advance Health Directives: A Collection of Essays by Lawyers, Psychologists and Medical Practitioners, Federation Press, Annandale, NSW.
Crippen, D., Levy, M., Truog, R., Whetstine, L., and Luce, J. (2000). Debate: What constitutes ‘terminality’ and how does it relate to a living will? Crit. Care (London) 4(6): 333–338.
Denney, R. L., and Wynkoop, T. F. (2000). Clinical neuropsychology in the criminal forensic setting. J. Head Trauma Rehabil. 15(2): 804–828.
Edelstein, B., Nygren, M., Northrop, K., Staats, N., and Pool, D. (1993). Assessment of Capacity to Make Financial and Medical Decisions. Paper presented at the Annual Meeting of the American Psycho-logical Association, Toronto.
Emanuel, L. L., Barry, M. J., Stoeckle, J. D., Ettelson, L. M., and Emanuel, E. J. (1991). Advance directives for medical care—A case for greater use. N.Engl.J.Med. 324(13): 889–895.
Etchells, E., Darzins, P., Silberfeld, M., Singer, P. A., McKenny, J., Naglie, G., et al. (1999). Assessment of patient capacity to consent to treatment. J. Gen. Intern. Med. 14(1): 27–34.
Farnsworth, M. G. (1989). Evaluation of mental competency. Am. Fam. Physician 39: 182–190.
Fazel, S., Hope, T., and Jacoby, R. (1999). Assessment of competence to complete advance directives: Validation of a patient centred ap-proach. Br. Med. J. 318(7182): 493–497.
Finucane, P., Myser, C., and Ticehurst, S. (1993). “Is she fit to sign, doctor?”—Practical ethical issues in assessing the competence of elderly patients. Med. J. Aust. 159: 400–403.
Fitten, L. J., Lusky, R., and Hamann, C. (1990). Assessing treatment decision making capacity in elderly nursing home residents. J. Am. Geriatr. Soc. 38(10): 1097–1104.
Flew, A. (1999). Advance directives are the solution to Dr Campbell's problem for voluntary euthanasia. J. Med. Eth. 25(3): 245–246.
Folstein, M. F., Folstein, S. E., and McHugh, P. R. (1975). Mini-Mental Status Examination: A practical method for grading the cognitive state of patients for the clinician. J. Psychiatr. Res. 12: 189–198.
Frank, L., Smyer, M., Grisso, T., and Appelbaum, P. (1999). Mea-surement of advance directive and medical treatment decision-making capacity of older adults. J. Ment. Health Aging 5(3): 257–274.
Greenlaw, J. (2000). Does the law interfere with ethical patient care? How it can and why it need not. Harv. Rev. Psychiatry 7(6): 361–364.
Grisso, T. (1994). Clinical assessment for legal competency of older adults. In: Storandt, M., and VandenBos, G. R. (eds.), Neuropsy-chological Assessment of Dementia and Depression in Older Adults: A Clinicians Guide, American Psychological Association, Washington, DC, pp. 119–139.
Grisso, T., and Appelbaum, P. S. (1995). MacArthur treatment compe-tence study. J. Am. Psychiatr. Nurses Assoc. 1(4): 125–127.
Grisso, T., Appelbaum, P. S., and Hill-Fotouhi, C. (1997). The MacCAT-T: A clinical tool to assess patients' capacities to make treatment decisions. Psychiatr. Serv. 48: 1415–1419.
Haldipur, C. V., and Ward, M. S. (1996). Competence and other legal issues. In: Hersen, M., and Van Hasselt, V. B. (eds.), Psychological Treatment of Older Adults: An Introductory Text (pp. 103–125), Plenum, New York.
Hasan, N. K., and Baker, D. G. (1993). Competency assessment in the elderly. W. V. Med. J. 89: 386–388.
Heinik, J., Werner, P., and Lin, R. (1999). How do cognitively impaired elderly patients define “testament”: Reliability and validity of the testament definition scale. Isr. J. Psychiatry Relat. Sci. 36(1): 23–28.
Janofsky, J. S., McCarthy, R. J., and Folstein, M. F. (1992). The Hopkins Competency Assessment Test: A brief method for evaluating pa-tients' capacity to give informed consent. Hosp. Community Psy-chiatry 43: 132–136.
Kirk, T., and Bersoff, D. N. (1996). How many procedural safeguards does it take to get a psychiatrist to leave the light bulb unchanged: A due process analysis of the MacArthur treatment competence study. Psychol., Public Policy, Law 2(1): 45–72.
Knowles, F. E., Liberto, J., Baker, F. M., Ruskin, P. E., and Raskin, A. (1994). Competency evaluations in a VA Hospital: A 10-year perspective. Gen. Hosp. Psychiatry 16: 119–124.
Landry, L. Y. (1999). Normativity, guardianship, and the elderly. Some lessons from Canadian legislation. Theor. Med. Bioeth. 20(1): 69–84.
Leathem, J. M., Murphy, L. J., and Flett, R. A. (1998). Self-and informant-ratings on the patient competency rating scale in patients with traumatic brain injury. J. Clin. Exp. Neuropsychol. 20(5): 694–705.
Leung, W. C. (1998).Who decides whether the patient is mentally incapacitated? [letter]. Br.Med.J. 317(7153): 280.
Lezak, M. D. (1995). Neuropsychological Assessment, 3rd edn., Oxford University Press, New York.
Lieff, S., Maindonald, K., and Shulman, K. (1984). Issues in determining financial competence in the elderly. Can. Med. Assoc. J. 130: 1293–1296.
Lo, B. (1990). Assessing decision making capacity. Law, Med. Health Care 18(3): 193–201.
Loeb, P. A. (1996). The Independent Living Sales, Psychological Cor-poration, New York.
Malloy, P. F., Cummings, J. L., Coffey, C. E., Duffy, J., Fink, M., Lauterbach, E. C., et al. (1997). Cognitive screening instruments in neuropsychiatry: A report of the Committee on Research of the American Neuropsychiatric Association. J. Neuropsychiatry Clin. Neurosci. 9(2): 189–197.
Marson, D. C., Annis, S. M., McInturff, B., Bartolucci, A., and Harrell, L. E. (1999). Error behaviors associated with loss of competency in Alzheimer's disease. Neurology 53(9): 1983–1992.
Marson, D. C., Chatterjee, A., Ingram, K. K., and Harrell, L. E. (1996). Towards a neurological model of competency: Cognitive predictors of capacity to consent in Alzheimer's disease using three different legal standards. Neurology 46: 666–672.
Marson, D. C., Cody, H. A., Ingram, K. K., and Harrell, L. E. (1995a). Neuropsychological predictions of competency in Alzheimer's dis-ease using rational reasons legal standard. Arch. Neurol. 52: 955–959.
Marson, D. C., and Harrell, L. E. (1999). Executive dysfunction and loss of capacity to consent to medical treatment in patients with Alzheimer's disease. Semin. Clin. Neuropsychiatry 4(1): 41–49.
Marson, D. C., Hawkins, L., McInturff, B., and Harrell, L. E. (1997a). Cognitive models that predict physician judgments of capacity to consent in mild Alzheimer's disease. J. Am. Geriatr. Soc. 45: 458–464.
Marson, D. C., Ingram, K. K., Cody, H. A., and Harrell, L. E. (1995b). Assessing the competency of patients with Alzheimer's disease un-der different legal standards: A prototype instrument. Arch. Neurol. 52: 949–954.
Marson, D. C., McInturff, B., Hawkins, L., Bartolucci, A., and Harrell, L. E. (1997b). Consistency of physician judgments of capacity to consent in mild Alzheimer's disease. J. Am. Geriatr. Soc. 45: 453–457.
Marson, D. C., Schmitt, F. A., Ingram, K. K., and Harrell, L. E. (1994). Determining the competency of Alzheimer patients to consent to treatment and research. Alzheimer Dis. Assoc. Disord. 8(4): 5–18.
Mattis, S. (1990). Neuropsychological assessment of competency in the elderly. Forensic Rep. 3: 107–114.
Mezey, M., Mitty, E., and Ramsey, G. (1997). Assessment of decision-making capacity: Nursing's role. J. Gerontol. Nurs. 23(3): 28–35.
Mezey, M., Teresi, J., Ramsey, G., Mitty, E., and Bobrowitz, T. (2000). Decision-making capacity to execute a health care proxy: Develop-ment and testing of guidelines. J. Am. Geriatr. Soc. 48: 179–187.
Midwest Bioethics Centre Ethics Consortium Committee. (1996). Guidelines for the Determination of Decisional Incapacity, Mid-west Bioethics Center, Kansas City, MO.
Miller, S. S., and Marin, D. B. (2000). Assessing capacity. Emerg. Med. Clin. N. Am. 18(2): 233–242.
Molloy, D. W., Silberfeld, M., Darzins, P., Guyatt, G. H., Singer, P. A., Rush, B., et al. (1996). Measuring capacity to complete an advance directive. J. Am. Geriatr. Soc. 44: 1–44.
Moye, J. (1999). Assessment of competency and decision making ca-pacity. In: Lichtenberg, P. A. (ed.), Handbook of Assessment in Clinical Gerontology (pp. 488–528), Wiley, New York.
Palmateer, L. M., and McCartney, J. R. (1985). Do nurses know when patients have cognitive deficits? J. Gerontol. Nurs. 11: 6–16.
Parker, M., and Cartwright, C. (in press). Mental capacity in medical practice and advance care planning: Clinical, ethical, and legal issues. In: Collier, B., Coyne, C., and Sullivan, K. (eds.), Mental Capacity in Powers of Attorney and Advance Health Directives: A Collection of Essays by Lawyers, Psychologists and Medical Practitioners, Federation Press, Annandale, NSW.
Pepper-Smith, R., Harvey, W. R. C., and Silberfeld, M. (1996). Compe-tency and practical judgment. Theor. Med. 17: 135–150.
Reid-Proctor, G. M., Galin, K., and Cummings, M. A. (2001). Evaluation of legal competency in patients with frontal lobe injury. Brain Inj. 15(5): 377–386.
Roth, Y. L., Meisel, A., and Lidz, C. W. (1977). Tests of competency to consent to treatment. Am. J. Psychiatry 134: 279–284.
Sachs, G. A., Stocking, C. B., Stern, R., Cox, D. M., Hougham, G., and Sachs, R. S. (1994). Ethical aspects of dementia research: Informed consent and proxy consent. Clin. Res. 42(3): 403–412.
Schumand, B., Gouwenberg, B., Smitt, J. H., and Jonker, C. (1999). Assessment of mental competency in community-dwelling elderly. Alzheimer Dis. Assoc. Disord. 13(2): 80–97.
Searight, H. R., and Hubbard, S. L. (1998). Evaluating patient capacity for medical decision making: Individual and interpersonal dimen-sions. Fam., Syst., Health 16: 41–53.
Silberfeld, M. (1994). Evaluating decisions in mental ca-pacity assessments.Int. J. Geriatr. Psychiatry 9(5): 365–371.
Silberfeld, M., and Checkland, D. (1999). Faulty judgment, expert opin-ion, and decision-making capacity. Theor. Med. Bioeth. 20(4): 377–393.
Smithline, H. A., Mader, T. J., and Crenshaw, B. J. (1999). Do patients with acute medical conditions have the capacity to give informed consent for emergency medicine research? Acad. Emerg. Med. 6(8): 776–780.
Sprehe, D. J., and Kerr, A. L. (1996). Use of legal terms in will con-tests: Implications for psychiatrists. Bull. Am. Acad. Psychiatry Law 24(2): 255–265.
Sullivan, K. (in press). Measuring mental capacity: Models, methods, and test. In: Collier, B., Coyne, C., and Sullivan, K. (eds.), Mental Capacity in Powers of Attorney and Advance Health Directives: A Collection of Essays by Lawyers, Psychologists and Medical Practitioners, Federation Press, Annandale, NSW.
Treloar, A. J. (1999). Advance directives: Limitations upon their applica-bility in elderly care. Int. J. Geriatr. Psychiatry 14(12): 1039–1043.
Verma, S., and Silberfeld, M. (1997). Approaches to capacity and competency: The Canadian view. Int. J. Law Psychiatry 20: 35–46.
Weisensee, M. G., Kjervik, D. K., and Anderson, J. B. (1994). Im-pairment of short-term memory as a criterion for determination of incompetency. Geriatr. Nurs. 15(1): 35–40.
Willis, S. L. (1996). Everyday cognitive competence in elderly persons: Conceptual issues and empirical findings. Gerontologist 36(5): 595–601.
Wong, J. G., Clare, C. H., Gunn, M. J., and Holland, A. J. (1999). Capacity to make health care decisions: Its importance in clinical practice. Psychol. Med. 29: 437–446.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Sullivan, K. Neuropsychological Assessment of Mental Capacity. Neuropsychol Rev 14, 131–142 (2004). https://doi.org/10.1023/B:NERV.0000048180.86543.39
Issue Date:
DOI: https://doi.org/10.1023/B:NERV.0000048180.86543.39