Mental Capacity Assessment

Bennett Blum, M.D.

“Mental capacity assessment” refers to the analysis of a person’s cognitive and emotional status as it relates to specific observable or legal behaviors. Three approaches to assessing mental capacity are used (singly or in combination) throughout the country. The three approaches are:

1. Behavioral (or “Functional”)
2. Medical
3. Philosophical

The behavioral approach focuses upon the appropriateness of a person’s actions and statements. If a person behaves in an odd, unusual, or abnormal manner, then concerns may exist as to whether the person is cognitively impaired. The next step is to categorize how the behavior is inappropriate. There are 12 categories of mental functions that are necessary to make knowledgeable, reasoned, and rational decisions. Describing these categories, and the associated abnormal behaviors, helps evaluators understand the extent and severity of decision-making problem.

• Benefits:
  1. The approach is logical and appeals to “common sense.”
  2. It does not require specialize expertise to evaluate the information.
• Drawbacks:
  1. The approach requires review of observations by both interested and objective parties (more time, greater expense).
  2. This approach does not provide information regarding causation, treatment, or likely prognosis. Medical and psychiatric evaluation is necessary to answer these questions.

Ideally, a behavioral assessment is done for a medical (that is, psychiatric or psychological) assessment. When it does not, the medical approach relies upon signs and symptoms of disease to determine capacity. The presence of symptoms is equated with cognitive impairment, and therefore, incapacity. Because there are situations in which a person has symptoms yet retains capacity, this approach is inadequate without consideration of actual behavior.  Furthermore, this type of evaluation requires specialized knowledge, skills, and experience that is not always readily available.

• Benefits:
  1. Record review may be limited to medical records (less expensive).
  2. This approach may provide information regarding causation, treatment, or likely prognosis.
• Drawbacks:
  1. Many medical personnel do not have the knowledge, skills, or experience to correctly assess cognitive impairment. When reviewing conclusions from experts in fields other than mental health, it is necessary to confirm that they performed the correct assessment.
  2. The presence of signs and symptoms must be compared to the person’ observable behaviors.

The philosophical approach uses vague and imprecise concepts to define mental capacity. The classic formulation says that a person has adequate capacity if he is able to express his desires, understands and appreciates the situation, and is rational.  Definitions of these terms vary, and there is no consensus regarding their evaluation, making this approach difficult to use.

• Benefits:
  1. Uses established legal language.
• Drawbacks:
  1. Terms are vague and imprecise.
  2. Poor and inconsistent guidelines for assessing the required abilities.

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