Sunday, 9 February 2014

Mental Capacity: Cognitive Deficit and Neurological Assessment.

There are occasions when a person's cognition is compromised to the extent that their mental capacity to make specific decisions may be impaired. Such scenarios sometimes occur when a person acquires a brain injury, degenerative condition or neurological disease or when the person has a severe learning disability or mental illness. 

Assessments of capacity can be conducted by the carer or health professional who initially raises concerns, however, what is often required is a thorough neuropsychological assessment including a measure of the person's current cognitive status conducted by a clinical psychologist or neuropsychologist. 

Neuropsychological assessment involves the integration of theoretical and clinical knowledge accrued from the study of brain behaviour relationships and information gleaned from the review of individual patient's medical records, patient presentation, patient interview, carer/relative assessment and the administration of standardised psychometric assessments. 

It is important to note that capacity cannot be inferred solely from standardised psychometric assessment but it is much more holistic. There are no performance cut-offs or black-and-white guidelines for assessing capacity. Psychometric tests will be chosen on the basis of the tests own reliability and validity credentials; on the basis of the anticipated cognitive deficits implicated by the pathology of the disease or insult; and often based upon the type of decision that has been examined. For example if the decision is one that involves the examination of ability to use judgement, executive tests measuring judgement may be chosen. Each neuropsychological assessment is therefore tailored to the situation. There are however certain helpful things to think about when conducting an assessment of capacity: 

1. Start off by thinking that everyone can make their own decisions. 
2. Give a person the support he/she needs to make decisions before concluding that he/she cannot make his/her own decisions. 
3. Nobody should be stopped from making a decision just because others may think it is unwise or eccentric. 
4. Anything done for, or on behalf of, a person without capacity must be in his/her “best interests” - a decision which is arrived at by working through a checklist. 
5. When anything is done or decided for a person without capacity, it must be the least restrictive of his/her basic rights and freedoms.

There is a duty by the assessor to ensure every avenue has been exhausted to facilitate a persons ability to make decisions, however following this, someone will fail to meet the requirements of capacity if they cannot fulfil all these prerequisites:

1: understand the information relevant to the decision
2: retain that information
3: use or weigh up the information
4: communicate the decision

Often a clinical psychologist or neuropsychologist will be instructed by the court of protection or a solicitor to conduct a neuropsychological assessment and produce a report to help the court make a decision as to a person's capacity and best interests. The instruction of these expert witnesses will offer an independent, evidence-based, reliable and valid opinion as to persons mental capacity on a specific decision(s). As well as being decision-specific, assessments are also time bound and subject to review depending on the prognosis and changeability of the person's cognitive status. For example, when a person recovers from severe mental illness /brain injury or where a person has periodically lucid periods within a neurological disease (sometimes seen in Parkinson's disease).

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