Decision-making capacity involves four (4) key abilities: the ability to understand information relevant to a decision, to retain the information relevant to the decision, to use the information relevant to the decision as part of the decision-making process and to communicate the decision once it is made. But since decision-making capacity involves mental abilities, how does one assess mental capacity?
Examining an elderly or disabled individual to assess decision-making capacity is a complicated process. Anyone who assesses an older person for the possibility of cognitive impairment assumes a great responsibility. Errors in evaluation can have far reaching consequences for the person being evaluated, typically involving the curtailment of individual liberty.
The most widely known and used tool to evaluate mental status is the mental status questionnaire, such as Folstein’s Mini-Mental Status Test. Mental status questionnaires provide a series of scores indicating the extent of a person’s understanding, appreciation, reasoning, and expressive abilities. However, using such questionnaires as the sole tool to evaluate mental status can lead to errors that impact care.
A wealth of information about an elderly or disabled person’s mental function can be obtained by “observing” the individual. How we appear and dress, the language we use, and how we behave provide clues that reveal our sense of “self,” and indirectly a person’s mental capacity. Level of mental functioning can be determined by observing the following physical characteristics:
1. APPEARANCE and GROOMING.
- General Attitude:Sometimes people with early mental impairment seem overly polite, too friendly and cooperative.Often people will use wit and intellect to avoid giving a “wrong” answer.Compromised individuals often have a flat, depressed, anxious, or suspicious attitude.Is the patient’s appearance congruent with their chronological age?
- Facial symmetry and expressiveness may reflect illness or drug effect, or the degree of interest in interacting.
- Hygiene and Facial Grooming: These areas of assessment may show signs of neglect, application of makeup, shaving or other facial features.
- These clues reflect personal taste, manual dexterity, joint range of motion, eyesight, degree of interest in appearance, and cognitive level, including the level of awareness, concentration, memory, and apraxia.
- Observations of dress can reveal personal tastes, ethnic or cultural influences, weight change, eyesight, seasonal variations, degree of interest in appearance, susceptibility to injury, and the ability to make choices compatible with social norms.
- The fit of clothing can reflect weight change and the state of fastenings can suggest a change in cognitive function.
- Look for potential barriers to communication which would include: Vision; Hearing; Receptive and expressive aphasia; Language; Too much ambient noise. An example might be seen in an elderly person who continually looks puzzled when spoken too, and frequently looks at family members
Can you capture and maintain the person’s attention?
- Be alert to linguistic modifications:
Analyze the delivery as well as the content of language.
Watch for speech rate, pauses, tonal quality, volume, pitch and articulation
These observations relate to level of awareness, ability to concentrate, memory, and dysphasia.
- Analyze the logic of the content of the patient’s statements.
- Consider the clearness and completeness of the thoughts expressed and the precision of answers.
- Consider digressions away from the theme of the conversation and whether the conversation returns at some point.
- Notice the flow of ideas, the person’s level of anticipation and insight, and evidence of judgment and abstract thinking. People with early dementia may have difficulty using their imagination. For example: Ask the person to take you on a walk through their home beginning at the front door.
- Pay close attention to the precision of answers making sure the boundaries of the question are contained in the question. For example: A woman with early dementia, who also loves to garden, is asked specifically what plants she planted last week? Her answer was annuals and perennials. This is too abstract.
- Posture shows general physical status, illness or drug effect, self-confidence, self-esteem, personality, degree of interest in interacting, and cognitive function.
For example: The elderly woman who sits hunched over, with her arms held close to her body, may be signaling vulnerability.
- Degree of interaction is an important area of behavioral observation. Interaction is revealed through eye contact and body language.
- Watch the performance of simple tasks or actions:
How does the person walk into the room, take a seat, and so on.
Pay attention to the amount of time and the degree of effort it takes to perform tasks. The performance of simple tasks is closely related to the person’s future needs for care.
Once the “observational” assessment is completed, a preliminary determination can be made about the extent to which the individual retains decision-making capacity.
(This blog post is based upon a PowerPoint presentation prepared by Mark Pass MD. Dr. Pass is a geriatrician with his medical practice, Jersey Shore Geriatrics, in New Jersey Dr. Pass was one of the speakers at our first full-day training in Estate and Elder Mediation entitled “Keeping the Peace Through Elder Mediation.”)
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