High inter-rater reliability, but lower test–retest reliability. Capacity is particularly relevant in the context of Power of Attorney (PoA), Guardianship, voting, contracts, wills, marriage and criminal responsibility [1–3]. Mum had a diagnosis of mixed dementia 4 years prior to the fall. Conversely, expression of choice is not emphasised in N.American literature, but is a key component of the UK legislation. Grisso T, Appelbaum PS MacArthur Competence Assessment Tool for Treatment (MacCAT-T). These can all be customised, and were designed for clinical use. Whilst the different UK nations have different legal criteria for mental capacity, they have four key elements in common. Give examples of how and why adjustments to care and support might need to be made when a mental health condition, dementia or learning disability is identified. Widely investigated in patients with dementia, mental health disorders and medical patients. Vignettes around planned treatment. Defining and judging mental capacity requires a fine balance between patient autonomy and protection of vulnerable adults. A learning disability. Clinicians and researchers must objectively assess understanding and retention of relevant information, and ability to use information to make and express a choice. Mental Capacity and Competency. However, not all patients ne… nine tools were identified which fulfilled the UK legal requirements. Standardised vignette regarding venepuncture. How can we evaluate the potential of innovative vaccine products and technologies in resource constrained settings? All detected poorer understanding in individuals with dementia. The complexity of capacity assessment means it is unlikely to be successfully reduced simply to a score on a memory test, or tick boxes in a questionnaire. The discrepancy between the MacCAT-CR and expert opinion raises concerns as to whether expert opinion may over-estimate capacity. This is vital to promote the autonomy of people with dementia, and to protect those who have lost decisional capacity. Informal ratings by the clinical team or relatives are much less reliable than either expert opinion or structured assessments [9]. Much of the literature has focused on how major mental health conditions impact on decision making, and it was felt that with due caution, insights from mental health research may be relevant to older adults with neurodegeneration (Box 3). For example, a person may be able to choose what to eat for breakfast; however, due to their mental disorder, they may not be able to remember which medication they should be taking, when they should take it, or how much. The greatest challenge is the current lack of a gold standard. Therefore, some tools are not compatible with the UK law because they do not assess all the key principles defined therein, or they include a test of ‘reasonableness’. Many families find that decisions are made about vulnerable older relatives without a proper Mental Capacity Assessment being carried out. What is the Test for Mental Capacity The Two Stage Test – Decision Making Capacity. London EC1M 4DN, Decisions, Decisions, Decisions: How to assess the mental capacity of people with dementia. Furthermore, some may require modification for certain groups. Capacity assessments in any medical or psychiatric conditions and healthy adults were also included. Competency is a legal term, defined as: "duly qualified: having sufficient capacity, ability, or authority" [Black's Law Dictionary].. Also, capacity is decision specific, meaning separate decisions require a standalone mental capacity assessment. For consent to be valid, the person giving it must have the mental capacity to understand what they are consenting to; it is the same as any other contract or agreement. No formal assessment procedures are required for health care assistants or support staff. Clinical teams may have agendas that conflict with the autonomy of the person under their care. These must always be assessed in a sensitive and careful fashion, to both maximise a person’s decision-making abilities and to protect those persons who are unable to make decisions for themselves. Someone lacking capacity because of a disability or illness such as a learning disability, dementia or a mental health problem would be unable to do one or more of the following four things: Understand information given to them about a particular decision Retain that information long enough to be able People with dementia experience changes to their ability to understand, evaluate and retain information, and may have problems expressing and remembering their decisions. For permissions, please email: journals.permissions@oup.com, This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (. Different tools have been developed for different patient groups and decision-making scenarios—for example, the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC) is a brief screening tool to help junior researchers identify research participants who need further capacity assessment [26]. Dementia. People with dementia should not be assumed to lack decision-making capacity. Palmer BW, Dunn LB, Appelbaum PS et al. Prisons and Probation Ombudsman for England and Wales. The UK legislation sets out clear requirements for the presence or absence of capacity. If a person lacks capacity, any decisions made must be in their best interests. compared the MacCAT-T, CCTI and the HCAI for the assessment of people with mild to moderate dementia and matched controls [27]. Dr Catherine Pennington is a Senior Clinical Research Fellow at the Centre for Dementia Prevention, University of Edinburgh, and honorary Clinical Lecturer at the University of Bristol ReMemBr Group. The article reviews the pros and cons of the different tools available, alongside cultural and neuropsychological aspects of decision making. It also avoids confusing adults with cognitive impairment by discussing hypothetical situations—a discussion that is arguably more complex than discussing a real-life, personally relevant decision. Jeste DV, Palmer BW, Appelbaum PS et al. . 1. Whilst many studies are limited by small sample sizes and limited replication, they highlight variability in clinician judgement, and bring into question what should be our gold standard capacity assessment. Therefore, people with mild dementia may be able to make informed decisions about a simple, low risk, high benefit change to medication, but not about a complex surgical procedure with a borderline risk/benefit ratio. The Mental Capacity Act 2005 (HM Government, 2005) is all about consent. Marson DC, Earnst KS, Jamil F, Bartolucci A, Harrell LE. Altered mental capacity can affect not only adults with dementia, but also those with learning difficulties, acquired brain injury or mental health disorders. A similar, relatively simple level of understanding is required when making a will—the individual must understand the provisions, and recall what property they have, and any legal claims upon it. Such superficial assessments are inadequate and will miss both those lacking capacity, and those who with support (e.g. When a person has dementia their mental capacity can change over time. And it’s still too common for people to be assumed to lack mental capacity because of a diagnosis – dementia, or a learning disability – or because they’re very old. Publications specific to the legal requirements of non-UK jurisdictions were excluded to allow proper cross-referencing to the relevant UK capacity legislation. There is considerable heterogeneity within patient groups. Decisions must take account of their wishes, so far as these are known. Admiral Nurses are dementia specialist nurses who provide the compassionate one-to-one support, expert guidance and practical solutions that help families face dementia with more confidence. An irrational decision does not equate to the absence of capacity. This could mean simplifying the language used, repeating information, and using clearly written, short documents. Patients may fail a test of capacity due to fixed, abnormal illness-related beliefs, rather than impaired understanding, recall or communication [9]. avoiding the evening, when confusion may worsen). They are not able to communicate a decision (whether by talking, using sign language or any other means). Limited published data available (no data on reliability available). An example of a more detailed need for capacity assessment may be in the context of a patient receiving a surgical intervention, where there may be large risks associated with the procedure itself. These staff and their employers have a duty to ensure they know how to use it. From the MCA asset: Mum was identified not to have capacity to make decisions. . Many people with mild or moderate dementia will still have the ability to make informed choices, particularly when information is given in an appropriate format. Development and Application of High-Throughput Single Cell Lipid Profiling: A Study of, The five key principles of the Mental Capacity Act 2005, Assessment of capacity for everyday decision making [. However, clinical judgements made without using a structured tool have lower reliability, particularly regarding people with dementia [29]. Prisons and Probation Ombudsman for England and Wales, Empirical advances in the assessment of the capacity to consent to medical treatment: clinical implications and research needs, Reliability of mental capacity assessments in psychiatric in-patients, Informed content in older medical inpatients: assessment of decision-making capacity, Assessing medical decision making capacity among cancer patients: preliminary clinical experience of using a competency assessment instrument, Structured assessment of mental capacity to make financial decisions in Chinese older persons with mild cognitive impairment and mild Alzheimer disease, Health care decision-making by adults with mental retardation, The development and piloting of a capacity assessment tool, Enhancing medical decision-making evaluations: introduction of normative data for the capacity to consent to treatment instrument, The capacity of people with a ‘mental disability’ to make a health care decision, Cognitive performance predicts treatment decisional abilities in mild to moderate dementia, Validity and reliability of structured interview for competency incompetency assessment testing and ranking inventory, The ability of persons with Alzheimer disease (AD) to make a decision about taking an AD treatment, Assessment of capacity to consent to research among older persons with schizophrenia, Alzheimer disease, or diabetes mellitus, Understanding of informed consent by demented individuals, Decisional capacity for research participation in individuals with mild cognitive impairment, Assessment of decision-making capacity in older adults: an emerging area of practice and research, A new brief instrument for assessing decisional capacity for clinical research, Capacity to consent to treatment: empirical comparison of three instruments in older adults with and without dementia, Consistency of physicians’ legal standard and personal judgments of competency in patients with Alzheimer’s disease, Consistency of physician judgements of capacity to consent Alzheimer’s disease, © The Author(s) 2018. Moye J, Karel MJ, Azar AR, Gurrera RJ. Tomoda A, Yasumiya R, Sumiyama T et al. Dementia is a clinical syndrome of deterioration in mental function which interferes with activities of daily living (ADLs). Published by Oxford University Press on behalf of the British Geriatrics Society. It is therefore vital that we are able to accurately assess a person's ability to make informed choices. Any assessment of capacity must include a: 1. global assessment of the person’s mental state and cognitive function - ideally with an estimate of severity and an assessment of the specific executive and functions of judgment, reasoning and planning which are relevant to decision-making; and 2. a functional assessment of decision-making i.e. Thirty-nine adults with mild to moderate cognitive impairment; 90 adults with AD, 92 with MCI. Mental Capacity Assessments. . This does not negate the usefulness of SICIATRI, but it is important to recognise that some tools may require context-specific modification. High inter-rater reliability from a pilot study. Please check for further notifications by email. There is a clear need for professionals to make accurate and reliable decisions regarding capacity, preferably in a standardised manner. Capacity is decision specific and should be assessed on this basis. This highlights that different tools have different strengths and weaknesses. Decisions must take account of the views of relevant others. Two hypothetical clinical vignettes, with detailed questioning and scoring of responses. As the elder population continues to grow, local, national, and international changes are occurring in criminal and civil litigation. The majority affected are older adults, who experience progressive cognitive decline. Mental capacity is a functional term that may be defined as: the "mental (or cognitive) ability to understand the nature and effects of one's acts.". Copyright © 2020 British Geriatrics Society. have reduced morbidity and/or mortality) residing in an institutional fa… Evaluating whether an individual can make a decision in the real world is very challenging. It can also include being bereaved, or shocked after an accident - it needn't be permanent or even medical. . Moye J, Gurrera RJ, Karel MJ, Edelstein B, O’Connell C. Cairns R, Maddock C, Buchanan A et al. More complex decisions will require greater cognitive ability. The Mental Capacity Act code of practice lists examples of when a professional might be ... although Mrs Smith has dementia, her capacity to make a decision should not be questioned ... Before I started the second element of the mental capacity assessment, known as the ‘functional Internationally, many areas where capacity legislation has been enacted follow a similar model to that of the UK. PART A: CHECKLIST BEFORE CARRYNG OUT FUNCTIONAL MENTAL CAPACITY TEST DIAGNOSTIC TEST This article aims to make that clearer.We’ve also included links to som… Further work in people with neurodegeneration would be of great interest, particularly investigating the role amnesia plays in impaired capacity. Structured Interview for Competency/incompetency assessment testing and ranking inventory [. safeguarding needs, support needs, housing needs etc. For example, if a professional believes that you lack mental capacity to make a decision about your treatment or care they must do this test with you. Understanding, retaining and using information are typically impaired, with expression of choice often remaining intact [24]. To consent to a marriage, an individual is only required to have a simple understanding of the basic concept. Deprivation of Liberty Safeguards (DoLS) are an amendment to the Mental Capacity Act (2005) to ensure that any care restricting a person's liberty is appropriate and in their best interests. No test of capacity is applied to the UK voting rights, provided the individual is registered and can express their choice. N.Ireland Assembly Mental Capacity Act (Northern Ireland). MacArthur Competence Assessment Tool for Treatment (MacCAT-T). Some are more stringent than UK law requires, whilst others are not stringent enough. Here, we review the UK legal framework for defining mental capacity, and published capacity assessment tools. Buckles VD, Powlishta KK, Palmer JL et al. High inter-rater reliability. They are not able to appreciate the relevance of the information or to use and weigh that information as part of the process of making the decision. dementia is a common cause of altered decision-making capacity. This may reflect the information available—if understanding, recall and decision making are not specifically probed then clear-cut impairments may be missed. Even when capacity is broken down into the basic components of understanding, weighing up choices, recalling information and expression of a choice, correlations with specific cognitive domains are variable, and of moderate strength. We also consider further disease and culture-specific factors which may influence decision making. You must always assume that a person is able to make a … MCA assessment was carried out by a Consultant Geriotrician in an A and E department. It may also vary over time (including over the course of a single day). Searches were conducted between December 2016 and February 2017, limited to papers published in English after 2000. A score of 19 or less on the Mini-mental state examination (MMSE) robustly predicts incapacity, but a higher score does not guarantee capacity [21]. Such changes could be brought on by the impact of a mental illness, physical illness, the use or withdrawal of medication, the use of illicit substances or alcohol. Semi-structured interview. Developed for adults with learning difficulties. Mental Capacity Assessment Dementia Example (Download) Mental Capacity Act 2005 Summary (Download) When carrying out a Mental Capacity Act Assessment, one must consider the 2 stage capacity test. Others are tailored for people with dementia, learning difficulties, or mental health disorders. Mental Capacity: Dealing with Fluctuating Capacity Fluctuating capacity is when a person’s ability to make a specific decision changes frequently or occasionally. Normative data from healthy adults available (. What is mental capacity? It is therefore highly recommended that those at risk of losing capacity (e.g. Wong JG, Clare CH, Holland AJ, Watson PC, Gunn M. Gurrera RJ, Moye J, Karel MJ, Azar AR, Armesto JC. Multiple tools exist to aid in the assessment of decision-making capacity. Many conditions cause a fluctuating cognitive state, for example Lewy body disease and delirium. Decisions about mental capacity should never have a blanket approach, and professionals should tailor their methods to the individual and decision in question. They cannot retain information for the time required to make the decision. Jefferson AL, Lambe S, Moser DJ, Byerly LK, Ozonoff A, Karlawish JH. Adaptable to different scenarios. Your comment will be reviewed and published at the journal's discretion. Generally, a capacity assessment should be related to a specific decision that you are making. Akechi T, Okuyama T, Uchida M et al. A person holding PoA, guardianship or similar cannot vote on their behalf [4]. The Mental Capacity Act gives guidance on assessing mental capacity – when it should be done and who should do it. When assessing reasoning, the MacCAT-T and CCTI identified impairments in the dementia group, whilst the HCAI did not. MacArthur competence assessment tool-clinical research [. The war against dementia: are we battle weary yet? ReMemBr Group, School of Clinical Sciences, University of Bristol, Bristol Brain Centre, Southmead Hospital, Bristol, UK, Neurology Department, North Bristol Trust, Southmead Hospital, Bristol, UK, Centre for Dementia Prevention, University of Edinburgh, 9A Bioquarter, 9 Little France Road, Edinburgh, UK. Each aspect of capacity scored individually and cut-off scores specified. Many people used to think it was ‘all or nothing’ – someone either has mental capacity or they haven’t. Scottish Parliament Adults with Incapacity (Scotland) Act 2000. 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