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Assessment of Competency: The Role of Neurobehavioral Deficits

Morris Freedman, MD; Donald T. Stuss, PhD; and Michael Gordon, MD
[+] Article and Author Information

Grant Support: Dr. Freedman was supported by a Career Scientist Award from the Ministry of Health of Ontario. Dr. Stuss was supported by the Ontario Mental Health Foundation.

Requests for Reprints: Morris Freedman, MD, Behavioural Neurology Unit, Baycrest Hospital, Room 4W36, 3560 Bathurst Street, Toronto, Ontario M6A 2E1.

Current Author Addresses: Dr. Freedman: Behavioural Neurology Unit, Baycrest Centre for Geriatric Care, 3560 Bathurst Street, Toronto, Ontario M6A 2E1.

Dr. Stuss: Rotman Research Institute, Baycrest Centre for Geriatric Care, 3560 Bathurst Street, Toronto, Ontario M6A 2E1.

Dr. Gordon: Medical Director, Baycrest Centre for Geriatric Care, 3560 Bathurst Street, Toronto, Ontario M6A 2E1.


© 1991 American College of PhysiciansAmerican College of Physicians


Ann Intern Med. 1991;115(3):203-208. doi:10.7326/0003-4819-115-3-203
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▪ We present a practical set of guidelines for assessing competency in patients with cognitive deficits due to neurologic disorders such as stroke, head injury, Alzheimer disease, and multi-infarct dementia. Our focus is the evaluation of cognitive processes underlying the ability to make competent decisions, with an emphasis on the identification of areas of preserved function that may be used to bypass intellectual deficits. The assessment of the cognitive processes underlying competency involves a series of steps designed to evaluate attention, language, memory, and frontal lobe function. The examiner must first show that the patient has an adequate level of attention for participation in the further testing of specific cognitive functions; second, that the patient is able to comprehend relevant instructions, retain information long enough to evaluate it in relation to relevant recent and remote experiences, and express his or her wishes; and finally, that the patient has sufficiently intact judgment and awareness. The examiner must determine whether the patient's preserved cognitive abilities are sufficient for him or her to make an adequate judgment in relation to the specific question being asked. If cognitive function is found to be significantly impaired, the examiner should do a detailed assessment for the presence of compensatory abilities that can be used to bypass the deficits. For example, the examiner should assess whether patients who cannot speak are still able to express their wishes by pointing, using gesture, or even by drawing pictures. Unless such an assessment has been done, patients should not be considered incompetent.

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