How is capacity assessed in individuals with potential cognitive impairment?

Assessment of Capacity in Individuals with Potential Cognitive Impairment

Capacity assessment should begin with the presumption that individuals have capacity until demonstrated otherwise, using context-specific, standardized tools that evaluate understanding, appreciation, reasoning, and ability to communicate choices.

Core Principles of Capacity Assessment

• Capacity is decision-specific and not a global characteristic; individuals may retain ability to make certain decisions while lacking capacity for others 1, 2
• Capacity assessment should be proportionate to the risks involved in the decision being made 1
• Capacity requires mental skills including memory, logic, calculation ability, and cognitive flexibility 1
• The assessment should be time and context-specific, as capacity may fluctuate in the short and long term 1

Key Components of Capacity Assessment

Four Essential Elements to Evaluate

• Understanding: Ability to comprehend information relevant to the decision 2
• Appreciation: Recognition of one's condition and likely consequences of decisions 2
• Reasoning: Ability to weigh risks and benefits and make decisions consistent with this evaluation 2
• Expression of choice: Ability to communicate a decision 2

Assessment Process

1. Detailed patient history including specific examples of confusion or impaired decision-making 1, 2
2. Collateral history from family members who can provide insight into baseline cognitive function 1
3. Focused physical and cognitive examination including standardized cognitive assessments 1
4. Exclusion of reversible conditions that may temporarily affect decision-making capacity 1

Cognitive Assessment Tools

• Montreal Cognitive Assessment (MoCA) is superior to MMSE for detecting mild cognitive impairment with better sensitivity (80.48% vs 66.34%) and less ceiling effect 3, 4, 5
• Mini-Mental State Examination (MMSE) may be used but has limitations in detecting subtle cognitive impairment 1, 6
• Stroop Test evaluates executive functions including cognitive flexibility and response inhibition 7
• Trail Making Test assesses psychomotor speed and sequencing abilities 1, 7

Tailoring Assessment to Risk Level

• For minimal risk decisions, capacity assessment may be integrated with an interactive process, potentially facilitated by family 1
• For moderate risk decisions, use brief screening tools first, then proceed to more formal assessments if uncertainty exists 1
• For high risk decisions, implement a rigorous, formal capacity assessment with higher thresholds for demonstrating capacity 1

Documentation Requirements

• Document specific examples of the patient's confusion and its impact on decision-making ability 2
• Record the clinical reasoning that led to the determination about capacity 2
• Specify which decisions the patient can or cannot make (avoid global assessments of incapacity) 2
• Document plans for reassessment if confusion may be temporary 2

Common Pitfalls to Avoid

• Relying solely on diagnosis, age, or appearance to determine capacity 2
• Using vague statements like "patient confused" without specific examples 2
• Determining capacity based only on MMSE scores without comprehensive assessment 1
• Failing to recognize that capacity may fluctuate and require reassessment 1
• Not considering cultural differences in capacity assessment 1

When Capacity Is Impaired

• Identify an appropriate surrogate decision-maker 1
• Review any advance directives or power of attorney documents 1
• Document discussions with surrogates about the patient's previously expressed wishes 1
• Ensure decisions made on behalf of the patient are in their best interests 1, 2
• Consider whether the patient retains capacity to appoint a legal representative even if lacking capacity for other decisions 1