Optimizing Cognition and Functioning Before Evaluating Capacity

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The ability to make voluntary (meaning not coerced), informed consent is known as decisional capacity. Capacity is specific to different decisions, so there is the capacity to consent to medical treatment, to make welfare decisions, to make a will, etc. In this sense, an individual may have full capacity in 1 domain (eg, consent to medical treatment), but may concurrently lack capacity in another domain (eg, financial decision capacity). Regardless of domain, to make a health care decision or to assist in disposition decision-making, one must be able to understand the question at hand, attend to and remember the information presented, reason logically to make a decision, and communicate a decision.¹

Clearly, deficits in attention, memory, language, or executive functioning can impair any part of this process. Capacity can be diminished temporarily, or one can be permanently incapacitated or lacking in capacity. Illnesses such as a stroke or dementia can affect one’s capacity, either temporarily or permanently. However, having cognitive impairment does not necessarily mean that one has diminished capacity. Capacity must be ascertained or assessed functionally at the time, either clinically and/or by a legal professional. In doing so, if it is determined that an individual comprehends the decision at stake (and can explain it in their own words), appreciates the consequences of their decision, can reason rationally and logically, and can communicate their choice, then they are considered to have decision-making capacity. Autonomy and self-determination (the right of competent adults to make their own choices and decisions) are presumed until proven otherwise. Even an “unwise” decision, or one that we personally would not choose in the same situation, does not by itself indicate someone is incapacitated. Likewise, having capacity is no guarantee someone will make a good decision and going against medical advice does not signify incapacity.

Capacity also exists on a continuum and can fluctuate. When assessing a patient's cognition ordecision-making capacity, we first need to maximize their functioning and abilities.² In fact, when assessing capacity, their daily functioning should be assessed along with their cognition.³Ideally, the patient’s capacity can be optimized, enhanced, or even restored for them to make their own decisions. For example, if time is not of the essence, waiting until their cognition improves (following treatment or therapies) and then reassessing their capacity may be an option; this strategy avoids unnecessarily restricting the patient’s autonomy. Restoring capacity may include first identifying and treating reversible causes of cognitive impairment and risk factors for dementia, many of which are modifiable.^4-8 Although providers may have conducted a cognitive screening, ruling out reversible causes of cognitive impairment is important before providers refer a patient for more comprehensive neuropsychological evaluation.^9-11 Some reversible causes of cognitive impairment include medication/polypharmacy, drugs and substance abuse, normal pressure hydrocephalus, vascular risk factors, brain tumor, sensory deficits, impaired sleep, depression or other psychiatric disorders, persistent pain, metabolic imbalance, infectious disease, and delirium. See the Table for a list of conditions to screen for.

Besides ruling out reversible causes of cognitive impairment, maximizing functioning also means providing practical accommodations and supports to optimize performance.^12,13 For example, assistive devices may be needed, such as ensuring the patient has their glasses or their hearing aids. Patients may also need enlarged written materials, a sound amplifier, or different methods for communication. Other adaptations include assessing the patient at their preferred time of day when they are most alert, and confirming they are not in acute and distracting pain, or hungry. It is very important that the patient can encode and process information, and that they have a thorough understanding of the situation before there can be any sort of examination. If the patient has difficulty understanding, education could be provided, or medical forms could be read aloud and interpreted. Additional supports include transportation and bill-paying services, prescription delivery, food delivery, medication reminders, life-alert devices, day programs, and assisted living. The goal is always to maximize and support the patient’s abilities and capacity before restricting their autonomy. Of course, there may be occasions when treatment or accommodations are already maximized (ie, for acute pain), but still appear to affect the assessment. In this case, if the evaluation cannot be deferred, all factors impacting the assessment should be mentioned in the report.

Case Example

“Mr Owen” is a 67-year-old man. He currently lives alone, but his family is concerned that he needs a guardian or some kind of intervention, as he has not been paying his rent and his landlord is threatening eviction. He is currently in poor mental and physical health, and has bipolar disorder, a past brain injury, hypertension, diabetes, and depression. He requires assistance with many of his activities of daily living and refuses to take medication for either his physical or mental conditions. He is cognitively and visually impaired, and at times refuses to recognize his illness or his need for medication. He has not updated his eyeglass prescription in several years, and his foot currently has a sore that is on the verge of becoming gangrenous. Mr Owen engages in hoarding behavior, can be angry and agitated, and shows poor insight and judgment. He is unable to provide for his personal needs or property and cannot adequately understand and appreciate the nature and consequences of such inability.

In evaluating the patient’s capacity, we want to balance “do no harm” versus “self-determination.” At this moment in time, Mr Owen would not have the capacity to live alone, nor could he make medical decisions for himself or manage his own finances. He is not taking care of his own physical or mental health and is facing eviction. Specifically, by not acknowledging his illnesses, refusing medication, and not paying his rent, he is not appreciating the consequences of his decisions—one of the foundational aspects of capacity.

However, before his autonomy is limited, we would want to first optimize and restore capacity as much as possible by treating his reversible conditions. This goal was explained to Mr Owen, and with his assent, he was brought to his primary care doctor and psychiatrist and started taking his medications. His depression improved, his blood sugar and blood pressure became better controlled, and his foot sore healed; he did not have to be hospitalized. Furthermore, he became less agitated and generally more cooperative. His insight improved and his cognition (especially his attention and orientation) became somewhat better.

We would also want to maximize his functioning further by providing needed accommodations and supports. Mr Owen was brought to the optometrist, where he was evaluated and fitted with updated glasses. His apartment was cleaned and his bills, including past rent, were paid. His family also set up a bill-paying service for future rent and other bills, and arranged for prescription delivery and a pill box with medication reminders to ensure he took his medication regularly.

Ultimately, Mr Owen regained capacity and was able to live again on his own, caring for his own medical and financial needs. Thus, capacity can first be restored or optimized, and then assessed (or reassessed), to prevent an unnecessary restriction of autonomy.

Concluding Thoughts

In the assessment of decisional capacity, clinicians are encouraged to take a patient-centered, least-restrictive approach that prioritizes restoring and supporting capacity before implementing any interventions that would limit a patient's rights or autonomy. Decisional capacity is domain-specific, and cognitive impairment does not necessarily indicate incapacity; capacity is always presumed unless proven otherwise. Because capacity is dynamic and may fluctuate over time, a comprehensive assessment should include cognitive and functional evaluation, identification and treatment of reversible causes of impairment, and the implementation of accommodations and supportive services to enhance the patient’s ability to participate in decision-making.

Dr Farrer is the associate program director of the School of Health and Medical Professions at the University of Idaho.

Dr Schaefer is the director of neuropsychology services and training of the Department of Psychiatry and Behavioral Sciences at the Nassau University Medical Center.

Dr Schaefer and Dr Farrer may receive royalties from potential sales of 2 books cited in this manuscript, including:

• Schaefer LA, Farrer TJ, eds. A Casebook of Mental Capacity in US Legislation: Assessment and Legal Commentary. Routledge; 2022.
• Farrer TJ, Schaefer LA. Reversible Causes of Cognitive Impairment and Dementia: From Neuroscience to Clinical Practice. Routledge, Taylor & Francis Group; 2025.

References

1. Grisso T, Appelbaum PS. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. Oxford University Press; 1998.

2. Schaefer LA, Farrer TJ. A Casebook of Mental Capacity in US Legislation: Assessment and Legal Commentary. Routledge; 2022.

3. Schaefer LA. A Handbook of Geriatric Neuropsychology: Practice Essentials. Routledge, Taylor & Francis Group; 2022:324-340.

4. Farrer TJ, Schaefer LA. Reversible Causes of Cognitive Impairment and Dementia: From Neuroscience to Clinical Practice. Routledge, Taylor & Francis Group; 2025.

5. Joshi P, Tariot PN. Dementia prevention: pipe dream vs possibility. Psychiatric Times. May 6, 2025. https://www.psychiatrictimes.com/view/dementia-prevention-pipe-dream-vs-possibility

6. Jones A, Ali MU, Kenny M, et al. Potentially modifiable risk factors for dementia and mild cognitive impairment: an umbrella review and meta-analysis. Dement Geriatr Cogn Disord. 2024;53(2):91-106.

7. Livingston G, Huntley J, Liu KY, et al. Dementia prevention, intervention, and care: 2024 report of the Lancet standing commission. Lancet Lond Engl. 2024;404(10452):572-628.

8. Bevins EA, Peters J, Léger GC. The diagnosis and management of reversible dementia syndromes. Curr Treat Options Neurol. 2021;23(1):3.

9. Wise LM, Aga VM. Diagnostic considerations in clinical cognitive assessment. Psychiatric Times. April 14, 2025. https://www.psychiatrictimes.com/view/diagnostic-considerations-in-clinical-cognitive-assessment

10. Pick LH, Schaefer LA, Scorpio KA, et al. Mental status examination. MedLink Neurology. May 12, 1999. Accessed June 24, 2025. https://www.medlink.com/articles/mental-status-examination

11. Schaefer LA, Farrer TJ, Dowling DJ. Improving the effectiveness of collaboration between neuropsychology and primary care. Prim Care Companion CNS Disord. 2024;26(5):24nr03766.

12. Schaefer LA, Pick LH. Considerations and suggested practices for psychological assessment and intervention when working with older adults with disabilities. Prof Psychol Res Pract. 2022;53(5):446-457.

13. Stucky KJ, Hatfield-Eldred M. A Handbook of Geriatric Neuropsychology: Practice Essentials. Routledge, Taylor & Francis Group; 2022:304-323.

Table. Potentially Reversible Medical and Psychiatric Conditions

Condition

Neuropsychiatric Conditions

•Depression, anxiety, or other mood disorder

•Schizophrenia, psychosis, or other serious mental illness

•Delirium or other encephalopathy

•Postictal confusion or non-convulsive status epilepticus

•Mild traumatic brain injury (eg, concussion)

•Sleep disorders:

•Insomnia/hypersomnia

•Sleep apnea

•Mild cognitive impairment (may not be fully reversible but may fluctuate)

Metabolic, Endocrine, and Nutritional Disorders

•Diabetes mellitus

•Hypoglycemia

•Cushing disease

•Addison disease

•Wilson disease

•Renal failure

•Pituitary adenoma

•Thyroid disease/Hashimoto encephalitis

•Hypercalcemia

•Electrolyte imbalances (eg, hyponatremia, hypernatremia)

•Vitamin deficiencies:

 •Vitamin B1, B6, B9, B12; Vitamin D; Vitamin E

Structural, Infectious, and Autoimmune Disorders

•Normal pressure hydrocephalus

•Infectious disease

•Autoimmune or paraneoplastic encephalitis (eg, anti-NMDA receptor)

•Tumor, space-occupying lesion, or paraneoplastic process

Substance-Related and Iatrogenic Causes

•Medication adverse effects and polypharmacy

•Drug or other toxin exposure

•Alcohol intoxication or withdrawal

•Substance use or withdrawal (eg, methamphetamine, cannabis)

•Benzodiazepine or opioid use or withdrawal

Other Medical and Physiologic Conditions

•Severe pain

•Congestive heart failure or hypoxia/hypoperfusion states

•Arrhythmia or syncope

•Postoperative cognitive decline

•Sensory-perceptual declines