Do you recommend any specific tools or processes/references to help with the determination of capacity for decision-making for hospitalized older adults with cognitive impairment?

It is important to recognize that decision-making capacity in hospitalized older adults with cognitive impairment is both decision-specific and time-specific. Assessment should focus on the patient’s ability to demonstrate the four elements described by Appelbaum and Grisso: understanding, appreciation, reasoning, and the ability to communicate a choice regarding the specific medical decision.

In practice, I generally first clarify the decision being evaluated (ie, consent for treatment, refusal of intervention, discharge planning, etc) and assess for reversible contributors to cognitive impairment. Screening for delirium (using tools like the CAM) is essential, as it is common in hospitalized patients and can significantly impair or fluctua...