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Dementia, Decision Making, and Capacity

Darby, R. Ryan MD; Dickerson, Bradford C. MD

doi: 10.1097/HRP.0000000000000163
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Learning objectives After participating in this activity, learners should be better able to:

• Assess the neuropsychological literature on decision making and the medical and legal assessment of capacity in patients with dementia

• Identify the limitations of integrating findings from decision-making research into capacity assessments for patients with dementia

Medical and legal professionals face the challenge of assessing capacity and competency to make medical, legal, and financial decisions in dementia patients with impaired decision making. While such assessments have classically focused on the capacity for complex reasoning and executive functions, research in decision making has revealed that motivational and metacognitive processes are also important. We first briefly review the neuropsychological literature on decision making and on the medical and legal assessment of capacity. Next, we discuss the limitations of integrating findings from decision-making research into capacity assessments, including the group-to-individual inference problem, the unclear role of neuroimaging in capacity assessments, and the lack of capacity measures that integrate important facets of decision making. Finally, we present several case examples where we attempt to demonstrate the potential benefits and important limitations of using decision-making research to aid in capacity determinations.

From Harvard Medical School; Department of Neurology, Vanderbilt University Medical Center, Nashville, TN (Dr. Darby); Department of Neurology, Massachusetts General Hospital, Boston, MA (Drs. Darby and Dickerson); Berenson-Allen Center for Noninvasive Brain Stimulation, and Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA (Dr. Darby).

Original manuscript received 16 August 2016; revised manuscript received 12 December 2016, accepted for publication subject to revision 10 February 2017; revised manuscript received 27 February 2017.

Correspondence: Ryan Darby, MD, Department of Neurology, Vanderbilt University Medical Center, A-0118 Medical Center North, Nashville, TN 37232. Email: richard.r.darby@vanderbilt.edu

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© 2017 President and Fellows of Harvard College
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