Capacity vs. Competence   

Capacity is typically considered a clinical term and relates to a person’s ability to make decisions regarding their medical care, financial management, assets, sexual consent, and future wishes. It has been referred to as a person’s “goodness of fit” between their current abilities and the performance demands of the particular context in question. Capacity is sometimes domain specific. For example, an individual may have financial capacity yet lack medical decision-making capacity, or vice versa. Capacity encompasses one’s ability to:  

• Comprehend information relevant to their medical conditions, treatment options, financial decisions, etc.  

• Appreciate the likely outcomes of each possible decision, including refusing proposed treatments.  

• Weigh the pros and cons of proposed treatments or decisions. 

• Express their intended decision. However, individuals (particularly those with dementia) may express a choice without adequately understanding, appreciating, or being able to weigh the benefits and risks of their decision. 

It is important to assess all components of capacity! 

Competence is a legal term that refers to whether a person has a legal right to make their own decisions. Competence is informed by an assessment of capacity.   

Conditions that may affect capacity: 

• Mild cognitive impairment 

• Dementia 

• Alzheimer’s disease 

• Parkinson’s disease 

• Disability 

• Mental illness (e.g., schizophrenia, bipolar disorder) 

• Chronic substance abuse 

• Traumatic brain injury 

• Some medical illnesses 

• End of life 

Possible consequences/risks of diminished capacity: 

Often, individuals with reduced capacity require assistance to make decisions regarding their medical care and financial management. If undetected or unassisted, individuals with diminished capacity are at risk for serious, potentially irreversible consequences including:  

• Financial abuse 

• Neglect 

• Exploitation 

• Loss of properties/assets 

• Invalid legal documents 

• Inadequate or inappropriate medical care (e.g., seriously infected wounds, taking expired prescriptions, forgetting to take or overdosing on medications) 

• Sexual abuse 

What is a capacity evaluation? 

Capacity is typically assessed using a structured or semi-structured interview by a medical/psychological professional. The interview often includes open-ended questions to assess comprehension, reasoning, appreciation, and expression of one’s decisions. A capacity evaluation may include: 

• Neuropsychological testing 

• Assessment of psychiatric symptoms 

• Interview of a family member or friend 

• Review of pertinent records 

Each of these sources provide vital information regarding an individual’s ability to make informed decisions, live independently, and  several medical, psychological, and legal bodies, including the American Psychological Association and the American Bar Association, have developed specific criterion for the assessment of capacity.  

When to consider a capacity evaluation 

Assessing capacity is an issue encountered daily by older adults, medical providers, attorneys, real estate and stock brokers, adult protective workers, and the courts. Factors including aging of the current population, medical advancements, rising prevalence of dementia, and patient rights all contribute to the increased need for professional capacity evaluations. Capacity evaluations may be considered by different individuals in any of the following cases:  

• Family/Medical Providers 

• Does a loved one or patient appear to have trouble understanding their medical treatment options? 

• Is he/she aware of their medical conditions and comprehend the importance of medication compliance for each of these conditions? 

•  Can he/she make an informed decision about whether to consent to medical procedures and treatments? Does he/she appear confused? 

• Does your loved one or patient have declining cognition (i.e., memory, attention, planning, organization, slow processing speed) or functional abilities? 

• Do you wonder if a loved one or patient can safely live independently?  

• Do you wonder if they can continue to drive safely? 

• Has a loved one or patient fallen victim to financial scams? 

• Attorneys/Real Estate Brokers 

• Does your client comprehend the legal information you provide? 

• Does your client comprehend and appreciate the impact of documents he/she signs? 

• Does he/she have the cognitive ability to make a new will or assign a trustee? 

• Is your client in a probate situation? 

• Can your client make sound financial decisions? 

• Is there a question of undue influence by strangers, friends, or family members? 

How cognitive decline impacts capacity 

Decision making and expressing a choice require a complex interplay between cognitive functions (i.e., attention, processing speed, language, memory, executive functioning). Importantly, many medical, neurodegenerative, and psychiatric conditions can negatively impact not only one, but several, cognitive domains involved necessary for intact capacity.   

Examples of those include: 

• Comprehension may be impacted by impaired conceptualization, poor receptive language, and memory deficits.  Example:  Individuals with a condition called primary progressive aphasia (PPA) have marked impairments in their ability to understand complex verbal information. 

• Appreciation can be impacted by executive dysfunction.  Example:  Some individuals with dementia with Lewy bodies show marked reductions in judgment, learning from errors, correcting mistakes, and problem-solving. 

• Reasoning may be affected by impaired abstract reasoning.  Example:  Patients with some neurodegenerative diseases, psychiatric conditions, and developmental disabilities have concrete reasoning and thus may have a hard time weighing the pros and cons of hypothetical situations. 

• Expression can be affected by impaired confrontation naming, reduced auditory comprehension, and reduced verbal fluency.  Example:  Alzheimer’s disease is often associated with deficits in comprehension, poor word finding ability, and reduced complexity of speech.  

Because cognitive functioning is determined by the interdependence, rather than isolated function, of multiple domains, comprehensive neuropsychological testing may shed light on an individuals’ strengths and weaknesses as they relate to capacity. If indicated, neuropsychological testing may take 2-4 hours, and all tests are selected based on individual needs.