Five short screening tests in the detection of prevalent delirium: diagnostic accuracy and performance in different neurocognitive subgroups.

BACKGROUND: Delirium is prevalent and serious, yet remains under-recognised. Systematic screening could improve detection; however, consensus is lacking as to the best approach. Our aim was to assess the diagnostic accuracy of five simple cognitive tests in delirium screening: six-item cognitive impairment test (6-CIT), clock-drawing test, spatial span forwards, months of the year backwards (MOTYB) and intersecting pentagons (IPT). METHODS: A cross-sectional study was conducted. Within 36 h of admission, older medical patients were assessed for delirium using the Revised Delirium Rating Scale. They also underwent testing using the five cognitive tests outlined above. Sensitivity, specificity, positive and negative predictive values (PPV; NPV) were calculated for each method. Where appropriate, area under the receiver operating characteristic curve (AUC) was also calculated. RESULTS: Four hundred seventy patients were included, and 184 had delirium. Of the tests scored on a scale, the 6-CIT had the highest AUC (0.876), the optimum cut-off for delirium screening being 8/9 (sensitivity 89.9%, specificity 62.7%, NPV 91.2%, PPV 59.2%). The MOTYB, scored in a binary fashion, also performed well (sensitivity 84.6%, specificity 58.4%, NPV 87.4%, PPV 52.8). On discriminant analysis, 6-CIT was the only test to discriminate between patients with delirium and those with dementia (without delirium), Wilks' Lambda = 0.748, p < 0.001. CONCLUSION: The 6-CIT measures attention, temporal orientation and short-term memory and shows promise as a delirium screening test. This study suggests that it may also have potential in distinguishing the cognitive impairment of delirium from that of dementia in older patients. Copyright © 2016 John Wiley & Sons, Ltd.

Measuring the Effect of Carers on Patients' Risk of Adverse Healthcare Outcomes Using the Caregiver Network Score.

BACKGROUND: Although caregivers are important in the management of frail, community-dwelling older adults, the influence of different caregiver network types on the risk of adverse healthcare outcomes is unknown. OBJECTIVE: To examine the association between caregiver type and the caregiver network subtest of The Risk Instrument for Screening in the Community (RISC), a five point Likert scale scored from one ("can manage") to five ("absent/liability"). To measure the association between caregiver network scores and the one-year incidence of institutionalisation, hospitalisation and death. DESIGN: Observational cohort study. SETTING AND PARTICIPANTS: Community-dwelling adults, aged >65, attending health centres in Ireland, (n=779). PROCEDURE AND MEASUREMENTS: The caregiver network subtest of the RISC was scored by public health nurses. Caregivers were grouped dichotomously into low-risk (score of one) or high-risk (scores two-five). RESULTS: The majority of patients had a primary caregiver (582/779; 75%), most often their child (200/582; 34%). Caregiver network scores were highest, indicating greatest risk, when patients had no recognised primary caregiver and lowest when only a spouse or child was available. Despite this, patients with a caregiver were significantly more likely to be institutionalised than those where none was required or identified (11.5% versus 6.5%, p=0.047). The highest one-year incidence of adverse outcomes occurred when state provided care was the sole support; the lowest when private care was the sole support. Significantly more patients whose caregiver networks were scored high-risk required institutionalisation than low-risk networks; this association was strongest for perceived difficulty managing medical domain issues, odds ratio (OR) 3.87:(2.22-6.76). Only perceived difficulty managing ADL was significantly associated with death, OR 1.72:(1.06-2.79). There was no association between caregiver network scores and risk of hospitalisation. CONCLUSION: This study operationalizes a simple method to evaluate caregiver networks. Networks consisting of close family (spouse/children) and those reflecting greater socioeconomic privilege (private supports) were associated with lower incidence of adverse outcomes. Caregiver network scores better predicted institutionalisation than hospitalisation or death.

Components of the Risk Instrument for Screening in the Community (RISC) that Correlate with Public Health Nurses' Perception of Risk.

BACKGROUND: Functional decline and frailty are common in community-dwelling older adults, leading to an increased risk of adverse outcomes. OBJECTIVE: To examine the factors that public health nurses perceive to cause risk of three adverse outcomes: institutionalisation, hospitalisation, and death, in older adults, using the Risk Instrument for Screening in the Community (RISC). DESIGN: A quantitative, correlational, descriptive design was used. SETTING AND PARTICIPANTS: A sample of 803 community-dwellers, aged over 65 years receiving regular follow-up by public health nurses. Procedure and Measurements: Public health nurses (n=15) scored the RISC and the Clinical Frailty Scale (CFS) on patients in their caseload. We examined and compared correlations between the severity of concern and ability of the caregiver network to manage these concerns with public health nurses' perception of risk of the three defined adverse outcomes. RESULTS: In total, 782 RISC scores were available. Concern was higher for the medical state domain (686/782,88%) compared with the mental state (306/782,39%) and activities of daily living (595/782,76%) domains. Concern was rated as severe for only a small percentage of patients. Perceived risk of institutionalisation had the strongest correlation with concern over patients mental state,(r=0.53), while risk of hospitalisation,(r=0.53) and death,(r=0.40) correlated most strongly with concern over the medical state. Weaker correlations were found for the other domains and RISC scores. The CFS most strongly correlated with the ADL domain,(r=0.78). CONCLUSION: Although the prevalence of concern was high, it was mostly rated as mild. Perceived risk of institutionalisation correlated most with concern over the ability of caregiver networks to manage patients' mental state, while risk of hospitalisation and death correlated with patients' medical state. The findings suggest the importance of including an assessment of the caregiver network when examining community-dwelling older adults. Validation of the RISC and public health nurses' ratings are now required.

The Community Assessment of Risk Instrument: Investigation of Inter-Rater Reliability of an Instrument Measuring Risk of Adverse Outcomes.

BACKGROUND: Frailty is increasingly common in community dwelling older adults and increases their risk of adverse outcomes. Risk assessment is implicit in the Aged Care Assessment Teams process, but few studies have considered the factors that influence the assessor's decision making or explored the factors that may contribute to their interpretation of risk. OBJECTIVE: to examine the inter-rater reliability of the Community Assessment of Risk Instrument (CARI), which is a new risk assessment instrument. DESIGN: A cohort study was used. SETTING AND PARTICIPANTS: A sample of 50 community dwelling older adults underwent comprehensive geriatric assessment by two raters: a geriatrician and a registered nurse. Procedure and measurements: Each participant was scored for risk by the two raters using the CARI. This instrument ranks risk of three adverse outcomes, namely i) institutionalisation, ii) hospitalisation and iii) death within the next year from a score of 1, which is minimal risk to 5, which is extreme risk. Inter-rater reliability was assessed with Gamma, Spearman correlation and Kappa statistics. Internal consistency was assessed with Cronbach's alpha. RESULTS: There were 30 female (mean age 82.23 years) and 20 male (mean age 81.75 years) participants. Items within domains showed good-excellent agreement. The gamma statistic was >0.77 on 6/7 Mental State items, 14/15 items in the Activities of Daily Living domain. In the Medical domain, 6/9 items had Gamma scores >0.80. The global domain scores correlated well, 0.88, 0.72 and 0.87. Caregiver network scores were 0.71, 0.73 and 0.51 for the three domains. Inter-rater reliability scores for global risk scales were 0.86 (institutionalisation) and 0.78 (death). The gamma statistic for hospitalisation was 0.29, indicative of lower inter-rater reliability. Cronbach's alpha was 0.86 and 0.83 for the Activities of Daily Living domain, 0.51 and 0.42 for the Mental state domain and 0.23 and 0.10 for the Medical state domain. CONCLUSIONS: Overall, the instrument shows good inter-rater reliability. Poor correlations on some items relate to poor communication of clinical data and variable interpretation based on professional background. Lack of internal consistency in the medical condition domain confirms the discrete nature of these variables.

Nurses' preferred end-of-life treatment choices in five countries.

BACKGROUND: Previous research has focused on physician's perspectives of end-of-life (EOL) decision making as well as patient and family EOL decision making. There is a lack of research pertaining to the EOL treatment preferences of nurses and especially nurses working in a variety of care settings. AIM: The aim of this study was to compare nurses' EOL treatment preferences in Hong Kong, Ireland, Israel, Italy and the USA. METHODS: A comparative descriptive design was used with a convenience sample of nurses (n = 1089). A survey questionnaire using EOL hypothetical clinical case scenarios was used to collect data between June 2011 and July 2012. RESULTS: Nurses in every country consistently chose a more aggressive option for patients than for themselves or for a parent. The treatment preferences of nurses varied from country to country. Lack of knowledge of patients' wishes and duty of care were the main influencing factors on treatment preferences. STUDY LIMITATIONS: The study was limited to the hypothetical nature of the scenarios; however, the study highlights numerous future research questions. CONCLUSIONS: This study is the first to examine and compare nurses' preferred EOL treatment choices in five countries from three different continents. The findings of this study raise several important questions for healthcare researchers, for policy development, and highlight the need for further international collaboration.

The influences of psychotic symptoms on the activities of daily living of individuals with Alzheimer disease: a longitudinal analysis.

OBJECTIVES: Psychotic symptoms associated with Alzheimer Disease (AD) contribute to excess functional dependence. Longitudinal studies have generally examined the association between rates of functional decline and the occurrence of psychotic symptoms from either a single evaluation or from multiple evaluations rather than through changes in frequency and severity of symptoms. Although the presence or absence of psychotic symptoms at initial or follow-up examinations may be associated with changes in functional status, the nature of the relationship between changes in these domains cannot be inferred. We examine the association between changes in the frequency of psychotic symptoms and changes in dependence in activities of daily living (ADL) over a period ranging from 1 to 74 months (median = 17.7). METHOD: Data from a cohort of 234 individuals referred to a memory clinic were analyzed using multilevel linear regression. Information on ADL, behavioral and psychological symptoms, depression, and cognition was collected. RESULTS: An increase in the frequency of psychotic symptoms had a unique influence on the deterioration of basic ADL, after controlling for demographic variables, changes in cognition, depression, and other behavioral and psychological symptoms (B = -.017, p = .003). However, changes in psychotic symptoms did not significantly contribute to declines in the ability to perform instrumental ADL (B = -.008, p = .439). CONCLUSION: Changes in psychotic symptoms may influence basic but not instrumental ADL over time. These findings may have ramifications for studies and treatment plans for individuals with AD who demonstrate psychotic symptoms.

Effects of acute exposure to aluminum on cognition in humans.

There is epidemiological evidence suggesting an association between aluminum in drinking water and Alzheimer's disease (AD), and between aluminum in dialysate and dialysis dementia. The exact role of aluminum in the pathogenesis of these and other dementias is not clear. This study examined the acute effects of aluminum on cognitive function in patients with AD and related dementias and in age-matched and younger volunteers with normal cognitive function. Whether individuals with AD and/or the APOE epsilon4 genotype had enhanced gastrointestinal absorption of aluminum was tested, and whether individuals with elevated blood aluminum concentrations exhibited acute cognitive effects was determined. Subjects were randomized to receive a single dose of aluminum orally (Amphojel plus citrate) for 3 d followed by a 3-wk washout, and then 3 d of matched placebo administration, or vice versa. Serum aluminum levels were measured and the daily dose of Amphojel was adjusted to a target aluminum level between 50 and 150 microg/L. Neuropsychological tests were administered at baseline and 90 min after the third dose of Amphojel or placebo. There was a large interindividual variation in aluminum serum levels in all study groups after the same initial dose of Amphojel. There were no significant differences in neuropsychological test scores after aluminum ingestion in normal volunteers or in patients with cognitive impairment. There was no association between APOE epsilon4 genotype and aluminum absorption. The results did not support the hypothesis that aluminum ingested at these doses produces acute effects on cognition or adverse effects, nor did they reveal that AD patients are more vulnerable to such outcomes. Further inquiry is required to explore any possible association between aluminum and cognition, but controlled trials may be limited by safety concerns.

The self-perceived role and educational needs of pharmaceutical representatives: a survey.

INTRODUCTION: Despite considerable debate in the medical literature about the educational utility of pharmaceutical representatives (PR), little is known about their attitudes towards their role as marketers and/or educators, their ability to provide comprehensive information about products and their learning needs. DESIGN: A survey. SUBJECTS AND METHOD: Questionnaires were mailed to 606 PRs from five Canadian pharmaceutical companies. RESULTS: Of 309 (51%) respondents, 98% strongly agreed or agreed they had a role in educating doctors, while 52% strongly disagreed or disagreed their main goal was marketing. Overall, 92% agreed they had received adequate training to perform a well-informed detail, and 96% reported the information they provide is accurate. The majority (66%) felt a university-accredited program would improve the quality of their detailing. CONCLUSION: Most PRs believe their main goal is education. Despite most reporting that they had received adequate training, they felt that a university-accredited educational program would improve the quality of detailing. The number of years that a PR spent in the industry appears to have an effect on how they perceive their role.

Standardized Mini-Mental State Examination. Use and interpretation.

OBJECTIVE: To review administration of the Standardized Mini-Mental State Examination (SMMSE) for dementia and depression and to evaluate how well it interprets older people's cognitive function. QUALITY OF EVIDENCE: Literature from January 1990 to December 1999 was searched via MEDLINE using the MeSH headings Alzheimer Disease, Vascular Dementia, Lewy Bodies, and Depression. Several studies have described the reliability and validity of the SMMSE. MAIN MESSAGE: The SMMSE, a standardized approach to scoring and interpreting older people's cognitive function, provides a global score of cognitive ability that correlates with daily function. Careful interpretation of results of the SMMSE, together with history and physical assessment, can assist in differential diagnosis of cognitive impairment resulting from Alzheimer's disease, vascular dementia, dementia with Lewy bodies, or depression. Repeated measurements can be used to assess change over time and response to treatment. CONCLUSION: The SMMSE is a valuable tool for family doctors who are often the first medical professionals to identify changes in patients' cognitive function. The SMMSE requires little time to complete and is a key component of a comprehensive dementia workup. Determining whether a patient has dementia is important because there are now effective medications that are most beneficial if started early.

The Zarit Burden Interview: a new short version and screening version.

PURPOSE: The purpose of the study was to develop a short and a screening version of the Zarit Burden Interview (ZBI) that would be suitable across diagnostic groups of cognitively impaired older adults, and that could be used for cross-sectional, longitudinal, and intervention studies. DESIGN AND METHODS: We used data from 413 caregivers of cognitively impaired older adults referred to a memory clinic. We collected information on caregiver burden with the 22-item ZBI, and information about dependence in activities of daily living (ADLs) and the frequency of problem behaviors among care recipients. We used factor analysis and item-total correlations to reduce the number of items while taking into consideration diagnosis and change scores. RESULTS: We produced a 12-item version (short) and a 4-item version (screening) of the ZBI. Correlations between the short and the full version ranged from 0.92 to 0.97, and from 0.83 to 0.93 for the screening version. Correlations between the three versions and ADL and problem behaviors were similar. We further investigated the behavior of the short version with a two-way analysis of variance and found that it produced identical results to the full version. IMPLICATIONS: The short and screening versions of the ZBI produced results comparable to those of the full version. Reducing the number of items did not affect the properties of the ZBI, and it may lead to easier administration of the instrument.

Development of a standardized, comprehensive "ideal drug detail".

OBJECTIVES: To develop a standardized, comprehensive ideal drug detail for use in face-to-face education about individual drugs. METHODS: A random sample of 603 physicians and pharmacists was selected and stratified to include input from each of the following specialties: family practice, internal medicine, surgery, pediatrics, psychiatry, obstetrics/gynecology, geriatric medicine and clinical pharmacology. Thirty-one potential items were generated by the investigators from a preliminary survey of a local convenience sample of physicians and pharmacists. A modified Delphi consensus process was used in the large sample to determine which items should be included in the ideal drug detail. In each round of the Delphi process, respondents rated each item on a seven-point scale of importance and were then given feedback of the cumulative ratings for each item. Rounds were continued until consensus was obtained on all items. RESULTS: The response rate to the first round was 55.3%; 85.5% of these respondents responded to the second round. Response rates varied between specialties from 44% to 70%. Attempts to contact nonresponders to measure potential nonrespondent bias were unsuccessful. Consensus was obtained on 19 items after the first round, and on the remaining 12 items after the second round. Four items were dropped because they were unimportant. There was variation in modal response between specialties on eight items. CONCLUSIONS: Consensus was obtained among a sizable and interested sample of Canadian physicians and pharmacists on the items of information needed to prescribe a drug appropriately. Subsequent work will refine this list into a usable template to develop ideal drug details for specific drugs, to develop an assessment process to measure quality of information, and to assess the impact of this program on prescribing and patient outcomes.

Clinical experience with Cerebrolysin.

Cerebrolysin is a peptidergic drug which displays neurotrophic action in various animal models. It is used for the treatment of dementia and in this report we provide evidence for the long-term clinical efficacy of Cerebrolysin in Alzheimer's disease. This evidence is based on our clinical experience with Cerebrolysin, stemming from our participation in a double-blind, placebo-controlled clinical trial, a compassionate use programme initiated thereafter, and a PET study. Our data suggests, that Cerebrolysin is a safe and effective treatment for Alzheimer's disease and that repeat treatments may maintain function in patients over the long-term.

Determinants and detection of low body mass index in community-dwelling adults with Alzheimer's disease.

OBJECTIVE: To determine the proportion of older adults with Alzheimer's disease presenting to a geriatric clinic with low body mass index (BMI), the proportion of these individuals recognized by clinicians as malnourished, and what patients' characteristics and caregivers' and clinicians' impressions are associated with low BMI. DESIGN: Cross-sectional study. SETTING: An outpatient geriatric clinic located in a university-affiliated teaching hospital. PARTICIPANTS: 340 patients with Alzheimer's disease, average age 75 years. MEASUREMENTS: Individuals with a BMI below 21 were considered at risk of malnutrition. Physical examination and medical information were obtained from patients and caregivers by clinicians using a standardized assessment protocol. Clinicians' impression regarding evidence of malnutrition was obtained. RESULTS: Forty-six patients (16%) had a BMI below 21. Clinicians reported evidence of potential malnutrition in 11 patients, 8 of whom had a BMI below 21. Using logistic regression, we found that women were five times more likely to have a BMI below 21 than men, and that individuals with low cognition were twice as likely to have a BMI below 21 than individuals with higher cognition. CONCLUSION: The proportion of patients with Alzheimer's disease with a BMI below 21 is similar to that encountered in the general population aged 65+. However, clinicians have difficulty identifying persons at risk of malnutrition according to BMI status. Women with low cognition were at increased risk of having a low BMI. Improvement in the detection of malnutrition is desirable. Further exploration of causal links between cognition and malnutrition is required.

Implementation of advance directives among community-dwelling veterans.

To evaluate the feasibility and effectiveness of implementing a "Let Me Decide" advance directive education program among veterans living in the community, the authors studied 150 veterans in south central Ontario. Thirty-four veterans had preexisting Powers of Attorney and were removed from the analysis, leaving a total sample of 116. Two methods of systematically implementing a directive program were evaluated after the intervention period and 6 months later. Eighty-two (71%) of the 116 veterans expressed interest in receiving detailed information about the program, and 67 (82%) of the 82 interested veterans were educated. Forty-two (63%) of the 67 educated veterans completed directives. Of the 116 interested veterans, 42 (36%) completed directives. Veterans who were educated about directives were surveyed at follow-up, and 37 of 38 (97%) respondents reported that the education process was beneficial and should be offered to other veterans. This response pattern was consistent among those who completed and those who did not complete directives.

Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial.

CONTEXT: Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation. OBJECTIVES: To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs. DESIGN: Randomized controlled trial conducted June 1, 1994, to August 31, 1998. SETTING AND PARTICIPANTS: A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each. INTERVENTION: The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives. MAIN OUTCOME MEASURES: Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes. RESULTS: Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20). CONCLUSION: Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.

Assessment of patient capacity to consent to treatment.

OBJECTIVE: To compare results of a specific capacity assessment administered by the treating clinician, and a Standardized Mini-Mental Status Examination (SMMSE), with the results of expert assessments of patient capacity to consent to treatment. DESIGN: Cross-sectional study with independent comparison to expert capacity assessments. SETTING: Inpatient medical wards at an academic secondary and tertiary referral hospital. PARTICIPANTS: One hundred consecutive inpatients facing a decision about a major medical treatment or an invasive medical procedure. Participants either were refusing treatment, or were accepting treatment but were not clearly capable according to the treating clinician. MEASUREMENTS AND MAIN RESULTS: The treating clinician (medical resident or student) conducted a specific capacity assessment on each participant, using a decisional aid called the Aid to Capacity Evaluation. A specific capacity assessment is a semistructured evaluation of the participant's ability to understand relevant information and appreciate reasonably foreseeable consequences with regard to the specific treatment decision. Participants also received a SMMSE administered by a research nurse. Participants then had two independent expert assessments of capacity. If the two expert assessments disagreed, then an independent adjudication panel resolved the disagreement after reviewing videotapes of both expert assessments. Using the two expert assessments and the adjudication panel as the reference standard, we calculated areas under the receiver-operating characteristic curves and likelihood ratios. The areas under the receiver-operating characteristic curves were 0.90 for specific capacity assessment by treating clinician and 0.93 for SMMSE score (2p =.48). For the treating clinician's specific capacity assessment, likelihood ratios for detecting incapacity were as follows: definitely incapable, 20 (95% confidence interval [CI] 3. 6, 120); probably incapable, 6.1 (95% CI 2.6, 15); probably capable, 0.39 (95% CI 0.18, 0.81); and definitely capable, 0.05 (95% CI 0.01, 0.29). For the SMMSE, a score of 0 to 16 had a likelihood ratio of 15 (95% CI 5.3, 44), a score of 17 to 23 had a likelihood ratio of 0. 68 (95% CI 0.35, 1.2), and a score of 24 to 30 had a likelihood ratio of 0.05 (95% CI 0.01, 0.26). CONCLUSIONS: Specific capacity assessments by the treating clinician and SMMSE scores agree closely with results of expert assessments of capacity. Clinicians can use these practical, flexible, and evaluated measures as the initial step in the assessment of patient capacity to consent to treatment.

Factors associated with motor vehicle crashes in cognitively impaired older adults.

Because cognitive impairment might pose a safety risk for these drivers and the public, we examined what patient characteristics might be associated with motor vehicle crashes, in a retrospective study of all new referrals to a geriatric clinic specializing in memory and behavior problems between July 1, 1990 and June 30, 1995. During this time, 989 new patients were evaluated by the clinic staff. Driving data were available from 634 patients. The only factor significantly associated with crashes was driving alone (odds ratio = 2.23, 95% confidence interval = 1.20-4.15). Twenty-five percent of patients who drove alone had caregiver-reported crashes in the previous 5 years, compared with 13% of those who drove only with a passenger. Patients who drove alone were more likely to have spousal caregivers than patients who drove only with a passenger (72% vs. 58%, p = 0.028). Thus, cognitively impaired patients allowed to drive alone were more likely to have been involved in crashes than patients not driving alone. However, the causal nature of this association cannot be established with the present design. Prospective studies are required to determine if the presence of a co-pilot represents a safe strategy to extend driving privileges in cognitively impaired older drivers.

Capacity to choose place of residence: autonomy vs beneficence?

Health care workers often perceive a conflict between autonomy and beneficence when dealing with clients living at risk in the community. Respect for personal freedom and the desire to help and protect vulnerable people frequently appear to demand opposite interventions. The assessment of decision-making capacity is a vital part of any process that deals with these complicated situations and can resolve some of the apparent conflict. Standardized assessment tools which are flexible enough to deal with the complexities of capacity assessment are needed. Health care workers aim to maximize the safety of people incapable of making decisions while protecting the freedom and autonomy of the capable. Some limits to autonomy must be accepted, especially where others' interests are threatened.