Decision-making capacity in older adults with SMI and cognitive impairment: an ethical, practice-oriented framework

To synthesize evidence on decision-making capacity in older adults with serious mental illness (SMI) and cognitive impairment (primarily dementia and delirium in hospital settings), and to propose an ethically grounded, practice-oriented framework for assessing and supporting autonomy across key decision domains.

A purposive narrative review and conceptual analysis integrated empirical and theoretical literatures from hospital medicine, gerontology, SMI, financial decision-making, end-of-life care, and capacity assessment. Particular attention was paid to older adults with SMI, dementia, and co-occurring SMI plus dementia, while explicitly noting where evidence is indirect or sparse.

The strongest direct evidence concerns treatment and hospital decisions, where capacity assessments typically arise around treatment consent and discharge, and many people with SMI retain capacity for at least some health decisions with symptom treatment, accessible information, and structured support. Evidence for independent living, financial, and end-of-life decisions is more heterogeneous, with very limited empirical work specifically on co-occurring SMI plus dementia.

An original five-step model of "assessing and supporting autonomy" is proposed, emphasizing presuming capacity, optimizing context, structured task-specific assessment with supports, least restrictive alternatives, and careful justification and reassessment of overrides. The framework is most evidence-based for medical decisions and intentionally hypothesis-generating in other domains.