With advances in biomarker-based detection of Alzheimer's disease (AD) and new treatment options with disease-modifying treatments (DMTs), we are heading toward a new conceptualization of diagnostics and therapy in the early stages of AD. Yet consensus guidelines on best clinical practices in predictive AD diagnostics are still developing. Currently, there is a knowledge gap regarding counseling and disclosure practices in early symptomatic disease stages, its implications for dementia risk estimation, and DMTs with associated risks and benefits. The crucial feature is the capacity of patients with (mild) cognitive impairment, eligible for DMTs, to consent. This perspective aims to (1) discuss the current challenges in assessing capacity to consent and (2) highlight the importance of a supported (informed) decision-making process. Measures to facilitate informed decision-making of patients constitute an ethical approach to enhancing the quality of care in this evolving therapeutic landscape. HIGHLIGHTS: This perspective: Explores biomarker-based early symptomatic AD detection and the implications for patient care. Emphasizes supported decision-making in DMTs for MCI and dementia patients. Discusses the need for standardized tools to assess the capacity to consent. Aligns diagnostic and treatment approaches with ethical care standards. Enhances patient autonomy in the evolving AD therapeutic landscape.

<h4>Background</h4>Decisional capacity is an important requirement for assisted suicide, which has been legalized in an increasing number of countries. While several instruments have been developed over the past few decades to assess the capacity to consent to treatment, little is known about their applicability to assessing capacity in the context of requests for assisted suicide.<h4>Methods</h4>Systematic review of instruments assessing decisional capacity published up to March 2024. Data concerning criteria for determining decisional capacity, psychometric properties, and other aspects were extracted from all instruments included. Selected instruments were analyzed regarding their applicability to requests for assisted suicide.<h4>Results</h4>We identified 23 instruments assessing the capacity to consent to treatment. There is considerable heterogeneity regarding the criteria utilized for assessing decisional capacity and their operationalization. Next to more cognitive abilities, some instruments directly incorporated emotions and values. Five instruments were assessed for applicability to requests for assisted suicide. The framing of decisional capacity within the context of disease and treatment options frequently limits the application of instruments to assess decisional capacity in the context of requests for assisted suicide.<h4>Conclusions</h4>No instrument could be identified that could be applied to assessing decisional capacity in the context of requests for assisted suicide without any limitations or without necessitating adjustments. Further normative and empirical work is required for developing an instrument that could be applicable in this context.

<h4>Background</h4>Transgender and gender expansive (TGE) youth often seek a variety of gender-affirming healthcare services, including pubertal suppression and hormone therapy requiring that TGE youth and their parents participate in informed consent and decision making. While youth must demonstrate the ability to understand and appreciate treatment options, risks, benefits, and alternatives as well as make and express a treatment choice, standardized approaches to assess the capacity of TGE youth to consent or assent in clinical practice are not routinely used. This scoping review identified the currently available data regarding adolescent capacity to consent to gender-affirming medical treatments.<h4>Methods</h4>Articles relevant to assessing adolescent capacity for clinical decision-making were identified using OVID Medline, Web of Science, and PubMed. Articles were reviewed and thematically analyzed.<h4>Results</h4>Eight relevant articles were identified using three tools for measuring adolescent clinical decision-making capacity: Measure of Understanding, Measure of Competence, and MacArthur Competence Assessment Tool (MacCAT). These studies explored hypothetical treatment decisions, mental health treatment decisions, HIV treatment decisions, genetic testing decisions, and gender-affirming medical decisions. Only one study specifically examines the capacity of TGE youth to consent to medical treatments. Age was correlated with capacity in most, but not all studies. Other studies found cognitive measures (IQ, literacy, numeracy) may impact important aspects of capacity (understanding and reasoning).<h4>Conclusions</h4>For clinicians caring for TGE youth, tools such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) may prove useful, in conjunction with consideration of youth developmental abilities and utilization of shared decision-making practices. A standardized, collaborative approach to assessing TGE youth capacity would benefit TGE youth and their parents, and allow clinicians to more easily resolve ethical concerns.

While there is increasing use of standardised tools to assist in determining decision-making capacity in adults, there is limited literature evaluating these tools in children/adolescents. The current PRISMA guided systematic review aimed to evaluate standardised capacity assessment tools used in the child/adolescent population, and to examine the relationship between these capacity assessment tools and cognition. Inclusion criteria comprised: (1) validation of a new/existing tool to assess capacity or competence; (2) participants < 18 years; (3) involved validation on normative or non-normative populations; (4) published in English in a peer review journal. Ten studies were included. The majority applied a version of the Macarthur Competence Assessment Tool. Findings suggest capacity assessment tools demonstrate sound psychometric properties, but research into capacity assessment in children is still in its infancy. Limitations include the lack of diagnostic gold standard of capacity and the inconsistent and minimal incorporation of cognitive functioning into standardised capacity assessment.