The role of telehealth models, including teleneuropsychology, in assessing decision-making capacity in older adults with cognitive impairments: a scoping review.

Objective: Decision-making capacity evaluations are decision-specific and typically rely on integrated evidence from interview-based assessments of decisions, functional abilities, collateral history, and behavioural observations, with cognitive testing providing supportive (non-determinative) evidence. Telehealth models, including teleneuropsychology, have potential to expand access to capacity-related assessments for older adults with cognitive impairments who cannot attend in-person services, but its use for decision-making capacity assessments remains unclear. This scoping review mapped how telehealth has been used to support decision-making capacity assessments, explicitly or implicitly, in older adults with cognitive impairments and summarised feasibility, validity/reliability, and implementation considerations. Method: A scoping review was conducted in accordance with PRISMA-ScR guidance. Five databases were searched from inception to 05 January 2026. Studies were eligible if they involved older adults with cognitive impairments (aged ≥65 years) and used telehealth for assessment processes that either evaluated decision-making capacity (Tier A), or informed capacity-adjacent decisions (e.g. driving, living alone, guardianship planning; Tier B). Results: The search produced 1,738 results; a total of 1,264 records were screened, and 102 full-text articles were retrieved for further review. Five studies met inclusion criteria, three of which were classified as Tier A for at least one patient. The remaining two studies primarily involved telehealth cognitive, geriatric, or psychiatric assessments that informed capacity-adjacent recommendations but did not operationalise decision-making capacity as a primary outcome. All telehealth models were supported by additional staff, with onsite staff supporting technology and, in some cases, components of the assessments. Reported opportunities included improved access and timeliness; barriers included sensory impairment, variable infrastructure, and limited reporting in tele-specific adaptations and decision-specific capacity procedures. Conclusion: Direct evidence for telehealth-delivered decision-making capacity assessments in older adults with cognitive impairments remains limited. Studies of telehealth capacity assessments involving teleneuropsychology are even more limited. Future work should prioritise clear operationalisation and reporting of decision-specific decision-making capacity procedures, applied frameworks, guidelines and policies, as well as telehealth delivery models (including facilitation), and outcomes addressing feasibility, reliability/validity, and stakeholder acceptability. The necessity for telehealth neuropsychology-specific normative data also needs to be evaluated.