Kerrigan Simon, Erridge Sara, Liaquat Imran, Graham Cat, Grant Robin
From the Edinburgh Centre for Neuro-oncology, University of Edinburgh (S.K., S.E., R.G.), and Wellcome Trust Clinical Research Facility (C.G.), Western General Hospital (I.L.), Edinburgh, UK.
Neurology. 2014 Aug 5;83(6):537-41. doi: 10.1212/WNL.0000000000000671. Epub 2014 Jul 2.
OBJECTIVE: To evaluate the prevalence of mental incapacity to make neuro-oncologic treatment decisions and to identify patients likely to experience difficulty with medical decision-making to enable a more rigorous and focused assessment. METHODS: The preoperative mental capacity to give valid consent to neurosurgery of 100 patients with radiologically suspected intracranial tumors was assessed. Mental capacity was formally assessed using the MacArthur Competence Assessment Tool for Treatment (MACCAT-T) conducted by a dual-qualified physician and lawyer. To assess the relationship between cognition and mental capacity, cognitive function was assessed after the MACCAT-T interview using the Addenbrooke's Cognitive Examination-revised (ACE-R). Decisions about capacity made by the assessor were compared with the informal assessment of capacity of the neurosurgical team. RESULTS: Of 100 patients, 25 were identified by the assessor as lacking the necessary mental capacity to give valid consent to neurosurgery. Mental incapacity was most common among patients with World Health Organization grade IV tumors (38%) and was more common in men than women (36% of men lacked capacity vs 14% of women). Patients lacking mental capacity were significantly more cognitively impaired than those with capacity (median [interquartile range (IQR)] total ACE-R of 44 [0, 65.5] for incapable patients compared with a median [IQR] total ACE-R score of 88 [82, 95] for patients with capacity). Of 25 patients found to lack capacity by the assessor, 13 (52%) were identified as lacking capacity by the neurosurgical team and were treated under the provisions of the Adults with Incapacity (Scotland) Act 2000. A score of <4/7 in the semantic verbal fluency subset of the ACE-R (naming up to 10 animals in 1 minute) was predictive of incapacity (96% sensitivity, 63% specificity). CONCLUSIONS: Mental incapacity in patients with intracranial tumors is common and is underestimated by clinicians seeking consent for neuro-oncologic treatment. Cognitive impairment is associated with incapacity. We propose a simple, brief cognitive screening test to identify patients who warrant a more rigorous interrogation of their mental capacity as part of the process of seeking consent for neuro-oncologic treatment.
目的：评估在做出神经肿瘤治疗决策时无行为能力的患病率，并识别可能在医疗决策方面存在困难的患者，以便进行更严格且有针对性的评估。 方法：对100例经影像学检查怀疑患有颅内肿瘤的患者进行术前给予神经外科手术有效同意的行为能力评估。行为能力由一名具备双重资质的医生兼律师使用麦克阿瑟治疗能力评估工具（MACCAT-T）进行正式评估。为评估认知与行为能力之间的关系，在MACCAT-T访谈后使用修订版的Addenbrooke认知检查（ACE-R）对认知功能进行评估。将评估者做出的行为能力判定与神经外科团队对行为能力的非正式评估进行比较。 结果：在100例患者中，评估者认定25例缺乏给予神经外科手术有效同意的必要行为能力。无行为能力在世界卫生组织IV级肿瘤患者中最为常见（38%），且男性比女性更常见（36%的男性无行为能力，而女性为14%）。无行为能力的患者比有行为能力的患者认知障碍明显更严重（无行为能力患者的ACE-R总分中位数[四分位间距（IQR）]为44[0，65.5]，而有行为能力患者的ACE-R总分中位数[IQR]为88[82，95]）。在评估者认定无行为能力的25例患者中，13例（52%）被神经外科团队认定为无行为能力，并根据《2000年苏格兰无行为能力成年人法案》的规定接受治疗。ACE-R的语义言语流畅性子集中得分<4/7（1分钟内说出多达10种动物名称）可预测无行为能力（敏感性96%，特异性63%）。 结论：颅内肿瘤患者的无行为能力情况常见，且在寻求神经肿瘤治疗同意的临床医生中被低估。认知障碍与无行为能力相关。我们提出一种简单、简短的认知筛查测试，以识别那些在寻求神经肿瘤治疗同意过程中需要对其行为能力进行更严格询问的患者。
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