失智症患者針灸治療知情同意情形與影響因子

Informed Consent and Influence Factors of Acupuncture Treatment for Patients with Dementia

前言：失智症患者最主要的症狀就是認知能力降低，無法正確的辨認、理解問題並據以作出合理的思考及回應，因此在臨床治療中常用的知情同意方法，失智患者大多難以理解，遑論有效的同意。近年有越來越多的失智患者開始接受中醫治療，其中又以針灸為大宗。針灸可以以減少失智患者的認知退化與精神行為症狀，但治療過程中會感到疼痛。如何在患者的醫療自主決定與實證醫學療效中取得平衡，是中醫治療過程中需要面對的難題。方法：本研究為回溯性橫斷研究（Retrospective Cross-Sectional Study），屬於觀察性研究（Observational Research）。利用台北市立聯合醫院仁愛院區，中醫失智症特別門診於2016年1月至2017年12月間之失智症患者的病歷資料與同意書內容，以研究台灣中醫失智症患者行使針灸治療同意權之情形與可能的影響因子。本研究的研究變項包含有性別、年齡、教育程度、婚姻狀況、簡易認知量表總分、臨床失智評分表總分、日常生活活動力量表總分、簡短版神經精神量表總分等變項，並以羅吉斯迴歸分析（Logistic regression）測試變項間是否有顯著的影響差距。結果：本研究共納入287位失智症患者，本研究發現失智症患者接受針灸治療呈現兩極化現象，在疾病嚴重度較低和較嚴重的患者，接受針灸的比率較高。從簡易心智量表總分與臨床失智評估量表分數和同意針灸治療的分析也可以驗證此現象；此外，簡短版的神經精神量表可以作為是否接受針灸治療的良好預測指標，神經精神量表分數越高的患者，接受針灸治療的傾向越低。我們發現隨著簡易心智量表總分或日常生活活動能力量表總分下降，或是臨床失智評估量表分數上升，則家屬代為行使同意權的傾向也顯著的上升。換句話說，隨著認知退化功能越嚴重，則家屬代為行使同意權的比例越高。結論：不同退化程度失智症病人，對於針灸的接受度和自己執行知情同意的能力有顯著的差異，單一制式化的針灸同意書並無法適用於各種類型的失智症，我們建議應該導入逐級升階的治療策略，以及醫病共享決策方法，協助醫療同仁更清楚的理解病患和家屬的需要，作出更合理且為多方接受的醫療決策。

Background: The main symptom of dementia patients is the cognitive decline, so patients can not perform informed consent for medical behavior. Acupuncture treatment can reduce cognitive deterioration and mental behavior symptoms in dementia patients, but the procedure is accompanied by pain. How to let patients correctly understand the side effects of acupuncture and implement valid informed consent is a difficult problem for clinicians. Method: This study is a Retrospective Cross-Sectional Study. We collected medical records and consents from dementia patients from Taipei City United Hospital from January 2016 to December 2017. The purpose of the study was to analyze the informed consent and possible impact factors of acupuncture in patients with dementia. Research variables included gender, age, education, marital status, Mini-Mental State Examination (MMSE), Clinical Dementia Rating (CDR), Activities of daily living (ADL), and Neuropsychiatric Inventory Questionnaire (NPI). We tested whether there were significant differences between variables in Logistic regression. Result: A total of 287 patients with dementia were included in the study. We found that patients with the lowest and highest disease severity had a higher rate of acupuncture. Besides, NPI is a good predictor of acupuncture treatment. Patients with higher NPI scores have a lower tendency to receive acupuncture treatment. We also found that as the total score of MMSE or ADL decreased, the proportion of family members who agreed to treat patients also increased significantly. Conclusion: Patients with different degrees of dementia have significant differences in the degree of acceptance and informed consent of acupuncture. Single-form acupuncture consent does not apply to all types of dementia. We suggest that the decision-sharing making method should be introduced. It can help medical colleagues understand the needs of patients and make more reasonable and multi-acceptable medical decisions.