EyeWorld India March 2020 Issue

34 EWAP MARCH 2020 CATARACT D ementia patients with cataracts are about half as likely to have cataract surgery compared to those without cognitive impairment, study results indicate. 1 “Currently, Alzheimer’s disease and related dementias affect more than 10% of adults 65 and older, and they’re predicted to affect 7.1 million adults by 2025 and up to 16 million by 2050,” Suzann Pershing, MD, said. Cataracts are very common among patients of older ages, affecting 70% of U.S. adults over the age of 80. “They’re one of the top 10 most prevalent chronic comorbidities among dementia patients over age 65,” Dr. Pershing said. Dementia implications Seeing a lot of patients with dementia in her practice, Dr. Pershing began thinking about the challenges around planning surgery for this group as well as the risks and benefits for these patients. Using data from a representative sample of more than 1 million U.S. Medicare beneficiaries, Dr. Pershing and coinvestigators evaluated the likelihood of patients with dementia having cataract surgery. Of these, more than 457,000 patients had cataract surgery, 23,331 of whom had prior dementia diagnosis. Results showed 16.7% of dementia patients had cataract surgery compared to 43.8% of patients without. Dr. Pershing suspects a number of factors are at play here. “It could mean inadequate access to care, that the patients aren’t getting in to see the ophthalmologist in the first place,” she said, adding that this might be the result of needing to have a caregiver bring them to the office or other logistical challenges. Or it might be that visual impairments aren’t as likely to be detected among those who have dementia. “Either they don’t report it or their caregivers don’t note the condition,” Dr. Pershing said. Another possibility is that practitioners might be reluctant to perform cataract surgery due to inherent challenges of operating on patients with dementia. “Normally, we do surgery with patients awake and cooperative during the procedure,” Dr. Pershing said. “But if there is a concern that the patient may become disoriented and may not be able to hold still, this may warrant general anesthesia.” Such anesthesia brings a higher risk and has been known to worsen cognitive impairment, and there can be potential issues with extubation, particularly with age. “Anesthesiologists and the patients as well as the family may be hesitant to go with anesthesia because of the systemic risks,” she said. Working with dementia patients Offering cataract surgery to patients with dementia can be tricky, with a lot depending on the individual, Dr. Pershing acknowledged. “To the extent that we can avoid general anesthesia, that’s ideal,” she said, adding that it’s preferable to establish a good rapport with a patient ahead of time and talk them through the procedure while awake, if possible. In cases where general anesthesia is required for the patient’s safety, Dr. Pershing recommends working with the anesthesiologist ahead of time and selecting something such as dexmedetomidine, which is less likely to provoke delirium or other problems. Dr. Pershing said she rarely performs bilateral, same-day cataract surgery, but she is more likely to recommend it when general anesthesia is used rather than subjecting the patient to general anesthesia twice. EWAP Reference 1. Pershing S, et al. Differences in cataract surgery rates based on dementia status. J Alzheimers Dis. 2019;69:423–432. Editors’ note: Dr. Pershing is assistant professor of ophthalmology at Byers Eye Institute, Stanford, California. She has relevant financial interests with Acumen and Verana Health. Dementia clouding cataract removal by Maxine Lipner EyeWorld Senior Contributing Writer This article originally appeared in the December 2019 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Pershing: suzannpershing@gmail.com