Challenges for the cataract surgeon treating people with dementia: a qualitative study exploring anesthetic choices

Cataract Phacoemulsification in People with Dementia: Characterization and Outcomes

PURPOSE

To characterize cataract surgery in people with dementia (PWD) using a cataract surgery outcomes database.

METHODS

Demographics, medical and ocular history, surgical characteristics, and postoperative measures were analyzed for differences between PWD and non-PWD cohorts. Patient-level data were analyzed with Fisher's Exact Test, and eye-level data were analyzed with logistic regression using generalized estimating equations to account for correlation of eyes from the same individual.

RESULTS

507 eyes from 296 PWD were identified using appropriate ICD codes and cross-referenced to a cataract surgery outcomes database containing 12,949 eyes from 7,853 patients who underwent cataract phacoemulsification at a single center between January 2014 and October 2019. PWD were older (p < .001), had shorter duration cataract surgeries (p = .006), and were more likely to have mature cataract (p = .017). The rate of general anesthesia was higher in PWD (p = .005). There were no differences in complication rates between PWD and non-PWD cohorts. Both preoperative best corrected LogMAR distance visual acuity (CDVA) (p < .001) and postoperative CDVA (p < .001) were worse in PWD. CDVA significantly improved in both groups (p < .001); however, the average magnitude of improvement in CDVA was not significantly different between groups (p = .169).

CONCLUSIONS

PWD present for cataract surgery at a later age and were more likely to have mature cataracts and general anesthesia, but did not have higher rates of complication, and showed significant improvement in CDVA following surgery. These findings should be encouraging to PWD undergoing counseling for cataract surgery, and for the potential for improved function in PWD.

Experience of Operating Room Health Care Providers in the Management of Patients With Dementia

The management of hospitalized patients with dementia is more complicated compared to patients without dementia, specifically in the surgery ward. The aim of the current study was to explore the experiences of operating room health care providers in the management of patients with dementia. A descriptive qualitative study was designed. Twenty semi-structured interviews were conducted with surgical professionals. Content analysis was performed. Four main themes emerged: Communication Issues, Experience-Based Protocol, Emotions, and Perceived Needs. Health care providers in a surgical ward face numerous challenges when attending to patients with dementia and tend to use strategies based on their own experience due to lack of specific action protocols. Therefore, specific training of the surgical team and protocols are needed to ensure quality care. [Research in Gerontological Nursing, xx(x), xx-xx.].

Incidence of cataract surgeries in people with and without Alzheimer's disease

PURPOSE

To investigate the incidence of cataract surgeries in relation to Alzheimer's disease (AD) diagnosis and to compare it with that in people without AD.

METHODS

The MEDALZ-study includes community-dwelling Finnish persons who received clinically verified AD diagnoses (n = 70718) during 2005-2011 and a matched comparison cohort without AD (n = 70718). The cataract surgeries were identified from the Care Register for Healthcare (1996-2015) using NOMESCO surgical procedure codes CJE (10,15,20,25,99), CJF (00,10,20,30,40,45,50,55,99) and CJG (00,05,10,15,20,25,99). The incidence rates for surgeries per 100 person-years were calculated from 10 years before to 3 years after the index date (date of AD diagnosis from the Special Reimbursement Register).

RESULTS

25 763 cataract procedures were performed on persons with AD and 26 254 on persons without AD during the follow-up. The incidence of surgery increased similarly in both groups before the index date of AD diagnosis, and the rate of surgery was similar in people with and without AD (3.5 and 3.3/100 person-years, respectively). The incidence diminished steeply in the AD group already one year after the index date, whereas the slow increase continued in the non-AD group. After the index date, the rates were 3.7 and 4.7/100 person-years in people with and without AD.

CONCLUSION

The diminishing surgery rate very soon after AD diagnosis is concerning. The stigma of AD diagnosis may lead to fewer referrals to surgery, although these patients are expected to benefit from surgery.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

Characteristics Associated With Receiving Cataract Surgery in the US Medicare and Veterans Health Administration Populations

Importance

Considerable variation exists with respect to the profiles of patients who receive cataract surgery in the United States.

Objective

To identify patient characteristics associated with receiving cataract surgery within the US Medicare and Veterans Health Administration (VHA) populations.

Design, Setting, and Participants

In this population-based retrospective cohort study of 3 073 465 patients, Medicare and VHA patients with a cataract diagnosis between January 1, 2002, and January 1, 2012, were identified from the 2002-2012 Medicare Part B files (5% sample) and the VHA National Patient Care Database. Patient age, sex, race/ethnicity, region of residence, Charlson Comorbidity Index (CCI) scores, and comorbidities were recorded. Cataract surgery at 1 and 5 years after diagnosis was identified. Data analysis was performed from July 1, 2016, to July 1, 2017.

Main Outcomes and Measures

Odds ratios (ORs) of cataract surgery for selected patient characteristics.

Results

The study sample included 1 156 211 Medicare patients (mean [SD] age, 73.7 [7.0] years) and 1 917 254 VHA patients (mean [SD] age, 66.8 [10.2] years) with a cataract diagnosis. Of the 1 156 211 Medicare patients, 407 103 (35.2%) were 65 to 69 years old, 683 036 (59.1%) were female, and 1 012 670 (87.6%) were white. Of the 1 917 254 VHA patients, 905 455 (47.2%) were younger than 65 years, 1 852 158 (96.6%) were male, and 539 569 (28.1%) were white. A greater proportion of Medicare patients underwent cataract surgery at 1 year (Medicare: 213 589 [18.5%]; VHA: 120 196 [6.3%]) and 5 years (Medicare: 414 586 [35.9%]; VHA: 240 884 [12.6%]) after diagnosis. Factors associated with the greatest odds of surgery at 5 years were older age per 5-year increase (Medicare: OR, 1.24 [95% CI, 1.23-1.24]; VHA: OR, 1.18 [95% CI, 1.17-1.18]), residence in the southern United States vs eastern United States (Medicare: OR, 1.38 [95% CI, 1.36-1.40]; VHA: OR, 1.40 [95% CI, 1.38-1.41]), and presence of chronic pulmonary disease (Medicare: OR, 1.26 [95% CI, 1.24-1.27]; VHA: OR, 1.40 [95% CI, 1.38-1.41]). Within Medicare, female sex was associated with greater odds of surgery at 5 years (OR, 1.14; 95% CI, 1.13-1.15). Higher CCI scores (CCI score ≥3 vs 0-2) were associated with increased odds of surgery among VHA but not Medicare patients at 5 years (Medicare: OR, 0.94 [95% CI, 0.92-0.95]; VHA: OR, 1.24 [95% CI, 1.23-1.36]). Black race vs white race was associated with decreased odds of cataract surgery 5 years after diagnosis (Medicare: OR, 0.79 [95% CI, 0.78-0.81]; VHA: OR, 0.75 [95% CI, 0.73-0.76]).

Conclusions and Relevance

Within both groups, older age, residence in the southern United States, and presence of chronic pulmonary disease were associated with increased odds of cataract surgery. Findings from this study suggest that few disparities exist between the types of patients receiving cataract surgery who are in Medicare vs the VHA, although it is possible that a smaller proportion of VHA patients receive surgery compared with Medicare patients.

Choosing anesthesia options for cataract surgery in patients with dementia

Background and Aims

Not all patients with dementia are the same, and Global Deterioration Scale (GDS) helps in staging dementia. Ophthalmologists usually prefer general anesthesia (GA) for cataract surgery in patients with dementia. We evaluated the impact of "Choosing Wisely" initiative on anesthesia options for cataract surgery in patients with dementia undergoing cataract surgery.

Material and Methods

A retrospective review of electronic perioperative database was performed over a 4-year period of patients with a specific diagnosis of dementia undergoing cataract surgery, after the introduction of the "Choosing Wisely" based on preoperative GDS assessment. Preferred method by the listing ophthalmologist, changes in anesthesia modality based on GDS, and the occurrence of intraoperative events were analyzed.

Results

One hundred and thirty-six patients with dementia underwent cataract surgery over a 4-year period. The mean patient age was 78 years, 73.5% female, and 55% ASA physical status III. GA was administered for GDS stage 6-7, and regional anesthesia (RA) for GDS stages 1-5. Surgery was uneventful under RA in 64% of the patients (87 out of 136), and 2% (3 patients) originally deemed suitable for RA were converted to GA.

Conclusions

The authors found a reduced requirement for GA when "Choosing Wisely' initiative was used based on the GDS stage.

Differences in Cataract Surgery Rates Based on Dementia Status

BACKGROUND

Cataract surgery substantially improves patient quality of life. Despite the rising prevalence of dementia in the US, little is known about use of cataract surgery among this group.

OBJECTIVE

To evaluate the relationship between dementia status and cataract surgery.

METHODS

Using administrative insurance claims for a representative sample of 1,125,387 US Medicare beneficiaries who received eye care between 2006 and 2015, we compared cataract surgery rates between patients with and without dementia via multivariable regression models to adjust for patient characteristics. Main outcome measures were annual rates of cataract surgery and hazard ratio and 95% confidence interval (CI) for receiving cataract surgery.

RESULTS

Cataract surgery was performed in 457,128 patients, 23,331 with a prior diagnosis of dementia. 16.7% of dementia patients underwent cataract surgery, compared to 43.8% of patients without dementia. 59 cataract surgeries were performed per 1000 dementia patients annually, versus 105 surgeries per 1000 nondementia patients. After adjusting for patient characteristics, dementia patients were approximately half as likely to receive cataract surgery compared to nondementia patients (adjusted HR = 0.53, 95% CI 0.53-0.54). Among the subset of patients who received a first cataract surgery, those with dementia were also less likely to receive second-eye cataract surgery (adjusted HR = 0.87, 95% CI 0.86-0.88).

CONCLUSION

US Medicare patients with dementia are less likely to undergo cataract surgery than those without dementia. This finding has implications for quality of care and dementia progression. More information is necessary to understand why rates of cataract surgery are lower for these patients, and to identify conditions where benefits of surgery may outweigh risks.

Care needs of people with dementia in the peri-operative environment: A systematic review

The care of people with dementia within the hospital setting is challenging for healthcare professionals. Hospital design and services are not optimized for people with dementia, owing to the lack of preparation of healthcare professionals and the busy environment of the acute hospital. The peri-operative environment may present particular difficulties but little is known about the experience and care of people with dementia in this setting. The aim of this review was to examine the care of surgical patients who have dementia and their family members in peri-operative environments and describe strategies adopted by healthcare professionals. A systematic search of the following databases was completed: BNI, CINAHL, PubMED and PsychINFO in accordance with PRISMA guidelines. Data were extracted and analysed within a thematic analysis framework as described by Braun and Clarke. Ten papers based on eight studies were included, five (n = 355,010 participants) containing quantitative data and five reporting qualitative data (n = 395 participants). People with dementia who go undergo surgery experienced higher adverse post-operative outcomes such as respiratory problems or urinary tract infections. The key elements in surgical care for people with dementia included: health assessment throughout the surgical trajectory (pre-, intra- and post-operative) and the resources used by healthcare professionals in the peri-operative care. Healthcare professionals reported difficulties in the completion of health assessments due to the cognitive status of people with dementia and a lack of skills in dementia management. The use of restraints was still a common practice and a source of conflict. Dementia-specific training and guidelines focused on the care of surgical patients who have dementia in peri-operative environments are required to improve care and post-operative outcomes. More research is required to develop effective interventions to improve care and decrease the risk of complications for people with dementia in the peri-operative care environment.