ALZHEIMER’S PATIENTS

Treating Alzheimer’s patients for cataracts not only improves visual acuity, it may also improve sleep and reduce depression in many patients, and significantly improve cognitive function in patients with milder dementia, Brigitte Girard MD, Paris, France, told the XXIX Congress of the ESCRS.

However, in her first-of-its-kind study of the neuropsychological impact of cataract surgery on Alzheimer’s patients, about one-quarter of the 38 patients followed displayed increased agitation and behavioural problems three months after surgery, with more severely demented patients apparently at higher risk. (The study has been called VIVA – la VIe par la Vue chez l’Alzheimer = Life by Sight in Alzheimer’s – LiSA.)

“According to Neuropsychological Inventory (NPI) the benefit of cataract surgery is real for 25 per cent of patients and it improves conditions for 25 per cent of caregivers. It improves sleep and depression in almost all subjects. But beware of possible behaviour deterioration, with the caregiver burden increased,†said Dr Girard, who also presented her study at the annual meeting of the American Academy of Ophthalmology.

While the study was not designed to identify predictive factors, the data suggest patients scoring higher than 14 on Mini Mental Status, or MMS, tests before surgery do better, with a net increase in aggregate NPI and depression scores at three months, Dr Girard noted. Overall about one-third of patients improved social skills, most of whom were in the higher MMS group. These included one 99-year-old-woman who began seeing her son again after several years.

By contrast, for patients scoring 14 to 10 on MMS before surgery, net aggregate NPI and depression scores were worse after surgery. They were more likely to display agitation, delusional ideas and hallucinations, increase the burden on caregivers, and many showed declines in social function, Dr Girard said. “When you relieve them of the cataract, at the bottom they are in a good or bad mood, and some of them are very aggressive. If they can see they can move and it is really a problem sometimes.â€

Local anaesthesia

This prospective interventional study was carried out at Tenon Hospital in Paris. In addition to standard visual tests, all patients were evaluated for neuropsychological function one month before and three months after surgery with the same psychologist administering NPI, Instrumental Activities of Daily Living (IADL) and depression questionnaires to all patients and caregivers. The main assessment criteria were behaviour improvement and relief of caregivers. Secondary assessment criteria were cognitive score (Adas cog) improvement, autonomy and mood disorders.

All patients had disabling cataracts and mild dementia, defined as an MMS score of 10 to 25. Mean age was 85 with nine patients over 90 years old, and 84 per cent were women.

Of 42 patients operated, 38 had complete follow-up data. Intraocular lenses were placed in the posterior chamber in 36 patients and in the sulcus in five patients. One patient was not implanted due to lack of cooperation during surgery. Only five patients required general anaesthesia, the other 37 received local or regional anaesthesia.

This surprised Dr Girard, who thought most patients would need general anaesthesia. However, anaesthesiologists were concerned over safety and how general anaesthesia might affect their brains. So Dr Girard used patient reaction to B-scan tests as a guide to their suitability for local anaesthesia. If they tolerated the probe touching the eye, they would probably tolerate surgery. Patients were mostly calm and cooperative during surgery, she reported. However, all surgeries were done in the hospital, with patients admitted the afternoon before for tests and discharged the morning after

Visual results

Surgery was difficult due to many hard cataracts and weak zonules, Dr Girard said. But results were excellent. Mean corrected distance vision improvement was 0.5 LogMAR from a pre-op mean of 0.55 LogMAR, or about 20/70, with 52 per cent achieving 20/25 at three months. Vision did not improve in two patients, one who was not implanted due to agitation, and one suffering dry AMD behind a white cataract.

At three months, NPI behaviour scores improved for 47 per cent, were unchanged for 26 per cent and decreased for 17 per cent with 10 per cent damaged. Mean scores improved, but not significantly. Sleep and appetite improved, but agitation and motor behaviour also increased.

Burden on caregivers improved for 26 per cent, was unchanged for 40 per cent and decreased for 26 per cent. Mean scores did not change significantly, but reduced caregiver burden correlated significantly with improved behaviour scores, p<0.001, and improved depression scores, p=0.02. Increased agitation in particular resulted in higher caregiver distress while improvements in sleep disturbances were associated with reduced stress.

Cognitive function improved for 32 per cent, was unchanged for 40 per cent and decreased for 22 per cent. However, mean instrumental activities and autonomy increased significantly, p=0.05. Twenty-four gained three points or more, 50 per cent were unchanged and 26 per cent decreased. More improvements were made in the easy gesture category, which includes eating and self-care. Patients were mostly stable in instrumental activities such as using a telephone. In social activities, one-third improved, one-third were stable and one-third decreased.

Mean depression scores improved for 48 per cent of patients with MMS higher than 14 compared with 27 per cent for those with MMS scores 14 or lower. Similarly, 13 per cent of the milder group showed mood declines compared with 27 per cent for those with more severe dementia.

If it was only for depression improvement it’s worth removing cataract in Alzheimer’s patients, especially before dementia decreases too much MMS, concluded Dr Girard.

contact Brigitte Girard – docteur.girard@orange.fr