Posted: Monday, February 3, 2014

Ophthalmologists on the front lines are battling age-related public health issues

The general global demographic shift in the US, Europe and Asia means that the number of cases of age-related vision problems and age-related dementia are both growing to near epidemic proportions. Ophthalmologists, whose patients are often elderly, increasingly have to play the part of neurologist, geriatrician and psychiatrist, in addition to helping with traditional eye care issues.

The statistics are daunting. Thanks to increased life expectancy and the baby boomer population bubble, by the year 2030 the population of adults over 65 years of age is expected to double in the developed world, comprising 20 per cent of the total population.

The US National Eye Institute estimates that 25 per cent of people over the age of 65 would be expected to develop cataracts. That number surpasses 50 per cent in those aged 80 years of age and older. Two per cent of 65-year-olds will have glaucoma, a number that will also double by age 80. Age-related macular disease is believed to affect approximately 10 per cent of people over the age of 65, with the number climbing sharply with the years.

With advancing years patients are at risk for developing slowly decreasing vision because of eye diseases and ageing of the visual system, notes Mats Lundstrom MD, adj. professor emeritus, Department of Clinical Sciences, Ophthalmology, Faculty of Medicine, Lund University, Sweden.

“This gradual change in vision is usually not accompanied by relevant changes in home lighting conditions. Elderly patients typically go on reading the newspaper in too weak light and do not make proper arrangements in their bedroom. It is always a good idea to recommend that elderly patients upgrade their lighting conditions for reading and cooking and to get a night lamp in their bedroom so they can see the floor when getting up during night,” he suggested.

The benefits of cataract surgery are well established. With improved vision comes significant improvement in functional ability, cognitive function and overall quality of life. Two recent studies indicate, for example, that patients undergoing cataract surgery appear to have a reduced risk of fall-associated hip fractures, as well as a lower chance of getting into an automobile accident.

However, recent research suggests there may be a disconnect between what benefits surgeons think patients are experiencing versus what patients actually believe. Research by Drs Mats Lundström and Ulf Stenevi reveals some surprising findings in this regard. Prof Lundström is the clinical director of the European Registry of Quality Outcomes in Refractive Surgery. Dr Stenevi is professor and chair, Department of Ophthalmology, University of Gothenburg, Sweden, and past president of the ESCRS.

Having observed that clinical and patient-reported outcomes sometimes diverge, the Swedish researchers designed a study to evaluate how patient-reported outcome measures could be connected to clinical outcome measures in cataract surgery. They looked at follow-up data from the massive Swedish National Cataract Register on more than 10,000 patients that underwent cataract extractions from 2008 to 2011.

Patient unhappiness The principal divergence was associated with patient unhappiness with poor near vision after surgery, in spite of an otherwise good clinical outcome. Other factors related to poor patient-reported outcomes after surgery included good preoperative self-assessed visual function, poor preoperative visual acuity in the better eye, postoperative astigmatism, ocular co-morbidity, surgical complications and large refractive deviation.

“These findings indicate that some patients are too healthy and some too sick to benefit from cataract surgery. It is possible that patients who are very satisfied with their vision and have no problems in performing daily life activities should not have cataract surgery at present,’ the researchers note.

“Cataract surgery patients want good vision at all distances. This means comfortable near vision and distance vision. Specifically we need to be sure that patients with good near vision before surgery also get good near vision after surgery. If the postoperative refraction means glasses for near vision we must inform and advise the patient about this. It usually means a follow up visit after surgery. This is the responsibility of the surgeon so we can answer the most important question in healthcare: What happened to the patient?” Prof Lundström told EuroTimes.

The findings add further support to the growing consensus that Snellen visual acuity testing is, by itself, an inadequate measure of visual outcome following surgery. They propose using patient reported outcomes as a measure of success in cataract surgery using instruments such as the Catquest-9SF questionnaire, with the goal of improving cataract surgery outcomes.

“It is important to measure patient satisfaction. You can do this very simply by asking the patients how happy they are with the outcomes of their operations. Satisfaction rates are typically very high, around 95 per cent. It is the five per cent that you really want to know about, because that is where you can affect your care, for example not selecting patients who have very little visual disability to begin with, or some miscommunication about the need for reading glasses afterwards. You can identify patterns and possibly modify what you do,” Konrad Pesudovs told EuroTimes in a podcast interview. Prof Pesudovs is the foundation professor of optometry and vision science at Flinders University in Adelaide, South Australia.

A recent study from Australia raises further potential issues cataract surgeons might want to discuss with patients. That study suggested a possible problem with patient safety following cataract surgery, between the time the first and second operations take place. (Age and Ageing, LB Meuleners et al., (2013) doi: 10.1093/ageing/aft177.)

The researchers assessed the risk of an injury due to a fall among 28,396 patients over the age of 60, looking at the periods two years before first-eye cataract surgery, between first-eye surgery and second-eye surgery, and two years after second-eye surgery. Patients waited an average of 10 months between first and second surgery.

That study found that the risk of an injurious fall that required hospitalisation doubled between the first- and second-eye cataract surgery compared with the two years before first-eye surgery. The study also revealed a 34 per cent increase in the number of serious falls in the two years after second-eye cataract surgery compared with the two years before first-eye surgery. The researchers believe this may be related to differences in vision between the operated and unoperated eyes. They suggest surgeons provide appropriate refractive management between surgeries.

Patients with dementia? With evidence indicating that the incidence of dementia doubles every five years from ages 65 to 90 years, and the number of “old old’ patients increasing around the world, the disease is now being labelled an epidemic. (EB Larson et al, N Engl J Med 2013; 369:2275-2277.)

Ophthalmologists are on the front lines in this public health battle. Nowhere is this more apparent than when the question of driving comes up. Questions of public safety collide with issues of patient confidentiality. While assessing the patient, a history and physical may well reveal clues to potential unsafe driving. In some areas clinicians may risk legal liability for not reporting a potentially dangerous driver, while at the same time upsetting the doctor-patient relationship and facing potential liability for violating privacy rules.

Consider the case of a patient, an 82-year old woman undergoing a routine eye examination, which revealed good visual acuity and no evidence of other eye disease. However, family members informed the ophthalmologist that the woman was in the early stages of Alzheimer’s disease and was showing considerable memory loss and trouble concentrating. Moreover, she had recently been involved in a series of minor accidents in her neighbourhood. The family members wanted the woman to stop driving, something the strong-willed patient refused to consider.

“You have two ways to go with a case like this,” Louis Kartsonis MD, a general ophthalmologist in San Diego, California, US told EuroTimes. “One, you could say my job as an ophthalmologist is vision care, and my responsibility stops with evaluating the status of vision. But we have to recognise a larger picture, particularly in a case where driving accidents have already occurred. If there is an element of dementia, you want to talk to the family and say we need to take some steps.”

One approach would be to immediately refer the patient to a neurologist for an evaluation of mental status, looking at the ability to do the things required in daily life including driving. One could also ask the family to have the patient take a driving test by an independent firm to see if the patient is safe on the road.

“However, in a case like this, where you have a history of accidents, you need to be proactive. You can’t just concentrate on the eyes. You have to realise your larger sphere of responsibility as a physician, not just an eye specialist. This patient was clearly a potential risk to herself and others,” emphasised Dr Kartsonis.

In this case, Dr Kartsonis followed a protocol common in the State of California, This involved filing a report with the Department of Motor Vehicles (DMV) questioning the patient’s fitness to drive. This triggers a sequence of events. The patient receives a letter from the DMV informing them that their license will be suspended. They are required to appear for a hearing test, a vision test, a written test and a driving test. In this case the patient passed the vision test, but failed both the written test and the driving test. Her license was suspended permanently and she no longer drives.

These cases are really difficult, as they alter the doctor-patient relationship, notes Dr Kartsonis. Patients from the World War II generation are particularly strong-willed and treasure their freedom. You may have had a long-term relationship with a patient who now may become angry and feel betrayed.

“I tell the patient what I am going to do. She has a right to know. I’ll explain my concerns. I tell the patient exactly what I’m going to do, so it doesn’t look to them like I’m going behind their back. I then discuss it with the family. Then I’ll do some simple things to verify if there is an element of dementia. I’ll ask what year it is; who the president of the United States is, simple things like that. If I do simple screening and the patient breaks down, I tell them I have to make contact with government agencies about their health, because they’ve had this history, and they are showing signs that could signal trouble in the future,” he explained.

He stressed the physician, in order to protect himself from legal liability, must also strictly document the discussion in his records, and must follow up. This would include noting that the discussion took place, a neurology examination was recommended, along with a driving test. If follow-up indicates that these steps have not been taken, the next step is informing the DMV.

“When the patients are put through this, they don’t like it. But if they fail in the physical, mental, visual component, they at least recognise that the physician and family members have done everything they can to give them a chance to not fail.”

George HH Beiko MD, assistant clinical professor of ophthalmology at McMaster University, Ontario, Canada, has written in the past about the problems of driving, vision and the elderly. Agreeing about the emotional difficulty such cases present, he concurred with Dr Kartsonis.

“I would inform a spouse or family member of my concerns regarding the patient’s cognitive ability and advise them to restrict or prevent driving until proper assessment by the patient’s own family doctor. If the patient appeared to be unlikely to follow this advice, then I would report him directly to the Ministry of Transport. My experience has been that the spouse or family members have usually already had their own concerns and will intervene to prevent driving until the family doctor assesses the patient,” Dr Beiko said.

There are some brief, simple cognition tests that a concerned ophthalmologist can conduct in the office setting. This would include trail making, where the patient is asked to draw lines connecting a series of letters and numbers, and the clock drawing test. This latter test is a favourite quick test to evaluate cognition. The patient is asked to draw a simple clock face, drawing in all of the hours and then setting the hands at five minutes before two o’clock. People who may otherwise appear cognitively intact on a conversation level, most often cannot complete this simple evaluation.

Both Dr Beiko and Dr Kartsonis would consider allowing an older patient who is cognitively sound to return to driving following cataract surgery.

“I would counsel the patient to restart driving when they felt they were ready to do so. I remind them that being legally fit for driving and being capable of driving are two different things. If they are confident in their driving abilities and have considerable previous experience driving, they are likely to start right away; however, if they rarely drove before, I would suggest that they start with short drives during off hours. High-speed, highway driving should be considered only once the patient is mentally set for this.”

However, this advice might not extend to a mentally acute patient who shows some signs of being physically diminished. This might include a patient who appears in the office to be slow moving, can’t turn his head, can’t walk well, who is somnolent or obviously frail. A quick in-office evaluation could include testing the ability to walk 20 feet in nine seconds, showing good limb flexion and extension, and adequate strength and range of motion of neck, shoulders, trunk and arms.

“I would inform that patient that although his vision is adequate for driving, I still have concerns regarding his physical ability to do so. I would tell him that I would be asking his family doctor to reassess him and to address my concerns regarding his physical limitations and that I would be informing the Ministry of Transport, as I am legally required to do, of my concerns,” Dr Beiko told EuroTimes.

Because Snellen testing fails to measure patients’ vision in real-world conditions, particularly in terms of
contrast sensitivity and glare, Dr Beiko believes changes in driver assessment at the national level would be an important step to improving public safety.

“Straylight testing has been advocated by European organisations as a means of assessing disability glare, and I strongly agree with this. Patients may have good visual acuity and full visual fields, and yet be impaired by disability glare. It has been found that although visual acuity may be decreased in 5.3 per cent of elderly patients, up to almost 30 per cent may be impacted by increased disability glare. Disability glare has been implicated in the causation of motor vehicle accidents.”

Resuming driving Ultimately, this testing could also be a good indicator of the necessity for cataract surgery, after which some patients might expect to regain vision to again resume driving.

Patients may need some convincing, notes Dr Kartsonis. “If you have a patient that is far enough along that it is reasonable to consider cataract surgery, they will often defer. They don’t want to have surgery, even thought the technology is wonderful, it can restore eyesight to that of a young person. You have to be patient. Learn how to convince patients that they have access to a technological world that is far different than what they grew up with. Then when patients ask if it is safe to resume driving following cataract surgery, as long as the patient is cognitively sound and physically able, I tell them to go ahead and get tested, and if that goes well, go for it!”