Association of Cognitive Impairment and Dementia With Receipt of Cataract Surgery Among Community-Dwelling Medicare Beneficiaries | Cataract and Other Lens Disorders | JAMA Ophthalmology | JAMA Network
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Table 1.  Characteristics of Study Sample by Cognitive Impairment and Dementia (CID) Status, National Health and Aging Trends Study 2011-2016
Characteristics of Study Sample by Cognitive Impairment and Dementia (CID) Status, National Health and Aging Trends Study 2011-2016
Table 2.  Association of Cognitive Impairment and Dementia (CID) Status on Receipt of Cataract Surgery, National Health and Aging Trends Study 2011-2016
Association of Cognitive Impairment and Dementia (CID) Status on Receipt of Cataract Surgery, National Health and Aging Trends Study 2011-2016
1.
Rogers  MAM, Langa  KM.  Untreated poor vision: a contributing factor to late-life dementia.  Am J Epidemiol. 2010;171(6):728-735. doi:10.1093/aje/kwp453PubMedGoogle ScholarCrossref
2.
Livingston  G, Sommerlad  A, Orgeta  V,  et al.  Dementia prevention, intervention, and care.  Lancet. 2017;390(10113):2673-2734. doi:10.1016/S0140-6736(17)31363-6PubMedGoogle ScholarCrossref
3.
Prevent Blindness America. Cataract prevalence by age. http://www.visionproblemsus.org/cataract/cataract-by-age.html. Accessed March 30, 2018.
4.
Rowe  S, MacLean  CH.  Quality indicators for the care of vision impairment in vulnerable elders.  J Am Geriatr Soc. 2007;55(suppl 2):S450-S456. doi:10.1111/j.1532-5415.2007.01355.xPubMedGoogle ScholarCrossref
5.
Kasper  JD, Freedman  VA, Spillman  BC. Classification of persons by dementia status in the National Health and Aging Trends Study: Technical Paper #5. https://www.nhats.org/scripts/documents/NHATS_Dementia_Technical_Paper_5_Jul2013.pdf. Accessed June 14, 2017.
6.
Bowie  H, Congdon  NG, Lai  H, West  SK.  Validity of a personal and family history of cataract and cataract surgery in genetic studies.  Invest Ophthalmol Vis Sci. 2003;44(7):2905-2908. doi:10.1167/iovs.02-1055PubMedGoogle ScholarCrossref
Research Letter
January 2019

Association of Cognitive Impairment and Dementia With Receipt of Cataract Surgery Among Community-Dwelling Medicare Beneficiaries

Author Affiliations
  • 1National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor
  • 2Center for Eye Policy and Innovation, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
  • 3Department of Internal Medicine, School of Medicine, University of Michigan, Ann Arbor
JAMA Ophthalmol. 2019;137(1):114-117. doi:10.1001/jamaophthalmol.2018.5138

Correcting visual impairment may optimize functioning and reduce the risk of further cognitive decline for people with cognitive impairment and dementia (CID).1,2 Cataracts cause visual impairment in more than 20% of older adults and are effectively treated with low-risk surgery.3 Clinical guidelines state that older adults with CID, except those with limited life expectancy or advanced dementia, should be offered effective treatments, including cataract surgery.4 It is not known whether older adults with CID in the United States receive cataract surgery at the same rate as those with normal cognition. We tested the hypothesis that community-dwelling Medicare beneficiaries with CID are less likely to receive cataract surgery than those with normal cognition.

Methods
Data and Analysis Sample

We used data from the National Health and Aging Trends Study (NHATS), a longitudinal survey annually administered to a nationally representative cohort of US Medicare beneficiaries 65 years and older (January 2011 to December 2016). We excluded participants who reported cataract surgery before enrollment. We censored participants after they reported receiving cataract surgery. In an effort to exclude those with advanced dementia, we excluded participants who required a proxy respondent or resided in nursing homes. The University of Michigan Institutional Review Board approved this study, and informed consent was waived because deidentified, publicly available survey data were used.

Variable Definitions

The outcome was self-reported receipt of cataract surgery measured annually. The predictor was CID using the NHATS system, which classifies participants as having probable CID (ie, report of physician diagnosis of dementia or Alzheimer disease or scores 1.5 SDs below the mean or lower on 2 or more cognitive tests of memory, orientation, and executive function), possible CID (a score 1.5 SDs below the mean or lower on 1 cognitive test), or no CID.5

Analyses

Based on the NHATS survey design, we calculated the weighted proportions of participants for each sociodemographic group stratified by classification of CID. We performed multivariable logistic regression to examine the effect of an individual’s CID classification on receipt of cataract surgery in the subsequent year while adjusting for patient-related factors, including age, sex, race/ethnicity, education, annual income, survey year, self-reported distance and near visual impairment, smoking status, depressive symptoms, social isolation, self-care and activity limitations, and comorbidity (ie, self-reported diagnosis of heart disease, hypertension, diabetes, lung disease, stroke, and cancer). We calculated adjusted predicted proportions of the outcome. All analyses accounted for the complex design of NHATS, including sampling weights, units, and strata, and were conducted using Stata version 14 (StataCorp).

Results

Table 1 presents participant characteristics. Participants with possible and probable CID were significantly less likely to receive cataract surgery than those with normal cognition after adjustment for patient factors (possible CID: adjusted odds ratio, 0.73; 95% CI, 0.56-0.95; P = .02; probable CID: adjusted odds ratio, 0.59; 95% CI, 0.36-0.96; P = .03). The adjusted predicted proportion receiving cataract surgery was 8.1% for those with normal cognition, 6.2% for those with possible CID, and 5.1% for those with probable CID (Table 2).

Discussion

In this large, nationally representative study, community-dwelling Medicare beneficiaries with CID were less likely to receive cataract surgery than those with normal cognition. It is possible that CID is a proxy for other correlated factors (eg, older age, nonwhite race, lower educational attainment, lower income, depression, activity of daily living deficits, and history of stroke), which are also barriers to cataract extraction. Although we adjusted for many of these potential confounders, residual confounding could be present. Our study relies on self-reported data. Older adults are able to accurately report receipt of cataract surgery,6 although the accuracy of self-reported cataract surgery in those with CID is unreported.

Conclusions

We found that Medicare beneficiaries with CID were less likely to receive cataract surgery than those with normal cognition. Given that cataract surgery may help optimize functioning in persons with and without CID, it is important for primary care physicians, geriatricians, and ophthalmologists to be aware of the potential underuse of this effective, low-risk treatment in patients with CID.

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Article Information

Accepted for Publication: September 8, 2018.

Corresponding Author: Brian C. Stagg, MD, National Clinician Scholars Program, University of Michigan Institute for Healthcare Policy and Innovation, 1000 Wall St, Ann Arbor, MI 48105 (staggb@med.umich.edu).

Published Online: October 25, 2018. doi:10.1001/jamaophthalmol.2018.5138

Author Contributions: Dr Stagg had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Stagg, Ehrlich, Choi.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Stagg.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Stagg, Choi.

Obtained funding: Ehrlich.

Administrative, technical, or material support: Levine.

Study supervision: Ehrlich, Choi, Levine.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Ehrlich has received grants from the National Eye Institute, National Institute on Aging, and Research to Prevent Blindness. Dr Levine has received grants from the National Institute on Aging and the National Institute of Neurological Disorders and Stroke. No other disclosures were reported.

Funding/Support: This research was supported by grant K23 EY027848 from the National Eye Institute (Dr Ehrlich); the American Society of Cataract and Refractive Surgery (Dr Ehrlich); grant P30 AG012846 from the National Institute on Aging to the Institute for Social Research at the University of Michigan; and an unrestricted grant from Research to Prevent Blindness to the Department of Ophthalmology and Visual Sciences at the University of Michigan.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Rogers  MAM, Langa  KM.  Untreated poor vision: a contributing factor to late-life dementia.  Am J Epidemiol. 2010;171(6):728-735. doi:10.1093/aje/kwp453PubMedGoogle ScholarCrossref
2.
Livingston  G, Sommerlad  A, Orgeta  V,  et al.  Dementia prevention, intervention, and care.  Lancet. 2017;390(10113):2673-2734. doi:10.1016/S0140-6736(17)31363-6PubMedGoogle ScholarCrossref
3.
Prevent Blindness America. Cataract prevalence by age. http://www.visionproblemsus.org/cataract/cataract-by-age.html. Accessed March 30, 2018.
4.
Rowe  S, MacLean  CH.  Quality indicators for the care of vision impairment in vulnerable elders.  J Am Geriatr Soc. 2007;55(suppl 2):S450-S456. doi:10.1111/j.1532-5415.2007.01355.xPubMedGoogle ScholarCrossref
5.
Kasper  JD, Freedman  VA, Spillman  BC. Classification of persons by dementia status in the National Health and Aging Trends Study: Technical Paper #5. https://www.nhats.org/scripts/documents/NHATS_Dementia_Technical_Paper_5_Jul2013.pdf. Accessed June 14, 2017.
6.
Bowie  H, Congdon  NG, Lai  H, West  SK.  Validity of a personal and family history of cataract and cataract surgery in genetic studies.  Invest Ophthalmol Vis Sci. 2003;44(7):2905-2908. doi:10.1167/iovs.02-1055PubMedGoogle ScholarCrossref
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