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Optometric Management

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Acting on AMD and cognitive decline

How can optometrists manage this complex relationship effectively?

By: ROYA ATTAR, OD, MBA, DHA, FAAO
Optometric Management October 1, 2024 Vol 59, No. 8, Issue October 2024 Page(s): 12, 14, 16

 

Dr. Attar explains why this article is crucial to practice.

 

Recent research suggests a potential link between age-related macular degeneration (AMD) and cognitive decline.1-6 (See “The AMD cognitive decline connection,” below.) In fact, research shows that lower visual acuity (VA), particularly in the moderate (20/70 to 20/160) to severe (worse than 20/200) impairment range, can be linked to an increased risk of cognitive decline and dementia.7-10

Because the association between AMD and cognitive decline has significant implications for clinical practice, it is necessary to implement several action steps to optimize visual function. After all, doing so could impact cognitive well-being for this patient population. Here are those action steps:

Customize a risk assessment
A personalized risk assessment for both AMD progression and cognitive decline can guide decision making on the frequency and need for surveillance of intervention. The factors to consider for this risk assessment are cardiovascular health history, poor lifestyle habits, such as smoking, poor diet, and lack of physical activity, and cognitive reserve, including education level, occupational complexity, cognitive demands, and tasks involved in a person’s job.
 
For example, a 65-year-old patient who has a history of hypertension, smoking, and a sedentary lifestyle would be considered at higher risk for AMD compared with a 65-year-old without these risks. As a result, the OD would want to see this patient for follow-up visits more often. 

AdobeStock/Jorm Sangsorn

Perform regular comprehensive eye exams
Regular comprehensive eye exams, with additional focused diagnostic tests based on availability, are imperative.

These diagnostic tests include Amsler grid, multimodal imaging (ocular coherence tomography [OCT], fundus autoflourescence, OCT-angiography, color fundus photography, perimetry, and genetic testing).

Obtaining  a thorough history of the patient’s visual symptoms, ocular, systemic and social history, while assessing their demeanor and ability to interact with people and respond to questions is also crucial during this visit.

Proper patient education about their condition and it’s  potential affect on vision and activities of daily living will help patients adhere to any recommended treatments and follow-up visits. This patient education:

• Provide a concise, easy-to-read educational pamphlet during the visit.
• Use resources from organizations, such as the National Eye Institute (bit.ly/NEIAMDRESOURCES), the macular society (bit.ly/MACULARSOCIETYAMDGUIDE), and the macular degeneration society (https://macularhope.org/resources/).
• Send a follow-up email with key information and reliable resources (often, this can be automatically generated via the clinic EHR system).
• Use patient portal systems to share educational materials.
• Incorporate brief, targeted discussions during the exam, highlighting the importance of regular check-ups for both vision and cognitive health.

The AMD cognitive decline connection

Multiple large-scale epidemiological studies demonstrate that individuals who have either form of AMD are at an increased risk of developing cognitive decline and dementia compared to age-matched controls without AMD.1-6 What’s more, several studies suggest a bidirectional association between vision impairment and cognitive decline.9,26-28 While the exact mechanisms underlying the link between AMD and cognitive decline remain unclear, the following theories have been proposed to explain this association:


• Shared risk factors and pathological processes. Both conditions share common risk factors, including advanced age, genetic predisposition (some genetic variants associated with increased AMD risk are also risk factors for forms of dementia, such as Alzheimer’s disease),29,30 and cardiovascular health. Further, poorly controlled blood pressure, diabetes, and smoking contribute to both conditions by damaging blood vessels, promoting chronic inflammation, oxidative stress, and vascular dysfunction, suggesting potential shared pathogenic mechanisms.28,31,32

• Neurodegeneration. Because the retina is an extension of the central nervous system, AMD-related changes may reflect or contribute to broader neurodegenerative processes. In fact, studies show that structural changes in AMD, such as retinal thinning, are associated with brain atrophy and cognitive decline.33,34

• Sensory deprivation. Vision loss associated with AMD may lead to reduced cognitive stimulation and social engagement, potentially accelerating cognitive decline. This hypothesis is supported by studies that show visual impairment is associated with an increased risk of cognitive decline, independent of eye disease etiology.35,36

• Vascular mechanisms. Recent studies show links between choroidal thickness, cerebral small vessel disease, and cognitive function in AMD patients.37,38 This means that impaired choroidal blood flow in AMD may indicate cerebral microvascular changes associated with cognitive decline.

Acquire annual cognitive screening
Incorporate annual functional vision tests that aid in the assessment of both vision and cognition for the early detection of cognitive decline.

For example, the Mini-Cog test (https://mini-cog.com/download-the-mini-cog-instrument/) may help in the early diagnosis of cognitive impairment in AMD patients.11 Incorporating this test facilitates prompt referral to a specialist, such as a geriatric psychiatrist, for further evaluation and potential interventions to slow cognitive decline.

To make annual cognitive screening efficient:
• Include a cognitive screening questionnaire in the pre-appointment paperwork. (See bit.ly/Exam pleCognitiveScreening.)
• Train staff to administer brief cognitive tests during the initial workup.
• Use digital tools or apps that can assist you in quickly assessing cognitive function (for example: https://nihtoolbox.org/).
• Schedule slightly longer appointments for AMD patients to accommodate for the additional screening.

Employ telemonitoring
Various home-monitoring technologies are available to enhance a patient’s prognosis. They are the ForeseeHome AMD Monitoring Program (Notal Vision) (https://foreseehome.com/); myVisionTrack (mVT) (https://myvisiontrack.com/en_uk/home.html); Macustat (RemoniHealth) (https://remonihealth.com/vision-tests/); and Heru Prime (Heru) (seeheru.com/). 

Prescribe vision loss and cognitive decline
interventions
AMD and cognitive decline are multifactorial conditions.12 Therefore, implementing a comprehensive interventional management plan that addresses both is essential. This plan:

• Address modifiable risk factors. Provide counseling on the following, which can help mitigate the risk and progression of AMD, while potentially benefitting cognitive health: smoking cessation (See bit.ly/OM2017SmokingCessation), dietary improvements, including emphasizing the benefits of a diet rich in antioxidants and omega fatty acids, and maintaining a healthy weight with regular physical activity.12-16

• Educate on environmental modifications. Advise AMD patients on maximizing lighting, increasing contrast and reducing glare in their homes and workspaces. These steps can improve visual comfort, reduce eye strain, and potentially enhance cognitive function in visually demanding tasks.17

• Promote ocular nutritional supplementation. Various supplements are available that may act as antioxidants, protecting retinal and brain cells from damage. (See bit.ly/OM2020MayAMDSupplements.)

• Discuss cognitive training activities. Encourage cognitive engagement through activities, such as reading, puzzles, and social interaction.18,19 Emerging evidence suggests that targeted cognitive interventions, such as eye movement training, may benefit both visual and cognitive function in AMD patients.20,21

To prescribe vision loss and cognitive decline interventions efficiently:
• Develop a standardized patient education packet covering the key topics.
• Use digital platforms to send personalized recommendations post-visit.
• Create short, focused video tutorials on each intervention for patients to review at home.
• Implement a team-based approach, with trained staff assisting in patient education.

Smoking cessation can decrease the risk of AMD and has been shown to slow cognitive decline.

Offer low vision
Studies suggest that VA worse than 20/40 may be a critical threshold where the risk of cognitive decline begins to significantly increase. As such, early referral to low vision therapy, ideally when VA drops below 20/40, can maximize current vision and provide the patient with more time to adapt to new strategies. 
   
Low vision aids help improve visual function for daily tasks, potentially reducing visual deprivation and its negative impact on cognitive function, 22,23,24 You can either offer this service yourself (see this month’s online exclusive feature on low vision), or you can refer these patients to a low vision specialist who can provide expertise in selecting and training patients on the use of various assistive devices and can tailor solutions to address both visual and cognitive limitations. To find such specialists, visit the International Academy of Low Vision Specialists, at https://ialvs.com/doctor-directory  

Dig for depression
Recognize the increased risk of depression in patients who have AMD and cognitive decline and consider:

• Implementing regular depression screening, using tools, such as the Patient Health Questionnaire-9 (PHQ-9). (See www.apa.org/depression-guideline/patient-health-questionnaire.pdf.)25

• Providing appropriate referrals for mental health support. Maintain an updated list of local mental health providers specializing in vision-related depression and develop partnerships with mental health professionals for streamlined referrals.

Also, provide patients with a resource sheet of contact information for mental health services and support groups, and use telehealth options to connect patients with mental health professionals.

Stay abreast of the latest research
Stay informed about ongoing studies and potential novel interventions, and encourage patients to stay knowledgeable about clinical trials by visiting clinicaltrials.gov. Also, consider collaborating with research institutions to facilitate patient recruitment for relevant studies.
To stay informed and facilitate research collaboration:
• Subscribe to relevant journals (e.g., Dementia) and attend
conferences focusing on AMD and cognitive health.
• Join professional networks and/or online forums dedicated to AMD research.
• Establish relationships with local universities or research
institutions.
• Attend CE programs/courses focusing on AMD and cognitive decline.
• Consider becoming a site investigator for clinical trials related to AMD and cognitive function. (See clinicaltrials.gov.)

Cognitive training activities, such as puzzles, encourage cognitive engagement.

Adopt a collaborative approach
A multidisciplinary collaborative approach is necessary for comprehensive patient care. It should include a:
• Retina specialist for advanced AMD treatment.
• Primary care physician for management of systemic risk factors.
• Neurologist or geriatric specialist for cognitive assessment and management.
• Mental health professional for addressing the psychological impact of vision loss.

Conquering the connection
In knowing the roles the OD plays in AMD and cognitive decline, we can better manage and support these patients and their caregivers to improve outcomes and quality of life. OM

References:

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ROYA ATTAR, OD, MBA, DHA, FAAO

ROYA ATTAR, OD, MBA, DHA, FAAO, is an associate professor and director of Optometric Services at the Department of Ophthalmology, University of Mississippi Medical Center (UMMC). She was awarded the Young Optometrist of the Year by the American Optometric Association and the Southern Council of Optometrists in 2020.

 

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