患有白內障的老年人接受手術與認知功能缺損之關係—一台灣追蹤研究

The association between cataract surgery and cognitive dysfunction in cataract patients— A population-based follow-up study in Taiwan

許粹剛(Tsui-Kang Hsu)

指導教授 ： 林先和

共同指導教授 ： 趙效明(Hsiao-Ming Chao)

國立臺灣大學/公共衛生學院/公共衛生碩士學位學程/碩士(2014年)

https://doi.org/10.6342/NTU.2014.01438

摘要

目的: 老年白內障與認知功能異常(老年失智、認知缺損、及阿茲海默症)常共同存在，部分眼科醫師相信白內障手術不但能回復病患眼睛的健康，而且還可改善患者退化的心智。然而，這樣的關連性並不確定，本篇研究主要調查白內障病患接受白內障手術與未來產生認知功能異常的關連性。

方法：回溯性世代研究設計。我們使用台灣國家健保資料庫評估從西元2000年1月至2010年12月曾接受白內障手術與未開刀的白內障患者，評估發生認知功能異常的機會是否相同。共計有31401位白內障患者納入研究，其中11385位病人接受白內障手術，另有20016位年齡、性別及診斷患有白內障的時間做配對之未接受白內障手術者為控制組。比較兩組在日後發生認知功能異常的風險（包括有認知功能缺損、老年失智及阿茲海默症）。我們使用克普藍麥爾(Kaplan-Meier)的方法來評估發生認知功能異常的存活曲線且利用扣克斯回歸分析模型(Cox proportional hazards regression model)去檢測白內障患者其接受手術與否與未來產生認知功能異常的風險有無相關性，並且矯正相關共病，例如：高血壓、糖尿病、高血脂症、心律不整及冠狀動脈疾病。

結果：將近十年的追蹤，共有505位接受手術的白內障患者產生認知功能異常，代表著4.44%的累積發生率（控制組為3.63%，共有727位）。在產生認知功能異常方面，接受手術的白內障患者有類似於未接受手術之白內障患者的風險[風險比例（HR）：1.08倍，95%信賴區間為0.97-1.21]。以年齡分層來看，在65至74歲間接受白內障手術者有較高風險得到認知功能異常的情況 (風險比例 1.20, 95% 信賴區間 1.04-1.39)，但於大於75歲的白內障患者卻沒有這樣的發現 (75-84歲, HR 0.948, 95%信賴區間 0.78-1.16; ≧85歲, HR 0.727, 95%信賴區間 0.41-1.28)。

結論：所有大於65歲的白內障患者是否接受手術與未接受手術組對於產生認知功能異常有相近的風險(HR 1.08, 95% 信賴區間 0.97-1.21)，以年齡分層後，可見介於65-74歲的白內障患者在接受手術該組，有較高風險產生認知功能異常，但這樣的風險並無法在大於75歲的組別發現；白內障手術可以回復病人的視力，但目前仍沒有證據顯示可以改善病人的認知功能。以另一個角度來看，在相對年輕的老年人若在較早期需要接受白內障手術，也許是一個全身器官老化的指標，眼科醫師應該對於較早期就需要接受白內障手術的患者有所警覺，因為有可能是認知功能會提早退化的警訊，眼科、神經醫學及老人醫學建立一個多方聯結的醫療網是相常重要的。

關鍵字

白內障 ； 老年失智 ； 認知功能異常 ； 阿茲海默症 ； 白內障超音波乳化手術 ； 白內障吸出術

並列摘要

Purposes Senile cataract and cognitive dysfunction (senile dementia, cognitive impairment and Alzheimer disease) are commonly coexisting. Some ophthalmologists believed the cataract surgery would not only restore health to patient’s eyes, but also in improving the degenerative state of mind. The association between them is not fully understood. This study aims to prospectively investigate the association between cataract surgery and long-term incidence of cognitive dysfunction among older people with senile cataract.
Methods Retrospective Cohort study design. We used the National Health Insurance Research Database of Taiwan to investigate the relationship between cataract surgery and incidence of cognitive dysfunction in patients with cataract between January 2000 and December 2010. A total of 31401 cataract patients were included. There are 11385 patients received cataract surgery and 20016 age- , sex-, and cataract-diagnosis-timing matched controls were linked to the claim data to identify the first occurrence of a primary or secondary diagnosis of cognitive dysfunction (including cognitive impairment, senile dementia, and Alzheimer disease). We used the Kaplan-Meier method to estimate the survival curves of cognitive dysfunction. Cox proportional hazards regression modeling was used to determine the association between patients with cataract who received surgery or not and risk for cognitive dysfunction, adjusting for comorbidity, such as hypertension, diabetic mellitus, hyperlipidemia, dysrhythmia, and coronary artery disease.
Results Over nearly 10 years of follow-up, a total of 505 cataract subjects who received surgery developed cognitive dysfunction, representing a cumulative incidence rate of 4.44% (n = 727; 3.63% in controls). Cataract patients who received surgery had a similar risk of cognitive dysfunction as patients who did not receive surgery [hazard ratio (HR): 1.08, 95% confidence interval (CI) 0.97-1.21]. In the age-stratified analysis, cataract surgery was associated with increased risk of cognitive dysfunction among patients between 65-74 years old (HR 1.20, 95% CI 1.04~1.39), and the association was null in patients over 75 years (75-84 years, HR 0.948, 95% CI 0.78-1.16; ≧85 years, HR 0.727, CI 0.41-1.28).
Conclusion Overall cataract patients (>65 years) underwent surgery had similar risk of cognitive dysfunction [HR 1.08, 95% confidence interval (CI) 0.97-1.21]. Among cataract patients who were 65-74 years old, the long-term risk for cognitive dysfunction seemed to increase in those who received cataract surgery compared to those who did not receive surgery. The risk of surgery was not observed in the older age groups (≧75 years old). The surgery for cataract could recover the better vision for patients, but there is no conclusive evidence for improvement in cognitive function. On the other sides, the necessary for cataract surgery could be an indicator for aging change, especially for “younger” aged people (<75 years). The ophthalmologists should be aware of the patients with the potential need for cataract surgery to be a sign of cognitive dysfunction. A multiple lines of communication between ophthalmology, neurology and geriatriology are very important.

並列關鍵字

cataract ； dementia ； cognitive dysfunction ； Alzheimer disease ； phacoemulsification ； lens extraction

參考文獻

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