In the course of my parallel career as a commercial pilot I was asked to take a retired Wing Commander for a last flight. He had suffered a stroke and also had terminal cancer and wanted one last experience before the end came.
I was told: ‘He has not been able to speak for over a year but has indicated that this is something he would like to do.’ We took off and during the initial the climb, much to my great surprise, a voice said, ‘This reminds me of when I first learned to fly.’ My passenger was talking. He then continued to tell me how he had started his flying career on Tiger Moths and graduated through piston Provost to jet Provost aircraft, then Meteors and finished his flying career on supersonic Lightnings.
At this point, I asked him if he would like to fly the plane and he said, ‘Yes, please.’ I said, in the formal manner ‘You have control’ and the reply came back immediately ‘I have control.’ I told him to maintain 1,000ft height, which he did perfectly, and after a short period advised him that it was time to return to the airfield by turning left – much to my amazement he did this without losing any height, as most people do. He then turned back to our final approach, maintaining the correct speed, while I simply adjusted the throttle setting, and descended to 500 ft where I had to take over for the final landing.
After landing he turned to me and said: ‘That was absolutely fantastic – thank you very much.’
These, apparently, were the last words he spoke, although his widow told me that whenever she mentioned the flight a big smile came over his face. She was content that he died happy three weeks later. This made me wonder whether taking people back to their memories might be a way of communicating better with them and it is a principle which I have put into practice and expanded in this article.
Cognitive disorders
These can be broken down into four main categories, all needing special care, as follows:1
- Dementia states, including Alzheimer’s disease
- Stroke complications (vascular dementia states)
- Traumatic brain injury
- Congenital and developmental conditions
Dementia and Alzheimer’s2,3
Such patients normally suffer from short term memory problems and yet can often clearly remember events from many years ago, particularly those from childhood.
Stroke
Depending on the severity and location of the cerebrovascular accident, patients may have similar problems to the above but, in addition, may have gaps in their memory or problems communicating, either due to speech difficulty or difficulties with image recognition and processing. Frustration, through being unable to communicate or physically perform properly, can also provoke temper tantrums, so a calm manner and an appreciation of their problems are both essential.
Trauma
The most common cause is through road traffic accidents resulting in head injury. Again, patients may have similar problems to stroke patients (depending on the nature of the injury, of course) but, because of the violent nature of the cause of their impairment, they may also have psychological problems and sometimes can be unintentionally violent or aggressive. Dealing with this is best done in a similar way as with stroke patients, but be ready to take evasive action and keep equipment out of reach.
Congenital
This broad group includes conditions as varied as Down syndrome, spina bifida, and hydrocephalus and there can be just as wide a range of impairment; from almost none at all, through slow response time, to almost a complete lack of comprehension. Violence and temper are rarely a problem in these cases. Interest in anything other than the examination is more of a problem.
Assessment
Initial discussion
Patients are often somewhat agitated because they are being taken out of their comfort zone, and so it is often useful to begin with some small talk, such as about the weather, what they had for lunch and so on. Hopefully, along with some pre-test information from carers or nursing home staff, you can turn the conversation round to what I call ‘their previous life’.
Sometimes it is necessary to put on an act of pretending to be familiar with previous experiences insofar as having ‘common friends’, ‘knowing the area they grew up in’, ‘having a knowledge of their type of work’, ‘supporting the same football team’ and so on. This not only establishes a common bond between you and the patient, but also gains their attention which is important bearing in mind many of them have short attention span. It also offers a reference point for when attention is lost. Certainly, much better than some cases, where I have known patients to have been shouted at to get their attention.
Having initially gained their attention, I recommend calling patients by their first name (or what care staff use), but always say ‘Is it alright to call you …’ to avoid any upset. This is particularly important for younger optometrists visiting elderly patients.
Technique
Apart from the physical and mental challenges when dealing with these patients, there is the fact that most of them are in nursing or convalescent homes, or domestic premises. You will be working with portable domiciliary equipment, often with no control of lighting and within confined spaces. Hence, you will need to be adept at looking for adequate power points or curtains which can be closed and getting used to inquisitive audiences who seem to take a delight in watching an event which provides a break from the boredom of day to day life.
This is where a good assistant is necessary for such tasks as keeping the patient’s attention, by pointing to letters on the chart, keeping their attention long enough for the ophthalmoscopic examination, comforting the nervous ones and holding their hands if the tropicamide stings, assisting with the paperwork and, in many cases undertaking the dispensing. To have a qualified dispensing optician is a bonus, but often economies dictate the assistant being in-house trained.
Figure 2: Use of a Tonopen
Physical fitness is also important for transporting equipment from the car park, up and down stairs, along corridors and then being able to undertake examinations from a kneeling (I sometimes jokingly call it the proposing) position, and bending over to do ophthalmoscopy on prone bedridden patients. Subsequently a day back in the consulting room is a rest.
Equipment
I use:
- A PanOptic ophthalmoscope (figure 1), because in less than dark conditions the rubber shielded eyepiece cuts out reflections and often reduces the need for pupil dilation. It offers a larger field of view than direct and avoids the bulk of indirect ophthalmoscopy.
- A hand-held contact tonometer such as the Tonopen (figure 2) or a rebound tonometer like the I-Care is preferable for intra-ocular pressures measurement because of the compact size compared to non-contact tonometers.
- An internally illuminated chart with a remote control and binocular loupes with powers of +/- 0.50, 1.00, 1.50 and 2.50 as an easy way to demonstrate blurring, reading addition and for retinoscopy.
- A portable field screener which, although not terribly heavy, may need to be held by an assistant.
Refraction technique
Starting with retinoscopy, it is better to have the assistant in position to maintain fixation by reminding your patient to keep looking at them rather than simply using an inanimate object as a fixation where concentration may not last.
For subjective refraction, I start by checking unaided (or current spectacle) vision so that, hopefully, the improvement with the new prescription can be demonstrated. It is advisable to have an assistant to point at letters in order to maintain concentration. If the patient become tired (as many elderly patients do), have a break and encourage them by telling them how well they are doing. This technique often elicits as much as two extra lines of acuity.
One thing you must not do is to emphasise or highlight any worsening of the vision from the previous examination. However, if there is markedly poor vision, try to lighten the situation by reassuring them that you will be doing everything possible to rectify the situation. During refraction use +/-0.50 D loupes for checking best acuity rather than +/- 0.25 D and also +/- 0.50 cross cylinder rather than +/-0.25 DC, which in poor lighting can be difficult to discern. A duochrome test is useful for binocular balancing of younger patients.
To assess binocular vision the cover test is my first approach as, particularly in poor lighting conditions, Maddox rod and Mallett tests are difficult to perceive.
Ophthalmoscopy
Dilation is often necessary, even with the PanOptic, due to both an inability to darken the temporary test room and the small pupils of many domiciliary patients. Bearing in mind that an applanation type of tonometer (Tonopen or Perkins) is likely to be used rather than a bulky non-contact model, instillation of both anaesthetic and dilation drugs at the same time should be considered, particularly in view of the fact that this also speeds up the dilation.
Diagnosis
In the event of finding some abnormality, it is essential to explain the situation not only to the patient but to a relative or helper at the time, irrespective of any subsequent report. Bearing in mind that these patients may well be already depressed and perhaps worried about their sight, always try to give the best possible spin on the diagnosis. ‘Cataracts are nowadays very easy to treat with a high success rate,’ or ‘macular degeneration does not mean blindness – peripheral vision will be retained’ or ‘vascular problems in one eye will not necessarily affect the other eye.’ Indeed, I try never to mention the dreaded word ‘blindness’.
Conclusion
This sort of work can be stressful, tiring and often has to be carried out in less than perfect conditions, but can also be extremely rewarding. To enable someone to read or watch television when, either through neglect or lack of awareness they could not previously, and see the happiness on their faces is something you rarely get in high street practice. The prevalence of pathological conditions tends to be higher in this population and you are in a position to give appropriate advice which they may not otherwise receive.
In a similar vein to my introductory anecdote, I once saw a patient in her 50s who had been in care all her life as mentally subnormal and could not read or write. I found that she had a horrible prescription (of approximately +8.00 sphere and -5.00 cylinder in each eye) and subsequently prescribed separate distance and reading spectacles for her. After initial giddiness problems, she learned to both read and write within six months and was able to transfer to self-accommodation in a warden assisted home within 12 months. It was from her own home she brought me some cakes she had baked to say thank you. That, colleagues, is what our profession is about.
Roy Carpenter is a semi-retired optometrist with a practice in the Algarve and doing locum work when in the UK.
References
1 Millington A, Preece L. Mental health: an introduction for eye care practitioners. Optician, 27.05.2016.
2 Harvey T. Communicating with the dementia patient. Optician, 08.06.2018.
3 Ghergal D. Alzheimer’s disease. Optician 21.04.2018.