A higher proportion of patients with dementia are suffering from visual impairment than their peers – with levels rising further still in care homes – often impacting their quality of life without proper correction.
The optical profession has an increasing role to play, following new research findings that a third of people with dementia had visual acuity worse than 6/12.
The research, entitled the Prevalence of Visual Impairment in People with Dementia (Provide), was launched by the College of Optometrists in collaboration with university research departments and charities last week (Optician 28.04.17).
A parliamentary reception heard how visual impairment was more than twice as common in those living in care homes than for those in their own homes. The study involved 708 people living with dementia aged 60 to 89 years, 389 of whom lived at home and 319 in care home settings.
Mike Bowen, director of research at the College of Optometrists and chief investigator for the study, told Optician: ‘If you’ve got dementia but your visual impairment is better managed you are more likely to be able to stay in your own home for longer.’
The Westminster event attracted MPs including Debbie Abrahams, Marion Fellows, Jim Fitzpatrick, Mark Durkan, Steve McCabe and Lord Low of Dalston, who pulled themselves away from the general election frenzy to hear more.
Easy fix at difficult time
In the Provide study, 32.5% of people with dementia had visual acuity worse than 6/12 and 16.3% had VA worse than 6/18. These figures were generally higher than in comparable data from prevalence studies on the general population, it noted.
However, half of the research sample were no longer classified as visually impaired when wearing their up-to-date spectacle prescription.
Furthermore, 16% of participants who could not read standard newspaper-size print with their current spectacles could do so wearing a prescription given following a dementia-friendly sight test.
Bowen said: ‘Of the vision impairment that we found, half of it was fixed with the right spectacle prescription. Of the vision impairment that was left, half of that was down to cataracts, so we’ve got a couple of big slices from the vision impairment risk profile for the dementia population that potentially we can fix relatively easily within our existing health systems.’
He went on to suggest regional thresholds for cataracts could be lowered when the patient had a dementia diagnosis.
However, screening remained an issue, with 22% of participants not having had a sight test in the previous two years in the study and an eye test not automatically part of the patient pathway.
The process of a dementia diagnosis usually involved a GP appointment with early symptoms such as memory loss. Vision loss was not usually among these, and the main priority for the patient is to visit a memory clinic for a firm diagnosis. However, the College called for an eye examination as soon as the dementia diagnosis is given.
Bowen said: ‘Among the things you should have when your diagnosis is given should be advice to get a full vision assessment as soon as possible. Although not every form of dementia has vision loss as an early symptom, all the forms of dementia will eventually lead to problems with vision.
MP Debbie Abrahams, Agnes Houston, who shared her experiences of dementia, Mike Bowen and fellow Provide researcher Dr Rakhee Shah
‘If you have that early baseline, there is the greatest possibility of people noticing changes later on. It’s going to be much more possible for the combination of healthcare professionals involved in your care to spot when there are problems with your vision that are due to ocular reasons, such as cataract, and when in fact they are a neurological feature of dementia.
‘As dementia progresses in many cases there will be issues around hallucinations and visual experiences. But even in those cases, having the optical elements as good as possible can help alleviate those problems.’
Home access to eye care
During the Provide study, each patient had a domiciliary eye examination, followed by the collection of qualitative data from 119 participants. Interviews with care workers, family care workers and optometrist focus groups added further insight.
It became clear optometrists did not feel enough training and support is provided to examine people with dementia. Furthermore, they were not always informed that an individual has dementia before their examination takes place.
Carers and care workers, meanwhile, were unsure that people with dementia could have a full eye examination if they had difficulty answering questions, but the College found it was possible to conduct key components of the exam with more than 80% of people examined.
James Pickett, head of research at Alzheimer’s Society, said: ‘The study helps to address the vast misconceptions that it is difficult or impossible for people living with dementia to get an eye test. It is not only possible but hugely important. The findings also show that for a large number of people affected by dementia, a simple correction such as getting glasses or surgery can greatly improve their quality of life.
‘We need to make sure that both eye professionals and people affected by dementia understand the importance of accessing eye care, and how correcting vision impairments can make a significant difference to the lives of people living with dementia.’
Meanwhile, constraints on time in busy practices presented difficulties for practices, meaning domiciliary visits were a valuable alternative for both patient and practitioner.
Bowen added: ‘It reflects the stress and anxiety involved for a carer and someone suffering from dementia in getting from home, into a car or taxi, into town and then into a busy environment. Already you are entering that examination room with a higher level of environmental stress.
‘That’s not to detract from what’s happening in community practices at all.
‘Even in busy practice settings, optometrists are keen to adjust what they are offering to suit the needs of the patient before them. So they will schedule appointments at more convenient parts of the day if they know a patient is living with dementia and they’ll give them some extra time if they possibly can.’
College chief executive Ian Humphreys speaks with MP Debbie Abrahams
He also suggested NHS England could split GOS into two time slots for patients with dementia.
Therefore, the importance and benefits of reaching out to patients with dementia are undisputed, while optometry was keen to step up. Case studies during the Provide research found dementia patients became more active and cheerful following vision correction and cataract surgery.
Bowen added: ‘However fast or slow your dementia is progressing, it seems reasonably uncontentious to suggest the best vision possible is going to improve the activities you are doing.
‘I’ve got tremendous confidence in the profession and its willingness to engage and ability to deliver that. We just need to make sure they’ve got support in terms of information and evidence that they need.
‘We probably all know someone within our family and friends who is living with dementia and perhaps it has motivated people to see it’s an important part of their practice.’
The College has generated a set of online resources for its members to use in everyday practice when seeing patients with dementia, including a Provide presentation from researcher Professor David Edgar and a DOCET