Providing eye care for patients with dementia
With Dementia Action Week focusing on the difference between symptoms of dementia and ageing, domiciliary optometrists told OT about the importance of patient-centred care, and the difference an eye test can make
18 May 2022
Alzheimer’s Society is encouraging people to ‘act on dementia’ as part of its annual awareness-raising campaign, held from 16-22 May.
This year, Dementia Action Week focuses on the topic of diagnosis, following a sustained five-year drop in rates of diagnosis.
More than 200,000 people will develop dementia this year, the charity said, the equivalent of one person every three minutes. However, with rates of diagnosis reaching a five-year low, the organisation said: “tens of thousands of people are now living with undiagnosed dementia, without access to the vital care and support that a diagnosis can bring.”
A new survey released by Alzheimer’s Society to mark the campaign found that confusing the symptoms of dementia with signs of ageing was the biggest reason people delayed getting a diagnosis.
Previous findings by Alzheimer’s Research UK highlighted that the biggest risk factor for dementia is age, though it is not an inevitable part of ageing. A person’s risk of developing dementia rises from one in 14 over the age of 65, to one in six over the age of 70. Overall, 70% of people in care homes have dementia or severe memory problems.
With an ageing population, and demand for domiciliary care growing exponentially, OT reached out to optometrists delivering care in patients’ own environments, to find out more about tailoring care for a person with a diagnosis of dementia.
Zetun Arif, optometrist with Specsavers’ Home Visit Service
Living with dementia can affect all aspects of a person’s life, as well as those who care for them. Everyday activities that were once easy, like routine check-ups, can suddenly become very difficult and confusing, which can sometimes mean that they’re avoided. This sadly can have a serious impact on eye health. People with dementia may experience problems with their sight and visual perception, which can lead to confusion and misinterpretations about the world around them. Some people living with dementia can experience hallucinations. On top of that, many people living with dementia may be wearing glasses with the wrong prescription, which can lead to increased isolation and confusion.
Living with dementia can affect all aspects of a person’s life
As optometrists, we are part of the bedrock of community health care, so we need to be aware of dementia to offer the best possible care, especially as the number of people living with dementia increases. Regular hearing tests are also important as research suggests that people with untreated hearing loss are more likely to develop dementia.
Taking a caring approach is key to supporting patients who might be experiencing dementia. I take extra time to make patients feel comfortable because eye tests can be demanding for this group. Patients may struggle with identifying letters on the chart, understanding instructions or communicating with me.
Since Specsavers partnered with Dementia Friends, 6000 colleagues have taken part in specialist training to learn how to support the needs of people with dementia. Colleagues wear a badge to indicate their increased level of awareness.
Many of the people I meet day-to-day are living with dementia. Having an eye test at home can offer a more comfortable experience, which can help the test run smoothly. I’ll always encourage loved ones to be present too as it can help create a safe and stress-free environment. Some people might also need to take a short break during the test, which is easier at home. If I am visiting a care home, I will always ask the manager about medication and hobbies in advance to give me a good idea of medical history and so I can make my patient feel at ease.
Tailor eye tests to individual needs, as part of a caring and understanding approach, to make the patient feel safe and comfortable
- Some people living with dementia can find it particularly difficult to explain or articulate any vision loss or symptoms they are experiencing. To help patients I only ever ask questions that require a yes or no answer
- Take care to clearly explain each process to help the patient understand what is happening
- Use Kay picture cards or single letter charts to check the patient’s vision. This avoids the need for reading from a whole page of words or long lines of letters
- Encourage colleagues to learn more about dementia and how they can make a difference to the experience of patients – become a Dementia Friend
- Always check the patient’s current glasses to see if they are still suitable. In some cases, an incorrect glasses prescription can be the cause of visual impairment.
Nick Wingate, director of professional services, OutsideClinic
Over 95% of OutsideClinic patients are still living in their own home. The vast majority of our patients who are living at home with dementia are going to be living with somebody. Throughout the patient’s optometric journey we try to engage with their next of kin as much as we can. One of our standard questions to patients is whether they would like support on the day. That can be next of kin, an advocate or a neighbour, because we know the value of support for patients.
This also helps us from a clinical perspective. We leave a lot of information behind with the patient about their prescription, the details of any referral or recall and information about their ocular health. It’s comforting to know that you are able to explain what you have done, why, and what your recommendations are, to the patient and, with their consent, to their next of kin or advocate.
We are only going to be there for an hour or so, but the recommendations we have made need to be reinforced, so having an advocate or carer present means they can continue to remind them: “You need your light on to help you see better,” and “Have you got the right glasses on?”
The difference a sight test can make
The study found that, of the 708 patients included, 32.5% had visual acuity worse than the driving standard (6/12), and 16.3% had visual acuity worse than the international standard for visual impairment (6/18).
However, 50% of those in the latter group were no longer classed as visually impaired once they had an updated prescription for spectacles.
Describing the findings to OT, Wingate said: “That is a massive number of people you can make a difference to by doing an eye test.”
We have a dementia training module as part of our onboarding process and a national training team to support our optometrists.
The electronic record-keeping software on our tablets also has a preloaded database of medications. There are a relatively small number of medications for short-term memory loss, and when an optometrist selects one of those they will receive a prompt reminding them of what this is for. The optometrist will probably already know, but it’s helpful to have that reminder and it enables them to piece together other signs they might have seen and consider how they provide a service to that patient.
Be mindful that all patients deserve the best service
If you organise your optometric routine for each individual patient, you can provide a really comprehensive service. If you break the eye test into smaller pieces then you can keep that patient's concentration for that short period of time, give them a break whilst you write up some notes, and then get them to concentrate again for another short period of time. You can build an eye test from lots of little blocks rather than a couple of large ones.
We should never deny somebody eye care service because they have dementia. And you can’t pigeonhole people with dementia.
- The most important thing is to take your time
- We all want an eye test to flow nicely and that works for many patients, but for patients with dementia, think about breaking the test into bite-size pieces
- Be mindful that all patients deserve the best service. If you give the patient the time, you’re going to be able to provide a fantastic service and a strong set of recommendations for how they can either support themselves or be supported by their next of kin or advocates.
Vic Khurana, clinical director for Visioncall
Patients with dementia can be a forgotten group of patients. It’s so frustrating because everyone has a fundamental right to a sight test, but patients with dementia don’t always have the access.
Figures suggest we’re going to reach a million people with dementia by 2025. We need to get ahead of the curve and make sure that we have the right people in place.
It’s important that we take a different approach to the sight test. Take your time and the patient will govern your routine. You have to watch their body language, the way they are communicating and have the emotional intelligence to know when to stop and come back to them. Our digital platform allows us to start an eye test, stop and come back flawlessly.
We also need to use a lot of objective measurements, because the patient’s dementia can influence the results and you need to be aware of that. Optometrists need to have a bit of training to understand dementia and short-term memory loss, and understand how the different types can impact the sight test.
Things that can happen with your sight with dementia: it can impact depth perception, your visual field, and your contrast when lights are low.
Everyone would like to say they take a patient-centred approach to prescribing, but it has never been more important for somebody living with dementia. When prescribing, it’s important to carefully consider the situation. If the frames or lenses are not familiar, it will only lead to them not wearing the spectacles, which will then lead to isolation, or the risk of falls.
Figures suggest we’re going to reach a million people with dementia by 2025. We need to get ahead of the curve and make sure that we have the right people in place
We also have to take the time to engage with carers and nurses. If a resident can’t tell us what they are doing day-to-day, we need to engage the people that support them and find out what they enjoy doing, if they have a hobby, or if there is anything they can’t do anymore. Then you need to make a really good management plan after engaging the patient’s support network, considering their prescription, and what the enjoy doing, how mobile they are, and who they interact with.
When we talk about how to communicate with somebody with dementia, I always say to my optometrists, as long as you treat each and every patient like they are a family member, you cannot go wrong. If your mum was living with dementia, how would you communicate with her?
You need to have patience and a good bedside manner, be understanding and engage with everyone around that patient.
I remember going to a meeting with Dementia Friends where they said that if you make an eye test a really enjoyable experience, then when you leave that care home the patient will continue to be happy. They may forget why they're happy, but because we had a bit of a giggle and they've got some nice glasses, then they had a bit of fun. However, if you did not do that; were not flexible, and didn't engage as well as you should have, then that patient can be really upset and anxious, potentially for the rest of the day, and not know why.
We might not think of an eye test as an experience, but for that resident it is an event, and so it’s important to make that really enjoyable. When I was told that I thought: every time I leave a patient now, I'm going to make sure they're smiling, laughing and giggling.
Every time I leave a patient now, I'm going to make sure they're smiling, laughing and giggling
People are not aware that you can have this experience as an optometrist. We need optometrists. There are lots of people living with dementia and there is a huge demand for our service. If you want to make a difference in someone’s life, this is it.
If a person is not seeing clearly, and is living a blurred life, having dementia is only going to exacerbate that situation. The impact you can have on that person can be huge in terms of their visual quality of life.
- Be patient and keep things simple
- Treat the patient like a family member, or how you would like to be treated yourself
- Have an acute awareness of your body language
- Engage with the people supporting the patient, because they know them better than you do
- Learn and discover as much as you can about that patient.
Exploring the referral pathway in practice
The Dudley Local Optical Committee (LOC), home to the Healthy Living Optical Practices pilot scheme, is exploring opportunities in Dementia pathway awareness for optical practices after the pandemic brought an interruption to a previous project.
“Screening is a possibility in Healthy Living Optical Practices, tapping into those patients that may have been missed by GPs and other healthcare professionals,” optometrist Shamina Asif told OT. She added that, as patients can be loyal to the same practice, “this is where optical staff may be able to pick up early signs of dementia, screen the patient and then signpost to local support groups or GPs.”
In 2018, the first Sight Loss and Dementia evening was held, organised by the LOC and the West Midlands Local Eye Health Network NHS England, attended by social workers and optical practice staff.
The session outlined the Dementia Strategy for Dudley, with attendees shown a video on what a sight test was like through the eyes of someone living with dementia, followed by a presentation on dementia identification and the referral pathways. Plans were made for Dementia Friends training for all optical staff, as well as producing signposting packs for optical practices with a view to potentially creating dementia eye care pathways.
However, developments were paused during the pandemic.
Now looking ahead, Asif said: “Dudley LOC are looking to work with public health on dementia pathway awareness in September 2022.”
“I think Healthy Living optical staff with their training are very well suited to screening and identifying these patients and so it's just a matter of time for commissioners to recognise the importance of Healthy Living Optical Practices in dementia detection,” Asif concluded.