Eye Tests, Screening and Spectacles

– tips for optometrists, families

and care staff

Declan McKeefry

~750,000 people have dementia in the UK

The majority of these are over 65

Visual problems caused by:

‘normal ageing’

pathological ageing

dementia

Introduction

Sight Loss due to ‘Normal Ageing’

About 2,000,000 (two million) people in the UK have significant sight loss.

Almost 90% are over the age of 60

Number of people registered as blind in the year ending 31 March, England 1997 - 2008¹

Number of people registered as partially sighted in the year ending 31 March, England 1997 - 2008

Sight Loss due to ‘Normal Ageing’

Media opacities

- floaters

Presbyopia

Senile Miosis (smaller pupils)

Sight Loss due to Pathology in the Ageing Eye

Media opacities

– cataracts

Age related macular degeneration

Glaucoma

Low-level Visual Deficits

Reduced visual acuity under conditions of low luminance

Contrast sensitivity in people with Alzheimer’s disease (AD) is reduced for low/coarse spatial frequencies

Colour vision deficiencies

Reduction in the ability to analyse depth or 3-dimensional information in a visual scene

Loss of accurate control and performance of eye movements.

Sight Loss due to Dementia

High-level Visual Deficits

Spatial localisation

Object recognition

Facial recognition

Reduced ability to discriminate between complex figures,

Impaired identification of incomplete figures (visual synthesis)

Visual attention and visual search

Visual Hallucinations

Visual variants of AD – posterior cortical atrophy/Balint’s Syndrome

Sight Loss due to Dementia

Sight Loss due to Dementia

Greater Susceptibility to Pathology

There is an increased prevalence of ocular pathology (glaucoma, age-related macular degeneration, cataracts) in people with Alzheimer’s disease.

A large proportion of people with dementia will have some kind of problem with their vision.

disorientation

decreased mobility

problems recognising familiar faces/places/objects

difficulties in carrying out daily living activities

increased susceptibility to falls

The effects of sight loss due to the ageing process will be compounded by dementia.

Consequences

Problems/Issues

Despite the prevalence of visuo-spatial changes and eye conditions amongst people with dementia, there remains a fundamental lack of awareness about vision in the field.

The prime focus in policy and the dementia care literature is memory rather than vision and so opportunities to highlight the particular issues facing people with dementia and sight loss are often overlooked.

Regular Eye Examinations

Koch et al. (2005) examined the visual requirements of AD patients in US care homes.

94% of the cohort required spectacles to correct significant refractive error.

One third either simply did not use their spectacles, or had prescriptions that were so out of date as to be insufficient to correct their vision!

3 recommendations:

1) Clearly label/mark eyewear

2) Spare spectacles

3) Annual or biannual eye exams

What can be done to improve visual/eye health in people with dementia?

Correction of refractive errors

Subsequent improvements in visual function have the potential to increase their independence and quality of life (de Winter et al., 2004)

Correcting refractive errors has been shown to reduce the disturbing consequences of hallucinations for people with AD.

Ocular health screening is important in people with dementia.

The early detection and intervention of any ocular pathology is vital these as the additional effects of vision loss (due to cataract, ARMD etc) to a patient suffering form dementia may be extremely damaging to their quality of life and independence.

What can be done to improve visual/eye health in people with dementia?

Regular Eye ExaminationsStudies of nursing home residents have shown that less than 20% of this group

receive routine eye care (Kirchner, 1988; Owsley et al., 2007).

Regular sight tests are important and subsequent improvements in visual function have the potential to increase their independence and quality life (Tielsch et al. 1995).

Not only will this have a positive effect on those with dementia but it will also relieve some of the burden on carers and family members.

Currently, optometrists who provide domiciliary services to care homes and private dwellings are best placed to deliver this improvement..

Better promotion in medical centres, day care centres, hospitals etc. of eye care services and availability would be crucial in this respect (individuals over the age of 60 are entitled to a free eye test every year).

What can be done to improve visual/eye health in people with dementia?

The quality of eye health care that people in care homes can receive is compromised by the terms of service laid out in the GOS contract

Timely access to an eye examination for dementia patients may be negatively affected by the GOS.

Currently, optometric practitioners must notify the PCT 3 weeks in advance of a visit to provide eye examinations for more than 2 people at a single address and 48 hours before the visit if they are seeing less than 2 people at the same address.

Effectively, this means that there is no emergency eye health service, except in the circumstances where the practitioner is already visiting a care home on a visit of which the PCT has previously been notified.

Current problems with sight tests provided under General Ophthalmic Services (GOS) contracts

What can be done to improve visual/eye health in people with dementia?

Better Communication of Outcomes and Visual Requirements

Optometrists Families and Care staff

LookUp Initiaitive 'Telling the optometrist about me'

'Feedback from the optometrist about my eye test'

Clearly outline specific visual problems and likely functional consequencesCare plan

Lack of information regarding the visual status of those with dementia has been highlighted as a major problem in care homes (Koch et al., 2005).

Indicate which spectacles are to be used for which tasks.

Clearly label or colour code different spectacles

What can be done to improve visual/eye health in people with dementia?

Better Education and TrainingThere needs to be efforts made to improve the education and training for

optometrists and carers in relation to visual and ocular health issues for people with dementia.

Optometrists

A better awareness of the nature of visual problems

Families and Care Staff

Have little training in assessing of the visual status and needs of people in their care.

Koch et al., 2005 stress the need for families and care staff to be made more aware of the basic visual requirements of dementia patients.

It is also important to bring to the attention of carers more complex visual problems that cannot be corrected.

What can be done to improve visual/eye health in people with dementia?

Living Environment Improvements

Increase contrast and colour

Use sharply contrasting colours between background and foreground This is particularly important for food intake (Dunne et al. 2004)

Try to contrast light colours with dark colours in decorating schemes.

What can be done to improve visual/eye health in people with dementia?

Living Environment Improvements

Modify lighting levels

Low levels of illumination have been found to impede movement around domestic environments and ensuring good lighting of steps, staircases and so forth, can reduce the risk of falls.

Certain general guidelines can be taken into consideration

make sure light is evenly distributed throughout a roomminimise glareutilise as much natural light as possibleuse localised task lighting wherever possible

What can be done to improve visual/eye health in people with dementia?

Acknowledgements

This work was supported by the Thomas Pocklington Trust.

Thank you

Collaborator

Dr Ruth BartlettBradford Dementia Group, School of Health Studies, University of Bradford