1. Eye Tests, Screening and Spectacles – tips for optometrists, families and care staff Declan McKeefry

2. ~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

3. 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

4. Sight Loss due to ‘Normal Ageing’ Media opacities - floaters Presbyopia Senile Miosis (smaller pupils)

5. Sight Loss due to Pathology in the Ageing Eye Media opacities – cataracts Age related macular degeneration Glaucoma

6. 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

7. 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

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

9. 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

10. 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.

11. 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?

12. 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?

13. Regular Eye Examinations Studies 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?

14. 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?

15. 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 consequences  Care 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?

16. Better Education and Training There 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?

17. 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?

19. 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 room minimise glare utilise as much natural light as possible use localised task lighting wherever possible What can be done to improve visual/eye health in people with dementia?

20. Acknowledgements This work was supported by the Thomas Pocklington Trust. Thank you Collaborator Dr Ruth Bartlett Bradford Dementia Group, School of Health Studies, University of Bradford