The College of Optometrists

Examining patients with dementia or other acquired cognitive impairment

Previous section Next section


Key points

  • Patients with cognitive impairment may have additional ocular conditions.
  • You should be flexible when examining the patient and adapt your techniques as required.
  • You must follow the guidance on consent when discussing the patient’s condition with a relative or carer.
  • Making decisions about treatment for patients who lack capacity is governed in England and Wales by the Mental Capacity Act 2005, in Scotland by the Adults with Incapacity (Scotland) Act 2000 and in Northern Ireland by common law.
  • You should only prescribe spectacles when it is in the patient’s best interests.
This guidance does not change what you must do under the law.
You should only carry out a sight test if there is a clinical need for this. You should document the reasons for this on the patient record.

What cognitive impairment means and how patients can be affected

Acquired cognitive impairment is a term used to describe a wide variety of conditions that impair brain function and memory. The most common condition is dementia, but others include stroke, brain injuries and psychiatric disorders.
Patients with cognitive impairment can have difficulty in remembering details of eye examinations or that they have had one. The impairment can also affect their personality. If possible, you should, therefore, have a relative or carer present during the examination.
Patients with cognitive impairments can have the same range of visual problems as the general population but are also susceptible to specific ocular conditions, including colour vision changes and reductions in contrast sensitivity which may influence your decision whether to provide a tint.

Key factors to help you act in the patient's best interests

As with any patient, you should always act in the patient’s best interests. When deciding how to do this you should take into account the following factors:
  1. the relative or carer’s wishes may not coincide with those of the patient
  2. the patient’s circumstances, and
  3. the degree of the patient's cognitive impairment and their capacity to consent. See section on Consent.

Principles of examining patients with cognitive impairment

When examining a patient with cognitive impairment you should:
  1. record the name of the person who accompanies the patient, and
  2. record the name of any person that the patient consents to receiving the results of, and recommendations from, the examination.
When examining a patient with cognitive impairment you should:
  1. be flexible and adapt your techniques or use alternative methods appropriate to the patient’s needs
  2. take longer if the patient’s responses are slow
  3. adapt the examination to place emphasis on objective techniques if the patient’s attention span is limited
  4. be aware that a patient’s capacity to consent and understand may vary and you may need to reassess them on another occasion, and
  5. record any reasons for limitations on the examination and results obtained.
You should provide advice on the findings of your examination to the patient, relative or carer, as appropriate, and with the patient’s consent. This should be in a simple way that is easy for the patient to understand. You should reassure the patient about visual function and the absence of abnormal ocular findings. You may need to explain how their condition affects their vision.
Making decisions about treatment and care for patients who lack capacity is governed in:
  1. England and Wales by the Mental Capacity Act 2005.27 The Act is supported by a Code of Practice28  for healthcare workers which you should refer to. Further information for those practising in England is available from the Department of Health
  2. Scotland by the Adults with Incapacity (Scotland) Act 2000.29 The Act is supported by Codes of Practice for healthcare professionals to which you should refer,30 and
  3. Northern Ireland by common law, which requires that decisions must be made in a patient’s best interests.31 32


When deciding whether to prescribe for the patients you should consider:
  1. whether there is a significant change in prescription
  2. whether there is an improvement in functional vision with the change in prescription
  3. the serviceability of their current spectacles
  4. the dangers of large changes in prescription for patients at risk of falling
  5. whether they currently use their spectacles
  6. their ability to make a choice about having a new prescription made up, and
  7. their desire for a new pair of spectacles.
You should only prescribe a tint where a clinical benefit can be demonstrated.
You should advise the patient and their relative or carer about the benefits and disadvantages of:
  1. appropriate spectacles
  2. low vision aids, and
  3. relevant environmental factors, such as lighting.
You may need to manage the patient’s expectations about what is, and what is not, possible with spectacles.

Supply and aftercare

If you supply spectacles to a patient with cognitive impairment you should consider labelling them with the patient’s name, date of supply and whether they are for distance or near tasks. Labelling should be suitable in terms of the patient’s dignity, infection control and type of frame supplied.
If you supply spectacles you must make arrangements for the patient to receive aftercare for as long as is reasonable. This is particularly important as the patient may be more likely to require adjustments.33


33 Opticians Act 1989 s27(3B)

Referral and support

The decision to refer patients with cognitive impairment is a complex one that may involve discussion with the patient and their relative or carer. The patient may benefit from referral.
If you have doubts about the patient’s wider circumstances you should report your findings to the patient’s GP and be prepared to discuss these if necessary.
Patients are more likely to require additional support services at the onset of visual impairment. How patients access these services can vary and you may wish to suggest that patients discuss this with their GP or nurse.

See section on Safeguarding children and vulnerable adults.

Winner of Memcom 2016 award for best microsite

Tel: +44 (0) 20 7839 6000



Website developed by NetXtra