The College of Optometrists

Examining patients with dementia or other acquired cognitive impairment

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Sub-sections

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 the Mental Capacity Act (Northern Ireland) 2016 (not yet in force).
  • You must only prescribe spectacles when it is in the patient’s best interests.
A102
This guidance does not change what you must do under the law.
A103
You must only carry out a sight test if this is clinically justified and in the best interests of the patient.43 You should document the reasons for this on the patient record.

What cognitive impairment means and how patients can be affected

A104
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.
A105
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.
A106
Patients with cognitive impairment 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.
A107
Cognitive impairment may also cause cortical visual loss.

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

A108
As with any patient, you must 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

A109
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.
A110
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.
A111
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.
A112
Making decisions about treatment and care for patients who lack capacity is governed in:
  1. England and Wales by the Mental Capacity Act 2005.44 The Act is supported by a Code of Practice45 for healthcare workers which you should refer to. A person lacks capacity if, at the time the decision needs to be made, they are unable to make or communicate the decision because of an ‘impairment or disturbance’ that affects the way their mind or brain works.
  2. Scotland by the Adults with Incapacity (Scotland) Act 2000.46 The Act is supported by Codes of Practice for healthcare professionals which you should refer to. A person lacks capacity if they cannot make decisions or communicate them, or understand or remember their decision because of a mental disorder or a physical inability to communicate in any form.47
  3. Northern Ireland by The Mental Capacity Act (Northern Ireland) 2016 (not yet in force).48 The Act will be supported by a Code of Practice for healthcare workers which you should refer to.49 A person lacks capacity if, at the time the decision needs to be made, they are unable to understand information, retain information, appreciate the relevance of the information or communicate their decision because of an impairment of, or a disturbance in, the function of the mind or brain. The timescales for implementing certain parts of the Act are as yet unclear, so you should seek legal advice if you have concerns about a person’s capacity to make decisions. 

References

44 Mental Capacity Act 2005.
45 Office of the Public Guardian (2007) Mental Capacity Act 2005 code of practice [Accessed 26 Oct 2017]
46 Adults with Incapacity (Scotland) Act 2000.
47 The Scottish Government. Adults with Incapacity (Scotland) Act 2000 codes of practice [Accessed 26 Oct 2017]
48 The Mental Capacity Act (Northern Ireland) 2016
49 Mental Capacity Act (Northern Ireland) Code of Practice [Not yet published]

Prescribing

A113
When deciding whether to prescribe for the patient, 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 falling50
  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.
A114
You must only prescribe a tint where it is clinically justified and in the best interests of the patient.51
A115
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.
A116
You may need to manage the patient’s expectations about what is, and what is not, possible with spectacles.

Supply and aftercare

A117
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.
A118
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.52 

References

52 Opticians Act 1989 s27(3B)

Referral and support

A119
The decision to refer a patient 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.
A120
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.
A121
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.

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