26 February 2019

NICE consultation on quality standards for dementia

Read the College's response to the NICE consultation on its quality standard for dementia (February 2019).

1. Quality statement 1

The training and support provided to service providers, health and public health practitioners, commissioners, and adults having NHS Health Checks would be critical to the success of this statement. This training and support should include information regarding eye health and care.

Recent studies suggest that there are genetic links between the risk of developing dementia and the risk of developing cataract. Evidence also suggests that cataract surgery can improve quality of life, and may even slow cognitive decline in people with dementia.

We recommend including the need to have regular sight tests to the information provided to adults about the risk factors for dementia.

2. Quality statement 2

It is essential that once someone is diagnosed with dementia they continue to regularly see their optometrist for eye examinations. This allows the optometrist to manage any visual impairment, something that the government-funded Prevalence of Visual Impairment in People with Dementia (PrOVIDe) study (2016) (Bowen, M., Edgar, D. F.et al, Health Services and Delivery Research, 4(21), pp. 1–200. doi: 10.3310/hsdr04210) led by the College of Optometrists has shown is more common in people with dementia. It is important that the patient and their general health, including vision, is not forgotten. This is especially important in dementias that initially involve predominantly visual symptoms, such as Posterior Cortical Atrophy. The successful management of visual impairment can also improve the quality of life of people with dementia.

Dementia and sight loss develop independently, but both dementia and the main causes of sight loss are age-related. The ageing population trends mean that more people will have both together.  Dementia alone has a significant impact on quality of life, and visual impairment in older people can lead to functional impairment, which may adversely affect quality of life even further. The ability of a person with dementia to cope with visual impairment is also reduced, which means the effects of both concurrently can be much more severe on activities of daily living and cognitive performance. 

Detecting and correcting impaired vision and refractive error can improve quality of life and reduce related co-morbidities among the dementia population. At dementia diagnosis stage, correcting the impaired vision with up-to-date spectacles or referring for cataract surgery could have a significant positive impact on a dementia patients’ ability to live life independently for longer.

The College of Optometrists would recommend commissioners to include a full visual assessment in their dementia care pathways.

3. Quality statement 3

See our comment 1 above.

The training and support provided to named care coordinator would be critical to the success of this statement and we recommend to ensure the named care coordinator is fully aware of the patient’s need to have regular sight test and to raise awareness on how good vision will help patients with dementia live better, and possibly slow their decline.

It is important to reassure carers and patients that people with dementia are generally able to undertake all the key elements of an eye examination, and to advise those with dementia, and their carers, of their eligibility for NHS funded sight tests to be performed either at home or in a community practice.

4. Quality statement 3 (rationale)

See our comment 2 above.

We suggest amending the sentence “people with dementia often have other long-term conditions, such as cardiovascular disease and diabetes” by adding “vision impairment”.

The sentence would read as, “people with dementia often have other long-term conditions, such as cardiovascular disease, vision impairment and diabetes”.

The PrOVIDe study finds that the prevalence of presenting visual impairment was 32.5% and 16.3% for visual acuity worse than 6/12 and 6/18 respectively. This is generally higher than in comparable data from prevalence studies on the overall population (after adjustment for age and gender).

5. Quality statement 5

See our comments 1 and 2 above.

We strongly recommend that the structured assessment includes a full visual assessment.

6. Quality statement 6

The PrOVIDe study finds that the primary cause of visual impairment worse than 6/12 was cataract, which is treatable with surgery in suitable patients. Most people with dementia interviewed during the PrOVIDe study said they would want surgery to correct cataract if required.

We recommend that a decision about referral for cataract surgery should take into account the need to try and do so while the person still has the capacity to consider the decision, consent to the procedure, and cope better with the recovery process after surgery.

Submitted: February 2019

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