NICE topic engagement: Dementia

Read our response to the NICE topic engagement on its quality standard for dementia (October 2018).

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What are the key areas for quality improvement that you would want to see covered by this quality standard? Please prioritise up to 5 areas which you consider as having the greatest potential to improve the quality of care. Please state the specific aspects of care or service delivery that should be addressed, including the actions that you feel would most improve quality.

Key area for quality improvement

Increased awareness of the link between vision and dementia.

Why is this important?

It is essential that once someone is diagnosed with dementia they continue to regularly see their optometrist for eye examinations, and that the optometrist is informed of their diagnosis. This allows the optometrist to adjust the eye examination to suit their needs, and allows the optometrist to manage any visual impairment, something that our research has shown is more common in people with dementia.1  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.5 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.6 

Detecting and correcting impaired vision and refractive error can improve quality of life and reduce related co-morbidities among the dementia population.  The Prevalence of Visual Impairment in People with Dementia (PrOVIDe) study (2016) (Bowen, M., Edgar, D. al, Health Services and Delivery Research, 4(21), pp. 1–200. doi: 10.3310/hsdr04210) shows that finding and correcting impaired vision in the dementia population is often not as difficult as many believe. Optometrists have the skills, equipment and expertise to perform a comprehensive eye examination on most people with dementia. 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. As the extra time needed by optometrists to examine people with dementia is not currently funded, there will need to be commissioned elements to allow optometrists to allocate the time that people with dementia need.

Why is this a key area for quality improvement?

Our research found that the prevalence of visual impairment was higher on average among those living with dementia than the general population, and yet many are not getting the eye care that they need.1 Other research has indicated that the effects of having both sight loss and dementia are much more severe than those resulting from either dementia or sight loss alone, and that there are genetic links between the risk of developing dementia and the risk of developing cataract. 2, 3, 4

Supporting information

1 The Prevalence of Visual Impairment in People with Dementia (PrOVIDe) study (2016) Bowen, M., Edgar, D. al, Health Services and Delivery Research, 4(21), pp. 1–200. doi: 10.3310/hsdr04210

2 Concurrence of Danish Dementia and Cataract: Insights from the Interactions of Dementia Associated Peptides with Eye Lens α-Crystallin (2008) Surolia I, Sinha S, Sarkar DP, Reddy PY, Reddy GB, et al. PLOS ONE 3(8): e2927

3 Cytosolic β-amyloid deposition and supranuclear cataracts in lenses from people with Alzheimer's disease (2003), L. E. Goldstein, J. A. Muffat, R. A. Cherny et al., The Lancet, vol. 361, no. 9365, pp. 1258–1265

4 Is there any relation between pseudoexfoliation syndrome and Alzheimer's type dementia? (2013) T. Cumurcu, F. Dorak, B. E. Cumurcu et al, Seminars in Ophthalmology, vol. 28, no. 4, pp. 224–229, 2013

5 (Trigg R1, Skevington SM, Jones RW (2007),How can we best assess the quality of life of people with dementia? the Bath Assessment of Subjective Quality of Life in Dementia (BASQID). Gerontologist. 2007 Dec;47(6):789-97).  

6 (McKeefry D, Bartlett R (2010) Improving Vision and Eye Health Care to People with Dementia. London: Thomas Pocklington Trust)

October 2018