Doctor Patient Relations

Patients with Dementia: Recognize, Provide Care and Products, Refer

By Pamela Miller, OD, FAAO, JD, DPNAP


With more patients displaying dementia, you need to recognize conditions, refer when warranted, and provide optical products that meet specialized needs.


RECOGNIZE POSSIBLE DEMENTIA. Signs include difficulty holding conversations and inability to recognize letters and shapes on eye chart.

PROVIDE NEEDED PRODUCTS. Polycarbonate and high-impact lenses with AR can make breakage less likely and improve visual quality.

KNOW WHEN TO REFER. If the patient doesn’t know there is a problem themselves, yet you notice something amiss, refer to a specialist or primary care doctor.

When patients with dementia, or those you suspect of having dementia, visit your practice, you have more to think about than just their eyes. Interacting with these patients, gathering information about their eye health and providing needed products requires a careful approach. Here are steps to enhance your handling of patients with dementia and protect your practice in the process from legal liability by referring appropriately. As with all matters, it is also best to check with your state optometric board and attorney about your approach to caring for patients with dementia.

While the majority of dementia patients are elderly, there are many other conditions that can cause dementia-like symptoms such as Parkinson’s, stroke, toxic reaction to too much alcohol and drugs (legal and illegal), AIDS, brain tumors, illnesses in organs like the kidney and liver, head trauma and even extreme stress and clinical depression. The important point is to recognize when a patient isn’t fully coherent and then to take steps to provide them with the care they need, and to refer when necessary. Dementia patients often suffer from a number of other health issues as well, so a careful visual examination coupled with detailed history is essential. You need to make certain that you document their level of alertness and orientation as part of your evaluation.

Recognize Patients with Dementia

The best way to gauge the mental state of any patient, including those with dementia or suspected dementia, is to have a conversation with them. You can notice something is off when asking a simple question like “how are you doing today?” Is the patient able to respond in a reasonable manner, or are they hesitant and unsure. A patient with dementia may not be able to answer that simple question at all, may take a minute or two to respond or may respond with something that doesn’t make sense or is out of context: “Yes, I believe I left the car out back.” Or they might address you as if they think you are someone else.

I also will bring up current events or an approaching holiday to the patient, noting something that’s been in the news or asking what they are doing for an upcoming holiday like Labor Day weekend or Thanksgiving. Patients with dementia may not recognize those holidays, or they may look at you confused, unable to respond. I keep notes in my records on the information patients share with me such as the birth of a grandchild or a wedding of one of their children. I then will refer to them having told me those things and see if they are able to have a cogent conversation about them.

Other red flags: The patient doesn’t have appropriate perception (staring into space), repeatedly can’t find things such as their glasses while their glasses are lying in their lap. They also may have trouble figuring out how to get into your exam chair. When testing the patient’s acuity, they may not be able to identify letters on your chart, and even when you switch to a chart used for children, they may be unable to identify shapes like squares and circles, while you know, based on your auto-refraction and examination of their eyes, that there is no visual or ocular health reason they shouldn’t be able to see those things.

Serve Patient Needs with Optical Products

Polycarbonate and high-impact lenses are helpful because when the patient falls, as many with dementia are prone to do, they are less likely to break. Anti-reflective treatment for lenses also is a good idea because it helps deflect glare improving the visual recognition that many who have dementia struggle with. Other visual challenges the right eyewear can help with are background contrast discrimination, depth and motion perception (the patient may try to put something on a table and miss the table). Patients who have suffered a stroke who are in the earlier stages of dementia may need prism in their glasses to improve vision, both function and acuity, including the ability to focus and concentrate on a task for an extended period of time, as well as optimizing actual performance.

Separate reading and distance eyewear often is best for these patients, as the eyes of a person with dementia may not be able to adjust properly to progressives or bifocals creating visual distortions, and they may not be able to coordinate their eyes enough to remember to look in the right part of the lens for near and far. Even if a patient is no longer able to work or do up-close tasks, they may still need a pair of reading glasses for when they eat.

Know When to Refer

You may be the first person who recognizes that something seems off with the patient. Many patients and their family or caregivers may assume the forgetfulness and confusion are just parts of growing old. However, it is important that in a gentle way you let the patient and family know they should be seen by a specialist. You might say: “It looks like you may have had a slight stroke or are having some problems where medication may help. This is my impression, but I feel you need to be evaluated by a neurologist or a specialist. If I am able to refer you directly to a neurologist, I will, otherwise, I will refer you to your primary care doctor, who can refer you to the appropriate specialist in your medical plan.”

If the patient brings a caregiver with them (a spouse, child, etc.), it is important to convey your recommendations to that individual as well, but only with the patient’s permission. Of course, if the patient is unable to communicate with you due to their dementia, the caregiver will typically come into the exam room and will have the legal ability to act in the best interests of the patient. If the patient is in the earlier stages, it is a simple matter to ask if it is alright to speak with the individual who came with them. Be certain you speak to that individual within the sight and hearing of your patient to minimize additional liability, and document that you have permission, who you have communicated with and what you advised.

If you aren’t sure which specialist a patient needs, it is always safe to simply refer them back to their primary care doctor, who can then make that determination. The most important thing is to care for your patient as effectively and expediently as you can, making certain their visual system is functioning as optimally as possible and prescribing for their needs, including referral when appropriate and reassessing those needs on a regular basis.

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Pamela Miller, OD, FAAO, JD, DPNAP, has a solo optometric practice in Highland, Calif. She has a law degree, holds a therapeutic license, is California State Board-certified and glaucoma-certified to prescribe eye medications, and offers comprehensive vision care, contact lenses, visual therapy and low vision services. To contact her:

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