A new "rule of thumb" developed by researchers for the sight loss charity, Thomas Pocklington Trust (1), has been designed to help GPs and practice nurses take action on sight loss in older people.

A new study, "Obstacles to improving visual health in older people," (2) by University College London, calls on GPs and practice nurses to use every encounter with an older patient to consider four key points. Spelled in the word FOCUS, the four points highlight the characteristics of those most at risk of undetected sight loss, and offer a simple test that could be used in surgeries.

"Some older people are reluctant go for eye tests," said Professor Steve Iliffe, an author of the study, "but they will readily visit their GP or practice nurse. This new approach would use those visits to catch undetected sight loss and could lead older people to the specialist treatment they need."

Up to half of older people have undetected visual loss and much of it could be improved with treatment. Apart from patients with diabetes, there is no requirement for GPs to test for eye health. The study found that primary care practitioners may not appreciate the scale of treatable undetected sight loss and may underestimate the likelihood of patients having it. They may doubt their diagnostic skills, or simply not recognise symptoms of visual impairment.

The researchers understood that for GPs to carry out this role they need two things: the ability to identify those at risk of undetected vision impairment and a simple vision test that fits into surgery routines.

They looked at why older people don't go for eye checks and discovered a complex mix of fatalism about old age, avoidance, and distrust of the commercial motives of opticians. Those who had undiagnosed visual impairment were more likely to have had only a basic level of education, be at risk of social isolation, be depressed, need help with basic activities, like preparing food, and self care, have impaired memory and describe their health as only fair or poor.

Those who had difficulty with close vision hobbies, or reading a newspaper were more likely to experience future visual deterioration even if their vision was currently apparently unimpaired. For example, those struggling with close vision hobbies were 4.5 times more likely to have vision related difficulty 3 years later.

The findings, combined with existing research, led to the development of a simple prompt. The word "FOCUS" could be used to frame discussion with the patient, and could then be followed with an examination, which the GP might want to do, or might prefer an optician to carry out.

- Frailty; visual impairment is part of frailty, and may predict its development
- Opportunistic Checks using two questions about close vision work or hobbies, or reading newsprint.
- Unrecognised visual function loss may be treatable, with significant improvement in the quality of life.
- Stoicism and Stigma are barriers to action to improve vision

Said Dr. Angela McCullagh, Director of Research at Thomas Pocklington Trust, "By simply considering eye health in routine checks on older people GPs and practice nurses could plug an important gap in eye care and ward off worsening vision for many older people."

The study has three key messages for GPs and Practice Nurses:

Eye disease in older people is treatable: Refraction errors, cataracts and even some forms of macular degeneration can all be treated. Glaucoma is manageable if identified early but profoundly disabling if not.

Those at risk can be identified: GPs may know the key characteristics of those who do not act on their worsening vision, but may not link them to a patient's failure to seek eye care. They include: fatalism about ageing; avoidance; fear of treatment and suspicion that eye tests are designed to sell spectacles.

Routine questions can spot future problems: Whatever the reason for an older person's visit, all practice teams can use the opportunity to test for sight loss with two simple questions: Do you find it more difficult to carry out close work and hobbies? Can you still easily read a newspaper? Frailty also indicates potential visual impairment, so the questions should particularly be routine for practice teams working with older populations, or with patients in care homes.

1. Thomas Pocklington Trust is a charity which aims to improve the quality of life of people with sight loss. It is a leading provider of housing, care and support services for people with sight loss in the UK, and is a major research and development body.

2. "Obstacles to improving visual health in older people" can be seen at http://www.pocklington-trust.org.uk from 11th March 2009.

3. The study was carried out at the Research Department of Primary Care and Population Health, University College London by Professor Steve Iliffe, Kalpa Kharicha and Sybil Myerson. Some 2000 patients were interviewed from three primary care group practices in outer London and two Primary Care Trusts. GPs, practice nurses and local community opticians also gave their views.

Thomas Pocklington Trust