Cognitive Vision Testing in Optometry: Precision “Medicine” for Eye Care
By Solomon Gould, OD, MBA
Inspired and Supported by Fred Ma, MD, Ph.D., Heather Harris, Mike Pier, OD, Brad Oatney, OD, and Scott Sedlacek, OD.
The eye care industry is progressing at lightning speed. Scope of practice continues to expand state by state, year by year. The Doctor of Optometry’s role as formative a frontline screener for systemic health and vitality is now well established and widely known.
Along with these changes to our scope of clinical care, the eye care industry as a whole is experiencing a myriad of changes. Market consolidation, corporatization, and e-commerce have posed challenges to both practice establishment and sustainability. These trends have also led to a state of hyper-competition and financial stress for many practice owners.
Consequently, optometry practice owners are seeking ways to improve patient care and retention, while also increasing revenue, widening their margins, and developing new revenue sources. Many Doctors of Optometry are implementing specialties such as dry eye, myopia management, sports vision, specialty contact lens, and aesthetic eye spas.
Experiencing and feeling the impact of these market and industry changes at my own private practices, I went back to the drawing board and took a detailed, strategic look at my existing practice offerings as well as my overall approach to the clinical care of my patients. I established that I wanted to find something that would not only help enhance my practice’s performance but that would also, most importantly, improve the clinical care that I provide.
As Doctors of Optometry, we are frequently inundated with new technologies and practice offerings promising to drive up revenue and referrals and offering a competitive edge over the competition. Whether the result of the method of implementation or the implementation itself, the results of many of these novelties fall short of expectations. Consequently, many Doctors of Optometry run for the hills or inherently scrutinize any new innovation’s claims “with a grain of salt.”
I knew that I wanted to incorporate something that resonated with the core competencies of comprehensive eye care. I was introduced to the Cognivue Thrive technology by a good friend and fellow optometrist. Upon learning the scientific validation and the technology behind Cognivue Thrive, I immediately knew I had discovered what I was looking for. Seeing the results speak for themselves at both locations over the past year has been the proof in the pudding I now wish to share with my fellow Doctors of Optometry.
Cognivue Thrive utilizes a patented technology called Adaptive Psychophysics to accurately measure people’s ability to receive, process, and respond to their visual world. Cognivue Thrive is based on FDA-cleared technology and has been shown to yield superior test and re-test reliability compared to other modalities of assessing cognition such as the Montreal Cognitive Assessment (MoCA) screening1 and SLUMS2. The Adaptive Psychophysics technology permits anyone to experience the technology regardless of their vision and/or motor skills. Cognivue® uses the patient responses during this specific, 5-minute, self-administered test to dynamically change & adapt the test to determine their thresholds (best achievable scores) or failure points as it would objectively detect the stimulus that captured and identified by the brain, hence differentiate in between the stimulus and describe the magnitude or nature of the difference. To highlight the significance of its accuracy, the Cognivue Thrive captures over 32,500 data points throughout the course of a single test. The Cognivue Thrive is the size of a laptop computer and is portable, permitting flexibility of use and a small office footprint.
The Trifecta Benefit
Going beyond just helping patients see.
Basic refraction was for decades considered the ‘bread and butter’ of a Doctor of Optometry’s work. This, of course evolved over time and, though it remains an integral component of our clinical repertoire, our role and the awareness thereof have both expanded significantly. Today, for many Doctors of Optometry, this component has become the responsibility of the optometric technician. Regardless of whether it is the Doctor of Optometry or their technician that does this portion of the exam, the Doctor of Optometry must analyze this data and ascertain both its validity and what contributing factors may be at play behind the results. For example, if a patient is diabetic and their refraction yields an appreciably higher myopic shift than would be considered normal, the Doctor of Optometry must include this awareness in the care they render for that patient.
The sheer concept of Doctors of Optometry also measuring the processing of the vision is a novelty in and of itself. I recall vividly the moment that this concept clicked with me. It was of course on a Sunday evening when I was anxiously dreading leaving the comfort of family time and freedom from the daily grind and going back to work on Monday. I was seeking a higher-level purpose to help expand upon the profession of optometry. Oddly enough, I must give all due credit for the ‘aha moment’ to my 10-month-old golden doodle, Maddie. As she always so charmingly does, Maddie was tilting her head side to side with an expression of inquisition and simultaneous curiosity. I must have looked like a mad man in my home office drawing on my marker board and both talking to and answering myself (a tendency that they say is not exactly normal).
I realized at that moment that we can now not only help patients see, but we can also measure how well they process what they are seeing. Additionally, as I will share with you in this article, we can use this information to help our patients also preserve their cognitive vitality and their ability to process what they are seeing. The reality, and something I do not believe most Doctors of Optometry take the time to reflect on, is that we look with our eyes but we see with our brain. I foresee this soon becoming the standard of care. The eyes and the brain are interconnected in so many ways, and they rely on one another for longevity and vitality as I will share with you in this article as well.
The Cognivue Thrive measures three key cognitive domains: visuospatial, memory and executive function. It also measures both reaction time and processing speed. The visuospatial cognitive domain is the responsibility of the parietal lobes. The parietal lobes allow us to assess our visual scenes and to determine the precise coordinates of those images within our visual scenes. The memory cognitive domain is the responsibility of the temporal lobes. The temporal lobes, using short-term memory, allow us to recognize objects within our visual scenes. The executive function cognitive domain is the responsibility of the frontal lobes. The frontal lobes allow us to focus on and make decisions based on our visual scenes.
Practice performance enhancement.
The impact that a new implementation has on a practice’s performance is important for most optometry practice owners. Though we all have humanitarian hearts, we must also run a business and we must do so without the forfeiture of efficacy, ethics, and standard of care. The importance of fostering the business component to being an optometry practice owner has increased as a result of the aforementioned industry and market changes.
In the past year, I have used the Cognivue Thrive with over 700 patients and growing by the day. As with any new practice implementation, I have tracked its performance along the way using various Key Performance Indicators, or KPIs. My New Patient Ratio, an indication of growth and referrals, has increased on average by on average 5 percent each month. From implementation, my Collections per Full Time Equivalent (FTE), an indication of staff productivity, has increased by $4,000. My Revenue per Patient, an indication of operational efficiency, has increased by $120. Lastly, the implementation has yielded a generous 10.5 percent Return on Investment (ROI). This implementation has also helped increase our patient retention and compliance with consistent, annual visits.
Not all ROIs are tangible or monetary. I have received countless compliments from patients on the quality of care we now provide at my practices. We have received more goodies deliveries from patients than we have the desire or insulin levels to consume ourselves. I have several testimonials on patients whose cognitive processing measurements led to referrals and are now stabilized with intervention – all of which would have otherwise gone undiscovered until it was too late for intervention. Lastly, both my staff and I feel a revitalized, higher-level purpose and sense of pride in our work on a daily basis. We realize that we are helping not only to better our patients’ lives, but we are simultaneously helping to advance the great profession of optometry.
Supporting a Higher-level Cause
Public health need.
In addition to enhancing clinical care and practice performance, I have discovered that it also renders a third benefit, the support of a higher-level cause.
In the past 20 years, the prevalence of most systemic ailments has improved thanks to the evolution of modern medicine. And yet, end-stage cognitive decline has increased by 123 percent2. In short, our bodies are outliving our minds. Ironically, as many studies show, end-stage cognitive decline is more feared by people across all age groups than any other disease3.
Societally, we have done a remarkable job at promoting the preservation of physical vitality by means of exercise, nutrition, regular routine medical care, medication compliance, and self-care. As for cognitive preservation, it was not until 2018 when several reputable entities, such as the Centers for Disease Control and Prevention (CDC), American Diabetes Association (ADA), American Academy of Neurology (AAN), and World Health Organization (WHO) began kicking off initiatives aimed at promoting cognitive health as a central part of public health practice. Sadly, the adoption and the incorporation of this paradigm shift in prioritization has not yet reached sufficient levels to meet the public health, economic, and societal needs.
Unbeknown to many, cognitive decline is not just about dementia and Alzheimer’s disease. The reality is that not all cognitive issues progress onto the dementias. The research validates two very important eye-opening realities. First, fostering various modifiable risk factors can significantly reduce the risk of onset or progression of cognitive decline4. These include, but are not limited to diet, exercise, sleep, vision, hearing, and socialization. Secondly, there are seven stages of cognitive decline5. Dementia does not even set in until stage four5. Just imagine the impact that fostering these modifiable risk factors throughout life could have, not just economically in the form of exorbitant health care savings – but also on the individuals and the family members of those who would otherwise develop end-stage cognitive decline disease.
The solution rests in one very simple recipe – early and regular screening throughout life. To date, the existing system in place for screening cognitive health has fallen short of the needs. Many studies show that primary care physicians routinely overlook cognitive impairment and dementia, failing to recognize these conditions at least 50 percent of the time6. Multiple specialties, including optometry, have been called upon to help with the initiative of offering early and regular cognitive screenings for people.
Economic paradigm shift warranted.
Last year alone, the United States spent $305 billion on dementia care, with the cost expected to increase to more than $1 trillion as the population ages7. U.S. health care spending grew 4.6 percent in 2020, reaching $3.8 trillion or $11,582 per person8. As a share of the nation’s Gross Domestic Product, healthcare spending accounted for 17.7 percent in 20208. These staggering numbers lend credence to the reality that a paradigm shift in the existing health care system is needed. Early and regular cognitive screenings throughout one’s life and the introduction of modifiable risk factors has the potential to remarkably curtail at least the cognitive decline healthcare expenditures.
Quality of life prioritization.
Quality of life is often under-fostered and under-appreciated. The COVID-19 pandemic, as catastrophically detrimental as it has been, helped many reassess and recalibrate the importance of their health and their quality of life. Many studies show a measurable impact of COVID-19 on cognitive health. In addition to fulfilling both public health and economic needs, assisting with this initiative has exorbitant potential for enhancing the quality of life for so many.
The Clinical Application
The clinical application of Cognivue Thrive may vary from one Doctor of Optometry to another. At my practices, I utilize Cognivue Thrive as part of the comprehensive eye examination workup. My Teams and I tee up the offering as an upgrade to the standard comprehensive eye exam. We describe it simply as a more thorough version of the comprehensive eye exam. My patients have been very intrigued by the value of also measuring the processing of their vision. Those patients who have now had this done a second year in a row have requested this version in advance. The upgrade fee we utilize is $40. I also offer it as a standalone appointment or bundled with other holistic diagnostic technologies that I have incorporated into my practices as a package offering. This flexibility of choice has been the reason I have been able to scan 724 patients and growing by the day.
The process itself is very efficient and streamlined. At my practices, my technician conducts the screening in the pre-workup room. Their results are placed into their record which I review prior to seeing them. I then address their results along with their vision, ocular findings, and any potential systemic contributions such as Diabetes.
Regardless of their results, I always introduce them to the Cogniwell Program. The Cogniwell Program provides patients with a complete list of those modifiable risk factors that can be fostered throughout life to minimize the chances of development and progression of cognitive decline. Concomitantly, it helps patients preserve the processing of their vision, which I have coined as “Cognitive Vision.” If their results are either borderline or categorized as sub-healthy, I utilize the Cognivue best practices referral guide algorithm. In some cases, this may involve a simple referral to either their Primary Care Physician (PCP) or neurologist for further workup. For patients who wish to speak with a specialist in greater depth prior to seeing their specialist, or even if they simply want to discuss the Cogniwell Program further, those patients are then put in contact with Cognivue Wellness Experts.
The Bidirectionality of Vision and Cognition
The relationship between vision and cognition has been extensively published in several scholarly articles such as JAMA, Internal Medicine, Neurology, and many others. Not only has it been validated that preserving and improving vision helps preserve cognitive function9, but it has also been validated that the relationship between vision and cognition is bidirectional10.
Public Health Initiatives
As referenced earlier in this article, the year 2018 served as a formative year for the prioritization of cognitive health. In 2018, the Centers for Disease Control and Prevention (CDC) launched an initiative called the Healthy Brain Initiative Road Map. Its objective was to improve the understanding of brain health as a central part of public health practice. It was also aimed at promoting the early detection and the risk reduction of cognitive decline11.
In 2019, several other initiatives were launched by other reputable entities. The World Health Organization (WHO) promoted cognitive health through the early diagnosis and the management of modifiable risk factors12. The American Diabetes Association (ADA) promoted early cognitive evaluation as a tool to improve the overall quality of care for people13. Additionally, the American Academy of Neurology developed the Workgroup Approved Six Measure System aimed at the early detection and the risk reduction of cognitive decline14.
The bidirectionality of vision and cognition lends credence to the importance of both the early detection and the risk reduction of cognitive decline. Of the many modifiable risk factors for preserving cognition, including the processing of our vision, vision is not only a very important one – it is also easily modifiable. There is so much more to our world than static objects in space. The reality is that cognitive vision has always been there. We just simply did not see it or have a way to measure it, until now.
The Cognivue Thrive, with its FDA cleared Adaptive Psychophysics technology, offers superior test and re-test reliability compared to other methods and, thus, serves as the best technology to help elevate our standard of care to the next level.
1 Practical Neurology. (2021). Digital Cognitive Evaluation May Be More Reliable Than Montreal Cognitive Assessment. Retrieved from: https://practicalneurology.com/news/digital-cognitive-evaluation-may-be-more-reliable-than-montreal-cognitive-assessment
2 Alzheimer’s Association. (2020). Facts and Figures. Retrieved from: https://www.alz.org/alzheimers-dementia/facts-figures
3 Centers for Disease Control. (2020). Alzheimer Disease. Retrieved from: https://www.cdc.gov/nchs/fastats/alzheimers.htm
4 Baumgart, M., Snyder, H., Carrillo, M., Fazio, S., Kim, H., Johns, H. (2015). Summary of the evidence on modifiable risk factors for cognitive decline and dementia: A population-based perspective. Alzheimer’s & Dementia, Volume 11, Issue 6, Pages 718-726. Retrieved from: https://doi.org/10.1016/j.jalz.2015.05.016.
5 Dementia. (2021). The Seven Stages of Dementia. Retrieved from: https://www.dementia.org/stages-of-dementia
6 Amjad H, Roth DL, Sheehan OC, Lyketsos CG, Wolff JL, Samus QM. Underdiagnosis of Dementia: An Observational Study of Patterns in Diagnosis and Awareness in US Older Adults. J Gen Intern Med. 2018 Jul;33(7):1131-1138. doi: 10.1007/s11606-018-4377-y. Epub 2018 Mar 5. PMID: 29508259; PMCID: PMC6025653.
7 Wong, W. (2020). Economic Burden of Alzheimer’s Disease and Managed Care Considerations. Retrieved from: https://www.ajmc.com/view/economic-burden-of-alzheimer-disease-and-managed-care-considerations
8 CMS. (2021). Health Care Spending in the U.S. Retrieved from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
9 Spierer, O., Fischer, N., Barak, A., & Belkin, M. (2016). Correlation Between Vision and Cognitive Function in the Elderly: A Cross-Sectional Study. Medicine, 95(3), e2423. https://doi.org/10.1097/MD.0000000000002423
10 Vu, T., Fenwick, E., Gan, A. (2020). The Bidirectional Relationship Between Vision and Cognition: A Systematic Review and Meta-Analysis. Ophthalmology. Retrieved from: https://doi.org/10.1016/j.ophtha.2020.12.010
11 CDC. (2018). Healthy Brain Initiative. Retrieved from: https://www.cdc.gov/aging/covid19/index.html
12 WHO. (2019). Risk Reduction of Cognitive Decline and Dementia. Retrieved from: https://www.who.int/publications/i/item/risk-reduction-of-cognitive-decline-and-dementia
13 ADA. (2019). Standards of Medical Care in Diabetes. Retrieved from: https://www.cognivue.com/wp-content/uploads/2019/06/ADA-2019.pdf
14 AAN. (2019). Mild Cognitive Impairment: Quality Measurement Set. Retrieved from: https://www.aan.com/siteassets/home-page/policy-and-guidelines/quality/quality-measures/2019.03.25-mci-measures.pdf