Health care concerns and guidelines for adults with Down syndrome

A Neuropathology Case Report of a Woman with Down Syndrome who Remained Cognitively Stable

In this neuropathology case report, we present findings from an individual with Down syndrome (DS) who remained cognitively stable despite Alzheimer's disease (AD) neuropathology. Clinical assessments, fluid biomarkers, neuroimaging, and neuropathological examinations were conducted to characterize her condition. Notably, her ApoE genotype was E2/3, which is associated with a decreased risk of dementia. Neuroimaging revealed stable yet elevated amyloid profiles and moderately elevated tau levels, while neuropathology indicated intermediate AD neuropathologic change with Lewy body pathology and cerebrovascular pathology. Despite the presence of AD pathology, the participant demonstrated intact cognitive functioning, potentially attributed to factors such as genetic variations, cognitive resilience, and environmental enrichment. The findings suggest a dissociation between clinical symptoms and neuropathological changes, emphasizing the complexity of AD progression in DS. Further investigation into factors influencing cognitive resilience in individuals with DS, including comorbidities and social functioning, is warranted. Understanding the mechanisms underlying cognitive stability in DS could offer insights into resilience to AD neuropathology in people with DS and in the general population and inform future interventions.

Compromised femoral and lumbovertebral bone in the Dp(16)1Yey Down syndrome mouse model

Down syndrome (DS), affecting ∼1 in 800 live births, is caused by the triplication of human chromosome 21 (Hsa21). Individuals with DS have skeletal features including craniofacial abnormalities and decreased bone mineral density (BMD). Lowered BMD can lead to increased fracture risk, with common fracture points at the femoral neck and lumbar spine. While the femur has been studied in DS mouse models, there is little research done on the vertebrae despite evidence that humans with DS have affected vertebrae. Additionally, it is important to establish when skeletal deficits occur to find times of potential intervention. The Dp(16)1Yey DS mouse model has all genes triplicated on mouse chromosome 16 orthologous to Hsa21 and displayed deficits in long bone, including trabecular and cortical deficits in male but not female mice, at 12 weeks. We hypothesized that the long bone and lumbovertebral microarchitecture would exhibit sexually dimorphic deficits in Dp(16)1Yey mice compared to control mice and long bone strength would be diminished in Dp(16)1Yey mice at 6 weeks. The trabecular region of the 4th lumbar (L4) vertebra and the trabecular and cortical regions of the femur were analyzed via micro-computed tomography and 3-point bending in 6-week-old male and female Dp(16)1Yey and control mice. Trabecular and cortical deficits were observed in femurs from male Dp(16)1Yey mice, and cortical deficits were seen in femurs of male and female Dp(16)1Yey mice. Male Dp(16)1Yey femurs had more deficits in bone strength at whole bone and tissue-estimate level properties, but female Dp(16)1Yey mice were also affected. Additionally, the L4 of male and female Dp(16)1Yey mice show trabecular deficits, which have not been previously reported in a DS mouse model. Our results indicate that skeletal deficits associated with DS occur early in skeletal development, are dependent on skeletal compartment and site, are sex dependent, and potential interventions should likely begin early in skeletal development of DS mouse models.

Management of chronic musculoskeletal pain in an adult with Down syndrome using a modified pain neuroscience approach: a case report

BACKGROUND

The use of pain neuroscience education (PNE) in the management of chronic musculoskeletal pain is well documented in the literature for the adult population. However, the use of this component within the larger biopsychosocial approach has not been examined in adults with intellectual disabilities. The purpose of this case report is to describe the utilization of a PNE approach combined with exercise in the physical therapy management of chronic musculoskeletal pain in an adult with Down syndrome.

CASE DESCRIPTION

The patient was a 40-year-old man with Down syndrome who presented with chronic low back pain that affected his sleep, participation at work, and social activities. Modified metaphors were used to assist the patient in understanding his pain experience as part of a multi-modal program that included exercise and aquatic therapy.

OUTCOMES

Upon concluding 11 weeks of treatment, the patient returned to his prior work schedule and social activities with a pain rating at worst of 3/10 on the numeric pain rating scale with only occasional pain episodes. His disability score on the Oswestry Disability Index improved by 39% relative to baseline.

DISCUSSION

The findings demonstrate how utilizing PNE within a physical therapy plan of care was used in the management of chronic musculoskeletal pain to improve function in an adult with Down syndrome.

The Underlying Relationship between Keratoconus and Down Syndrome

Keratoconus (KC) is one of the most significant corneal disorders worldwide, characterized by the progressive thinning and cone-shaped protrusion of the cornea, which can lead to severe visual impairment. The prevalence of KC varies greatly by ethnic groups and geographic regions and has been observed to be higher in recent years. Although studies reveal a possible link between KC and genetics, hormonal disturbances, environmental factors, and specific comorbidities such as Down Syndrome (DS), the exact cause of KC remains unknown. The incidence of KC ranges from 0% to 71% in DS patients, implying that as the worldwide population of DS patients grows, the number of KC patients may continue to rise significantly. As a result, this review aims to shed more light on the underlying relationship between KC and DS by examining the genetics relating to the cornea, central corneal thickness (CCT), and mechanical forces on the cornea, such as vigorous eye rubbing. Furthermore, this review discusses KC diagnostic and treatment strategies that may help detect KC in DS patients, as well as the available DS mouse models that could be used in modeling KC in DS patients. In summary, this review will provide improved clinical knowledge of KC in DS patients and promote additional KC-related research in these patients to enhance their eyesight and provide suitable treatment targets.

Low bone mass and impaired fracture healing in mouse models of Trisomy21 (Down syndrome)

Individuals with Down syndrome (DS), the result of trisomy of human chromosome Hsa21 (Ts21), present with an array of skeletal abnormalities typified by altered craniofacial features, short stature and low bone mineral density (BMD). While bone deficits progress with age in both sexes, low bone mass is more pronounced in DS men than women and osteopenia appears earlier. In the current study, the reproductive hormone status (FSH, LH, testosterone) of 17 DS patients (males, ages range 19-52 years) was measured. Although testosterone was consistently low, the hypothalamic-pituitary-gonadal axis was intact with corresponding rises in FSH and LH. To provide further insight into the heterogeneity of the bone mass in DS, the skeletal phenotypes of three of the most used murine DS models, Ts65Dn (Ts65), TC1, and Dp16(Yey1) (Dp16) were characterized and contrasted. Evaluation of the bone phenotype of both male and female 3-month-old Dp16 mice demonstrated sexual dimorphism, with low bone mass apparent in males, as it is in Ts65, but not in female Dp16. In contrast, male TC1 mice had no apparent bone phenotype. To determine whether low bone mass in DS impacted fracture healing, fractures of the middle phalanx (P2) digits were generated in both male and female Dp16 mice at 15 weeks of age, an age where the sexually dimorphic low BMD persisted. Fracture healing was assessed via in vivo microCT over (13 weeks) 93 days post fracture (DPF). At 93 DPF, 0 % of DS male (n = 12) or female (n = 8) fractures healed, compared to 50 % of the male (n = 28) or female (n = 8) WT littermate fractures. MicroCT revealed periosteal unbridged mineralized callus formation across the fracture gap in Dp16 mice, which was confirmed by subsequent histology. These studies provide the first direct evidence of significantly impaired fracture healing in the setting of DS.

Changes in bone mineral density in Down syndrome individuals: a systematic review and meta-analysis

Data evaluating changes in bone mineral density (BMD) in Down syndrome (DS) individuals remains controversial. Therefore, we conducted a systematic review and meta-analysis to better understand associations between BMD and DS. A systematic literature search of PubMed, EMBASE, Web of Science, and the Cochrane Library up until 1st January 2021 was conducted. We used the keywords "bone mineral density" and "Down Syndrome." Fifteen studies were included. Overall, our results showed a significant decrease in BMD of total body (TB BMD) [MD =  - 0.18; 95% CI (- 0.23 and - 0.12), P < 0.00001, I2 = 89%], total hip (TH BMD) [MD =  - 0.12; 95% CI (- 0.15 and - 0.10), P < 0.00001, I2 = 0%], lumbar spine (LS BMD) [MD =  - 0.12; 95% CI (- 0.14 and - 0.09), P < 0.00001, I2 = 18%], and femoral neck (FN BMD) [MD =  - 0.08; 95% CI (- 0.10 and - 0.06), P < 0.00001, I2 = 0%] in DS individuals when compared with controls. Moreover, the volumetric BMD of lumbar spine (LS vBMD) [MD =  - 0.01; 95% CI (- 0.02 and - 0.01), P = 0.0004, I2 = 19%] also showed a decreasing tendency while the volumetric BMD of the femoral neck (FN vBMD) [MD = 0.01; 95% CI (0.00 and 0.02), P = 0.02, I2 = 0%] was elevated in DS individuals versus controls. These findings demonstrated that individuals with DS had a decreased total and regional (TH, LS, and FN) BMD when compared with the general population. Additionally, when BMD was adjusted for skeletal volume, LS vBMD was also lower, while FN vBMD was elevated in DS individuals versus controls.

Current Analysis of Skeletal Phenotypes in Down Syndrome

PURPOSE

Down syndrome (DS) is caused by trisomy 21 (Ts21) and results in skeletal deficits including shortened stature, low bone mineral density, and a predisposition to early onset osteoporosis. Ts21 causes significant alterations in skeletal development, morphology of the appendicular skeleton, bone homeostasis, age-related bone loss, and bone strength. However, the genetic or cellular origins of DS skeletal phenotypes remain unclear.

RECENT FINDINGS

New studies reveal a sexual dimorphism in characteristics and onset of skeletal deficits that differ between DS and typically developing individuals. Age-related bone loss occurs earlier in the DS as compared to general population. Perturbations of DS skeletal quality arise from alterations in cellular and molecular pathways affected by the overexpression of trisomic genes. Sex-specific alterations occur in critical developmental pathways that disrupt bone accrual, remodeling, and homeostasis and are compounded by aging, resulting in increased risks for osteopenia, osteoporosis, and fracture in individuals with DS.

Prevalence of keratoconus in persons with Down syndrome: a review

Purpose

Keratoconus is a vision-threatening condition, and there is a need for knowledge about the occurrence in subgroups of the population. The progression of the disease can be effectively stopped, and vision may be restored, if keratoconus is diagnosed at an early stage. The purpose of this review was to evaluate the literature of the prevalence of keratoconus in persons with Down syndrome.

Methods

We conducted a literature review of keratoconus prevalence in persons with Down syndrome. A thorough search was performed in Pubmed (Medline), and the quality of evidence was evaluated.

Results

The literature review identified 20 relevant studies, which reported keratoconus in 0%–71% of persons with Down syndrome. These studies varied greatly in design, patient selection, sample sizes and mean age, and the quality of evidence concerning estimates for the prevalence of keratoconus was generally evaluated as low. Most studies that included adults reported high prevalences of keratoconus–in many studies more than 10-fold the prevalence in the general population. No large screening studies in persons with Down syndrome were identified.

Conclusions

The present review showed that the prevalence of keratoconus in persons with Down syndrome is higher than in the general population. However, estimates from previous studies vary widely. Screening for keratoconus in this group should be considered.

Excitatory/Inhibitory Synaptic Ratios in Polymicrogyria and Down Syndrome Help Explain Epileptogenesis in Malformations

BACKGROUND

The ratio between excitatory (glutamatergic) and inhibitory (GABAergic) inputs into maturing individual cortical neurons influences their epileptic potential. Structural factors during development that alter synaptic inputs can be demonstrated neuropathologically. Increased mitochondrial activity identifies neurons with excessive discharge rates.

METHODS

This study focuses on the neuropathological examinaion of surgical resections for epilepsy and at autopsy, in fetuses, infants, and children, using immunocytochemical markers, and electron microscopy in selected cases. Polymicrogyria and Down syndrome are highlighted.

RESULTS

Factors influencing afferent synaptic ratios include the following: (1) synaptic short-circuitry in fused molecular zones of adjacent gyri (polymicrogyria); (2) impaired development of dendritic spines decreasing excitation (Down syndrome); (3) extracellular keratan sulfate proteoglycan binding to somatic membranes but not dendritic spines may be focally diminished (cerebral atrophy, schizencephaly, lissencephaly, polymicrogyria) or augmented, ensheathing individual axons (holoprosencephaly), or acting as a barrier to axonal passage in the U-fiber layer. If keratan is diminished, glutamate receptors on the neuronal soma enable ectopic axosomatic excitatory synapses to form; (4) dysplastic, megalocytic neurons and balloon cells in mammalian target of rapamycin disorders; (5) satellitosis of glial cells displacing axosomatic synapses; (6) peri-neuronal inflammation (tuberous sclerosis) and heat-shock proteins.

CONCLUSIONS

Synaptic ratio of excitatory/inhibitory afferents is a major fundamental basis of epileptogenesis at the neuronal level. Neuropathology can demonstrate subcellular changes that help explain either epilepsy or lack of seizures in immature brains. Synaptic ratios in malformations influence postnatal epileptogenesis. Single neurons can be hypermetabolic and potentially epileptogenic.

Pneumonia and respiratory infections in Down syndrome: A scoping review of the literature

Pneumonia and respiratory infections impact infants and children with Down syndrome; pneumonia is a leading cause of mortality in adults with Down syndrome. We aimed to review the literature to evaluate gaps and address key questions. A series of key questions were formulated a priori to inform the search strategy and review process; addressed prevalence, severity, etiology, risk factors, preventive methods, screening, and financial costs, potential benefits or harms of screening. Using the National Library of Medicine database, PubMed, detailed literature searches on pneumonia and respiratory infections in Down syndrome were performed. Previously identified review articles were also assessed. The quality of available evidence was then evaluated and knowledge gaps were identified. Forty-two relevant original articles were identified which addressed at least one key question. Study details including research design, internal validity, external validity, and relevant results are presented. Pneumonia and respiratory infections are more prevalent and more severe in individuals with Down syndrome compared to healthy controls through literature review, yet there are gaps in the literature regarding the etiology of pneumonia, the infectious organism, risk factors for infection, and to guide options for prevention and screening. There is urgent need for additional research studies in Down syndrome, especially in the time of the current COVID-19 pandemic.

Interaction of sexual dimorphism and gene dosage imbalance in skeletal deficits associated with Down syndrome

All individuals with Down syndrome (DS), which results from trisomy of human chromosome 21 (Ts21), present with skeletal abnormalities typified by craniofacial features, short stature and low bone mineral density (BMD). Differences in skeletal deficits between males and females with DS suggest a sexual dimorphism in how trisomy affects bone. Dp1Tyb mice contain three copies of all of the genes on mouse chromosome 16 that are homologous to human chromosome 21, males and females are fertile, and therefore are an excellent model to test the hypothesis that gene dosage influences the sexual dimorphism of bone abnormalities in DS. Dp1Tyb as compared to control littermate mice at time points associated with bone accrual (6 weeks) and skeletal maturity (16 weeks) showed deficits in BMD and trabecular architecture that occur largely through interactions between sex and genotype and resulted in lower percent bone volume in all female and Dp1Tyb male mice. Cortical bone in Dp1Tyb as compared to control mice exhibited different changes over time influenced by sex × genotype interactions including reduced cortical area in both male and female Dp1Tyb mice. Mechanical testing analyses suggested deficits in whole bone properties such as bone mass and geometry, but improved material properties in female and Dp1Tyb mice. Sexual dimorphisms and the influence of trisomic gene dosage differentially altered cellular properties of male and female Dp1Tyb bone. These data establish sex, gene dosage, skeletal site and age as important factors in skeletal development of DS model mice, paving the way for identification of the causal dosage-sensitive genes. Skeletal differences in developing male and female Dp1Tyb DS model mice replicated differences in less-studied adolescents with DS and established a foundation to understand the etiology of trisomic bone deficits.

STOP-Bang questionnaire should be used in all adults with Down Syndrome to screen for moderate to severe obstructive sleep apnea

STUDY OBJECTIVES

To determine the prevalence of obstructive sleep apnea (OSA) in adults with Down syndrome (DS), to investigate factors related to OSA severity and to identify which sleep questionnaire is the most appropriate for the screening of OSA in this population.

METHODS

Cross-sectional study that consecutively included 60 adults with DS. All patients underwent type III polysomnography and clinical and laboratory data were collected; sleep assessment questionnaires were applied. Multiple linear regression models evaluated the associations between OSA severity (measured by the respiratory event index-REI) and clinical and laboratory data and sleep questionnaires (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, BERLIN and STOP-Bang questionnaires).

RESULTS

Results show that 60 (100%) adults with DS had OSA, with moderate-severe OSA identified in 49 (81.6%). At the multivariate linear regression, REI significantly correlated with hematocrit levels, BMI and STOP-Bang questionnaire (SBQ) results (P <0.001). The positive STOP-Bang ≥3 points) showed 100% of sensitivity (95%CI: 92.75-100%), 45.45% of specificity (95%CI: 16.75-76.62), positive predictive value of 89.09% (95%CI: 82.64-93.34%), negative predictive value of 100%, accuracy of 90% (95%CI: 79.49-96.24%) and OR of 24.29.

CONCLUSIONS

Adults with DS have a very high prevalence of OSA. Hematocrit levels, BMI and SBQ showed a strong correlation with OSA severity. The SBQ performed well in identifying moderate to severe OSA in this population. Considered together, these results point to the need to perform OSA screening in all adults with DS, and STOP-Bang may play a role in this screening.

Co-occurring medical conditions in adults with Down syndrome: A systematic review toward the development of health care guidelines. Part II

Adults with Down syndrome (DS) represent a unique population who are in need of clinical guidelines to address their medical care. Many of these conditions are of public health importance with the potential to develop screening recommendations to improve clinical care for this population. Our workgroup previously identified and prioritized co-occurring medical conditions in adults with DS. In this study, we again performed detailed literature searches on an additional six medical conditions of clinical importance. A series of key questions (KQ) were formulated a priori to guide the literature search strategy. Our KQs focused on disease prevalence, severity, risk-factors, methodologies for screening/evaluation, impact on morbidity, and potential costs/benefits. The available evidence was extracted, evaluated and graded on quality. The number of participants and the design of clinical studies varied by condition and were often inadequate for answering most of the KQ. Based upon our review, we provide a summary of the findings on hip dysplasia, menopause, acquired cardiac valve disease, type 2 diabetes mellitus, hematologic disorders, and dysphagia. Minimal evidence demonstrates significant gaps in our clinical knowledge that compromises clinical decision-making and management of these medically complex individuals. The creation of evidence-based clinical guidance for this population will not be possible until these gaps are addressed.

Skeletal dynamics of Down syndrome: A developing perspective

Individuals with Down syndrome (DS) display distinctive skeletal morphology compared to the general population, but disparate descriptions, methodologies, analyses, and populations sampled have led to diverging conclusions about this unique skeletal phenotype. As individuals with DS are living longer, they may be at a higher risk of aging disorders such as osteoporosis and increased fracture risk. Sexual dimorphism has been suggested between males and females with DS in which males, not females, experience an earlier decline in bone mineral density (BMD). Unfortunately, studies focusing on skeletal health related to Trisomy 21 (Ts21) are few in number and often too underpowered to answer questions about skeletal development, resultant osteoporosis, and sexual dimorphism, especially in stages of bone accrual. Further confounding the field are the varied methods of bone imaging, analysis, and data interpretation. This review takes a critical look at the current knowledge of DS skeletal phenotypes, both from human and mouse studies, and presents knowledge gaps that need to be addressed, differences in research methodologies and analyses that affect the interpretation of results, and proposes guidelines for overcoming obstacles to understand skeletal traits associated with DS. By examining our current knowledge of bone in individuals with Ts21, a trajectory for future studies may be established to provide meaningful solutions for understanding the development of and improving skeletal structures in individuals with and without DS.

The Relationship between Shoe Fitting and Foot Health of Persons with Down Syndrome: A Case Control Study

Background: Down syndrome is the most common chromosomal abnormality and a cause of intellectual disability. It is also associated with orthopaedic and musculoskeletal problems of the locomotive apparatus, especially of the feet. These problems are believed to have a harmful effect on health, social functioning, and mobility. In addition, these persons generally don’t have access to podiatric health services, even when their foot problems are well known, because of limited access to healthcare facilities. The goal of our research was to evaluate and compare the foot health status of study participants with and without Down syndrome and to determine whether inadequate footwear is being used with normalized reference values. Methods: A total of 105 participants with and without Down syndrome, with a mean age of 35.71 (SD = 12.93) years, were enrolled in the study. They self-reported demographic data and their clinical characteristic data were recorded. Measurements of their foot and shoe fitting were taken at all stages of the research process. Ninety-two percent of the participants with Down syndrome had foot problems. Results: Only 12 (24%) participants with Down syndrome used bilateral shoes that met the requirements of their feet compared to their controls (50 participants, 90.9% for the right foot; 46 participants, 83.6% for the left foot). Participants with Down syndrome presented statistically significant differences with respect to controls and wore incorrectly sized shoe. Conclusions: Evaluation of foot length and width may prevent development of foot deformities, as well as to improve general health.

Improving the general health of people with learning disabilities

People with learning disabilities suffer an increase in common morbidity, communication difficulties, a high prevalence of serious conditions such as epilepsy, and specific patterns of health needs associated with the aetiology of their disability. Unfortunately, this combination of need is mirrored by a consistent picture of poor health promotion uptake, inadequate care for serious morbidity, unrecognised health need and poor access to health care. Consequently, there is a great disparity between the health of learning-disabled people and that of the general population. Psychiatrists can address this disparity in clinical practice by focusing on these patients' mental health, epilepsy management and the impact of behaviour on health. They can also influence health planning and service development.

Sclerostin Antibody Treatment Stimulates Bone Formation to Normalize Bone Mass in Male Down Syndrome Mice

Down syndrome (DS), characterized by trisomy of human chromosome 21, is associated with a variety of endocrine disorders as well as profound skeletal abnormalities. The low bone mass phenotype in DS is defined by low bone turnover due to decreased osteoclast and osteoblast activity, decreasing the utility of antiresorptive agents in people with DS. Sclerostin antibody (SclAb) is a therapeutic candidate currently being evaluated as a bone anabolic agent. Scl, the product of the sclerostin gene (SOST), inhibits bone formation through its inhibition of Wnt signaling. SclAb increases bone mass by suppressing the action of the endogenous inhibitor of bone formation, Scl. To examine the effects of SclAb on the DS bone phenotype, 8‐week‐old male wild‐type (WT) andTs65Dn DS mice were treated with 4 weekly iv injections of 100 mg/kg SclAb. Dual‐energy X‐ray absorptiometry (DXA), microCT, and dynamic histomorphometry analyses revealed that SclAb had a significant anabolic effect on both age‐matched WT littermate controls and Ts65Dn DS mice that was osteoblast mediated, without significant changes in osteoclast parameters. SclAb treatment significantly increased both cortical and trabecular bone mass at multiple sites; SclAb treatment resulted in the normalization of Ts65Dn bone mineral density (BMD) to WT levels in the proximal tibia, distal femur, and whole body. Ex vivo bone marrow cultures demonstrated that SclAb increased the recruitment of the mesenchymal progenitors into the osteoblast lineage, as indicated by increased alkaline phosphatase–positive colonies, with no effect on osteoclast differentiation. Together, in the setting of a murine model of DS and decreased bone turnover, SclAb had a potent anabolic effect. SclAb stimulated bone formation and increased osteoblastogenesis without affecting osteoclastogenesis or bone resorption. These data suggest that SclAb is a promising new therapy to improve bone mass and reduce fracture risk in the face of the low bone mass and turnover prevalent in the DS population. © 2017 The Authors JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Co-occurring medical conditions in adults with Down syndrome: A systematic review toward the development of health care guidelines

Adults with Down syndrome (DS) represent a unique population who are in need of clinical guidelines to address their medical care. The United States Preventive Service Task Force (USPSTF) has developed criteria for prioritizing conditions of public health importance with the potential for providing screening recommendations to improve clinical care. The quality of existing evidence needed to inform clinical guidelines has not been previously reviewed. Using the National Library of Medicine (NLM) database PubMed, we first identified 18 peer reviewed articles that addressed co-occurring medical conditions in adults with DS. Those conditions discussed in over half of the articles were prioritized for further review. Second, we performed detailed literature searches on these specific conditions. To inform the search strategy and review process a series of key questions were formulated a priori. The quality of available evidence was then graded and knowledge gaps were identified. The number of participating adults and the design of clinical studies varied by condition and were often inadequate for answering all of our key questions. We provide data on thyroid disease, cervical spine disease, hearing impairment, overweight-obesity, sleep apnea, congenital heart disease, and osteopenia-osteoporosis. Minimal evidence demonstrates massive gaps in our clinical knowledge that compromises clinical decision-making and management of these medically complex individuals. The development of evidence-based clinical guidance will require an expanded clinical knowledge-base in order to move forward.

Parenting children with down syndrome: An analysis of parenting styles, parenting dimensions, and parental stress

BACKGROUND

Effective parenting is vital for a child's development. Although much work has been conducted on parenting typically developing children, little work has examined parenting children with Down syndrome.

AIMS

The purpose of the current study was to compare the parenting styles and dimensions in mothers of children with DS and mothers of TD children.

METHODS AND PROCEDURES

Thirty-five mothers of children with DS and 47 mothers of TD children completed questionnaires about parenting, parental stress, child behavior problems, and child executive function.

OUTCOMES AND RESULTS

We found that mothers of children with DS use an authoritative parenting style less and a permissive parenting style more than mothers of TD children. Additionally, we found that mothers of children with DS use reasoning/induction and verbal hostility less and ignoring misbehavior more than mothers of TD children. All of these differences, except for those of reasoning/induction, were at least partially accounted for by the higher levels of parental stress in the DS group.

CONCLUSIONS AND IMPLICATIONS

Parenting interventions should be focused on reducing parental stress and training mothers to parent under stress in an effort to improve parenting techniques, which would, in theory, improve long-term child outcomes for children with DS.

Bone health in Down syndrome

Patients with Down syndrome have a number of risk factors that theoretically could predispose them to osteoporosis, such as early aging, development disorders, reduced physical activity, limited sun exposure, frequent comorbidities and use of drug therapies which could affect bone metabolism. In addition, the bone mass of these people may be affected by their anthropometric and body composition peculiarities. In general terms, studies in adults with Down syndrome reported that these people have lower areal bone mineral density (g/cm²) than the general population. However, most of them have not taken the smaller bone size of people with Down syndrome into account. In fact, when body mineral density is adjusted by bone size and we obtain volumetric body mineral density (g/cm³), the difference between both populations disappears. On the other hand, although people with Down syndrome have risk factor of hypovitaminosis D, the results of studies regarding 25(OH)D in this population are not clear. Likewise, the studies about biochemical bone markers or the prevalence of fractures are not conclusive.

Obstructive sleep apnoea/hypopnoea syndrome in adults with Down syndrome

Key points

Educational aims

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is characterised by repeated cycles of upper airway obstruction during sleep, leading to diurnal symptoms. Individuals with Down syndrome are predisposed to OSAHS due to overlap between the Down syndrome phenotype and OSAHS risk factors. Recent large studies using subjective and objective measures estimate that OSAHS affects around 40% of adults with Down syndrome, in contrast to 2–4% of the general adult population. The “double-hit” of comorbid Down syndrome and OSAHS may accelerate cognitive decline in adults with Down syndrome. However, with the appropriate care and support, OSAHS can be treated effectively in this group using continuous positive airway pressure (CPAP) therapy, improving daytime function and behaviour. Symptoms of OSAHS should be routinely monitored in this population, with testing and treatment available to all adults with Down syndrome; however, this is not currently commonplace, and health inequalities are evident.

Obstructive sleep apnoea/hypopnoea syndrome affects ∼40% of adults with Down syndrome cut can be treated effectivelyhttp://ow.ly/Jdco3062xP5

Prenatal Screening, Ethics and Down’s Syndrome: a literature review

This article reviews the literature on prenatal screening for Down’s syndrome. To be evidence based, medicine and nursing have to take account of research evidence and also of how this evidence is processed through the influence of prevailing social and moral attitudes. This review of the extensive literature examines how appropriate widely-held understandings of Down’s syndrome are, and asks whether or not practitioners and prospective parents have access to the full range of moral arguments and social evidence on the matter. Highly valued ideals of justice, personal autonomy, parental choice, women’s control over their reproduction and of avoiding harm can all tend towards negative rather than neutral approaches to Down’s syndrome. This article considers how ethics and prenatal screening policies and practice that take greater account of social evidence of disability could use moral arguments that inform rather than determine the choices of people who use prenatal services.

Transmission of trisomy decreases with maternal age in mouse models of Down syndrome, mirroring a phenomenon in human Down syndrome mothers

Background

Down syndrome incidence in humans increases dramatically with maternal age. This is mainly the result of increased meiotic errors, but factors such as differences in abortion rate may play a role as well. Since the meiotic error rate increases almost exponentially after a certain age, its contribution to the overall incidence aneuploidy may mask the contribution of other processes.

Results

To focus on such selection mechanisms we investigated transmission in trisomic females, using data from mouse models and from Down syndrome humans. In trisomic females the a-priori probability for trisomy is independent of meiotic errors and thus approximately constant in the early embryo. Despite this, the rate of transmission of the extra chromosome decreases with age in females of the Ts65Dn and, as we show, for the Tc1 mouse models for Down syndrome. Evaluating progeny of 73 Tc1 births and 112 Ts65Dn births from females aged 130 days to 250 days old showed that both models exhibit a 3-fold reduction of the probability to transmit the trisomy with increased maternal ageing. This is concurrent with a 2-fold reduction of litter size with maternal ageing. Furthermore, analysis of previously reported 30 births in Down syndrome women shows a similar tendency with an almost three fold reduction in the probability to have a Down syndrome child between a 20 and 30 years old Down syndrome woman.

Conclusions

In the two types of mice models for Down syndrome that were used for this study, and in human Down syndrome, older females have significantly lower probability to transmit the trisomy to the offspring. Our findings, taken together with previous reports of decreased supportive environment of the older uterus, add support to the notion that an older uterus negatively selects the less fit trisomic embryos.

Electronic supplementary material

The online version of this article (doi:10.1186/s12863-016-0412-3) contains supplementary material, which is available to authorized users.

Oral Steroid Usage for Otitis Media with Effusion, Eustachian Tube Dysfunction, and Tympanic Membrane Retraction

OBJECTIVES

Avoiding oral steroids for otitis media with effusion (OME) is endorsed as a performance measure by the National Quality Foundation, but data regarding current gaps and practice patterns are lacking. Our objectives were to evaluate oral steroid use for OME and the related diagnoses of eustachian tube dysfunction (ETD) and tympanic membrane retraction (TMR), to assess variations by visit setting, and to identify opportunities for measurable performance improvement.

STUDY DESIGN

Cross-sectional analysis of a national database.

SETTING

Ambulatory visits in the United States.

SUBJECTS

Children and adults in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (2005-2010).

METHODS

Data were coded for patient demographic information, potential confounders (eg, concurrent conditions managed by oral steroids), and diagnosis of OME, ETD, or TMR (OME/ETD/TMR). The latter 2 diagnoses were included to meet minimum numbers for reliability of weighted estimates, but OME constituted the majority of cases. Multivariate regression was used to determine the variables associated with oral steroid use.

RESULTS

Among 590,772 observations representing 7,191,711,480 visits for OME/ETD/TMR, 3.2% resulted in a new prescription for oral steroid medication (2.3% for children, 7.0% for adults). Adults were more likely to receive steroids (odds ratio = 3.50, P < .001) than those with other diagnoses, but a similar association was not found for children. Patients seen by an otolaryngologist or in the emergency department were less likely to receive steroids than those seen in other settings.

CONCLUSIONS

OME/ETD/TMR is infrequently treated with oral steroids, particularly in children. Opportunities for performance improvement are limited.

Trying to see, failing to focus: near visual impairment in Down syndrome

The majority of individuals with Down syndrome (DS) do not exhibit accurate accommodation, with the aetiology of this deficit unknown. This study examines the mechanism underlying hypoaccommodation in DS by simultaneously investigating the ‘near triad’ – accommodation, vergence and pupillary response. An objective photorefraction system measured accommodation, pupil size and gaze position (vergence) under binocular conditions while participants viewed an animated movie at 50, 33, 25 and 20 cm. Participants were aged 6–16 years (DS = 41, controls = 76). Measures were obtained from 59% of participants with DS and 99% of controls. Accommodative response was significantly less in DS (p < 0.001) and greater accommodative deficits were associated with worsening visual acuity (p = 0.02). Vergence responses were as accurate in DS as in controls (p = 0.90). Habitual pupil diameter did not differ between groups (p = 0.24) but reduced significantly with increasing accommodative demand in both participants with and without DS (p < 0.0001). This study is the first to report simultaneous binocular measurement of the near triad in DS demonstrating that hypoaccommodation is linked to poor visual acuity. Vergence responses were accurate indicating that hypoaccommodation cannot be dismissed as a failure to visually engage with near targets, but rather is a consequence of underlying neurological or physiological deficits.

Sleep problems and associated comorbidities among adults with Down syndrome

BACKGROUND

Sleep problems, including sleep apnoea and behavioural sleep disturbances, are common among adults with Down syndrome (DS). Despite a preliminary understanding of potential medical and behavioural comorbidities of these sleep problems among children with DS, little is known about comorbid conditions associated with these sleep problems among adults with DS. Understanding causes and sequelae of sleep problems in this ageing population is essential to providing quality health screening and treatment. The current study examines the physical health problems, mental health conditions, functional abilities and behavioural problems associated with sleep apnoea and behavioural sleep disturbances among adults with DS.

METHOD

Family caregivers participated in clinical interviews and completed questionnaires, providing reports regarding 75 adults with DS. Caregivers reported on sleep problems, physical and mental health conditions, daily living skills and behaviours regarding their ageing family member with DS.

RESULTS

Sleep apnoea was associated with more common other respiratory concerns, and more frequent visits to physicians, but not with some expected medical comorbidities (cardiac). Behavioural sleep disturbances (delayed sleep onset, night-time awakenings and morning awakenings) were associated with poorer health, more frequent overnight hospital and emergency department visits, more common cardiac conditions, less common thyroid condition, more common mental health conditions (anxiety, depression and dementia) and a higher rate of daytime behaviour problems.

CONCLUSION

The study findings suggest that there are differential correlates for the various sleep problems in adults with DS, which warrant attention when screening for medical and mental health comorbidities, assessing behavioural problems and in treatment planning for ageing adults with DS.

Rescue of the abnormal skeletal phenotype in Ts65Dn Down syndrome mice using genetic and therapeutic modulation of trisomic Dyrk1a

Trisomy 21 causes skeletal alterations in individuals with Down syndrome (DS), but the causative trisomic gene and a therapeutic approach to rescue these abnormalities are unknown. Individuals with DS display skeletal alterations including reduced bone mineral density, modified bone structure and distinctive facial features. Due to peripheral skeletal anomalies and extended longevity, individuals with DS are increasingly more susceptible to bone fractures. Understanding the genetic and developmental origin of DS skeletal abnormalities would facilitate the development of therapies to rescue these and other deficiencies associated with DS. DYRK1A is found in three copies in individuals with DS and Ts65Dn DS mice and has been hypothesized to be involved in many Trisomy 21 phenotypes including skeletal abnormalities. Return of Dyrk1a copy number to normal levels in Ts65Dn mice rescued the appendicular bone abnormalities, suggesting that appropriate levels of DYRK1A expression are critical for the development and maintenance of the DS appendicular skeleton. Therapy using the DYRK1A inhibitor epigallocatechin-3-gallate improved Ts65Dn skeletal phenotypes. These outcomes suggest that the osteopenic phenotype associated with DS may be rescued postnatally by targeting trisomic Dyrk1a.

Abnormal mineralization of the Ts65Dn Down syndrome mouse appendicular skeleton begins during embryonic development in a Dyrk1a-independent manner

The relationship between gene dosage imbalance and phenotypes associated with Trisomy 21, including the etiology of abnormal bone phenotypes linked to Down syndrome (DS), is not well understood. The Ts65Dn mouse model for DS exhibits appendicular skeletal defects during adolescence and adulthood but the developmental and genetic origin of these phenotypes remains unclear. It is hypothesized that the postnatal Ts65Dn skeletal phenotype originates during embryonic development and results from an increased Dyrk1a gene copy number, a gene hypothesized to play a critical role in many DS phenotypes. Ts65Dn embryos exhibit a lower percent bone volume in the E17.5 femur when compared to euploid embryos. Concomitant with gene copy number, qPCR analysis revealed a  ~1.5 fold increase in Dyrk1a transcript levels in the Ts65Dn E17.5 embryonic femur as compared to euploid. Returning Dyrk1a copy number to euploid levels in Ts65Dn, Dyrk1a(+/-) embryos did not correct the trisomic skeletal phenotype but did return Dyrk1a gene transcript levels to normal. The size and protein expression patterns of the cartilage template during embryonic bone development appear to be unaffected at E14.5 and E17.5 in trisomic embryos. Taken together, these data suggest that the dosage imbalance of genes other than Dyrk1a is involved in the development of the prenatal bone phenotype in Ts65Dn embryos.

Females with Down syndrome: lost opportunities in primary care

PURPOSE

Nurse practitioners (NPs) need to be aware of the health disparities that exist between adult females with and without Down syndrome (DS). It is essential that necessary primary and preventive healthcare services are available to women with DS to maintain adequate health and quality of life, and reduce the occurrence of misdiagnosed or underdiagnosed treatable diseases.

DATA SOURCES

Review of published literature, DS society reports, and U.S. government reports.

CONCLUSIONS

A lack of agreed guidelines for the screening of adult females with DS contributes to unmet health needs in primary care for this population. Adequate promotion of health in all persons with disabilities, including the specific needs of women with DS, will help prevent the development of preventable secondary disabilities. Research shows that health promotion, screenings, and preventive care are overlooked or ignored in the female population with DS. Barriers to this care were consistent with misconceived attitudes and beliefs about adults with DS and a lack of training for primary care providers in caring for persons with disabilities.

IMPLICATIONS FOR PRACTICE

Although much research is needed, there are some resources for NPs who provide care for this vulnerable population. Screening for preventable conditions, such as obesity, sexually transmitted infections, and sexual exploitation, can improve the quality of life for adult women with DS.

Validation and application of health utilities index in Chinese subjects with down syndrome

Objectives

The objectives of the study were (1) to validate the Chinese version of Health Utilities Index (HUI-Ch); (2) to examine the Health-related Quality of Life (HRQoL) of Chinese subjects with Down syndrome (DS); and (3) to study the impact of chronic health conditions on HRQoL of Chinese with DS.

Methods

The multiple choice questionnaire for scoring Health Utilities Index Mark 2 (HUI2) and Health Utilities Index Mark 3 (HUI3) was translated and validated. In addition to the HRQoL scores from HUI2 and HUI3, proxy-data on socio-demographics, and 10 common chronic health conditions for people with DS were collected and analyzed. Data analysis involves multiple imputation and multiple regression analysis to predict variations in HRQoL in relation to different factors. Lastly, a gradient interval was constructed on the number of chronic health conditions in relation to HRQoL.

Results

HUI-Ch was validated according to standard guidelines. People with DS were found to have a lower HRQoL as compared to the general population, with the majority categorized as moderate or severe on the scale. Behavioral and hearing problems on HUI2, and hearing problems on HUI3 were found to be statistically significant predictors of a lower HRQoL score. A significant gradient relationship existed showing when the number of health problems increased, the HRQoL scores decreased.

Conclusions

HUI-Ch is a valid instrument to assess HRQoL. It can have broad application in Chinese subjects with DS including the study of the impact of different chronic health conditions on their quality of life. The quantifiable nature of HUI-Ch will facilitate longitudinal study on the well-being of subjects with DS and evaluation of effectiveness of intervention programs in the near future.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-014-0144-x) contains supplementary material, which is available to authorized users.

Aneuploidy and skeletal health

The normal human chromosome complement consists of 46 chromosomes comprising 22 morphologically different pairs of autosomes and one pair of sex chromosomes. Variations in either chromosome number and/or structure frequently result in significant mental impairment and/or a variety of other clinical problems, among them, altered bone mass and strength. Chromosomal syndromes associated with specific chromosomal abnormalities are classified as either numerical or structural and may involve more than one chromosome. Aneuploidy refers to the presence of an extra copy of a specific chromosome, or trisomy, as seen in Down's syndrome (trisomy 21), or the absence of a single chromosome, or monosomy, as seen in Turner syndrome (a single X chromosome in females: 45, X). Aneuploidies have diverse phenotypic consequences, ranging from severe mental retardation and developmental abnormalities to increased susceptibility to various neoplasms and premature death. In fact, trisomy 21 is the prototypical aneuploidy in humans, is the most common genetic abnormality associated with longevity, and is one of the most widespread genetic causes of intellectual disability. In this review, the impact of trisomy 21 on the bone mass, architecture, skeletal health, and quality of life of people with Down syndrome will be discussed.

Health conditions and their impact among adolescents and young adults with Down syndrome

Objective

To examine the prevalence of medical conditions and use of health services among young adults with Down syndrome and describe the impact of these conditions upon their lives.

Methods

Using questionnaire data collected in 2011 from parents of young adults with Down syndrome we investigated the medical conditions experienced by their children in the previous 12 months. Univariate, linear and logistic regression analyses were performed.

Results

We found that in addition to the conditions commonly experienced by children with Down syndrome, including eye and vision problems (affecting 73%), ear and hearing problems (affecting 45%), cardiac (affecting 25%) and respiratory problems (affecting 36%), conditions also found to be prevalent within our young adult cohort included musculoskeletal conditions (affecting 61%), body weight (affecting 57%), skin (affecting 56%) and mental health (affecting 32%) conditions and among young women menstrual conditions (affecting 58%). Few parents reported that these conditions had no impact, with common impacts related to restrictions in opportunities to participate in employment and community leisure activities for the young people, as well as safety concerns.

Conclusion

There is the need to monitor, screen and provide appropriate strategies such as through the promotion of healthy lifestyles to prevent the development of comorbidities in young people with Down syndrome and, where present, to reduce their impact.

Cataract surgery outcomes in adult patients with Down's syndrome

PURPOSE

To describe the outcomes of cataract surgery in adult patients with Down's syndrome at a tertiary eye hospital in Hong Kong.

METHODS

Retrospective case-file analysis was performed to identify patients with Downs's syndrome who underwent cataract surgery between January 2002 and December 2012. Morphology of cataract, associated ocular features and surgical and visual outcomes were analysed.

RESULTS

Cataract surgery was performed in 33 eyes of 20 patients (12 males, 8 females, mean age 42.9±10.6 years) over a 10-year period. Nine patients (9/20, 45.0%) had bilateral cataracts at the time of diagnosis. White cataracts were noted in 12 eyes of 10 patients (12/33, 36.3%) at the time of presentation. Associated ocular problems included myopic maculopathy (18 eyes, 54.5%), keratoconus (12 eyes, 36.3%), nystagmus (2 eyes, 6.0%), corneal scar (2 eyes, 6.0%) and glaucoma (2 eyes, 6.0%). Five eyes (15.1%) underwent extracapsular cataract extraction whereas a phacoemulsification was performed in 28 (84.9%) eyes. Intraocular lens implantation was performed in 32/33 eyes. The most common postoperative complication was posterior capsular opacification (8 eyes, 24.2%). The mean best-corrected visual acuity improved from 0.07±0.11 preoperatively to 0.17±0.19 at 3 months postoperatively (p=0.000).

CONCLUSIONS

A high incidence of bilateral cataracts as well as white cataracts was observed in patients with Down's syndrome in our study. Although the surgical outcomes of cataract surgery were good, the visual outcomes were suboptimal in our cases due to associated ocular comorbidities.

Rule-based category learning in Down syndrome

Rule-based category learning was examined in youths with Down syndrome (DS), youths with intellectual disability (ID), and typically developing (TD) youths. Two tasks measured category learning: the Modified Card Sort task (MCST) and the Concept Formation test of the Woodcock-Johnson-III ( Woodock, McGrew, & Mather, 2001 ). In regression-based analyses, DS and ID groups performed below the level expected for their nonverbal ability. In cross-sectional developmental trajectory analyses, results depended on the task. On the MCST, the DS and ID groups were similar to the TD group. On the Concept Formation test, the DS group had slower cross-sectional change than the other 2 groups. Category learning may be an area of difficulty for those with ID, but task-related factors may affect trajectories for youths with DS.

Multimorbidity in older adults with intellectual disabilities

Multimorbidity may be related to the supposed early aging of people with intellectual disabilities (ID). This group may suffer more often from multimorbidity, because of ID-related physical health conditions, unhealthy lifestyle and metabolic effects of antipsychotic drug use. Multimorbidity has been defined as two or more chronic conditions. Data on chronic conditions have been collected through physical assessment, questionnaires, and medical files. Prevalence, associated factors and clusters of multimorbidity have been studied in 1047 older adults (≥ 50 years) with ID. Multimorbidity was prevalent in 79.8% and associated with age and severe/profound ID. Four or more conditions were prevalent in 46.8% and associated with age, severe/profound ID and Down syndrome. Factor analyses did not reveal a model for disease-clusters with good fit. Multimorbidity is highly prevalent in older adults with ID. Multimorbidity should receive more attention in research and clinical practice for targeted pro-active prevention and treatment.

Primary care for adults with Down syndrome: adherence to preventive healthcare recommendations

BACKGROUND

Due to significant medical improvements, persons with Down syndrome now live well into adulthood. Consequently, primary care for adults with Down syndrome needs to incorporate routine care with screening for condition-specific comorbidities. This study seeks to evaluate the adherence of primary care physicians to age- and condition-specific preventive care in a cohort of adults with Down syndrome.

METHODS

In this retrospective observational cohort study, preventive screening was evaluated in patients with Down syndrome aged 18-45 years who received primary care in an academic medical centre from 2000 to 2008. Comparisons were made based on the field of patients' primary care providers (Family or Internal Medicine).

RESULTS

This cohort included 62 patients, median index age = 33 years. Forty per cent of patients received primary care by Family Physicians, with 60% seen by Internal Medicine practices. Patient demographics, comorbidities and overall screening patterns were similar between provider groups. Despite near universal screening for obesity and hypothyroidism, adherence to preventive care recommendations was otherwise inconsistent. Screening was 'moderate' (50-80%) for cardiac anomalies, reproductive health, dentition, and the combined measure of behaviour, psychological, or memory abnormalities. Less than 50% of patients were evaluated for obstructive sleep apnea, atlanto-axial instability, hearing loss or vision loss.

CONCLUSIONS

We observed inconsistent preventive care in adults with Down syndrome over this 8.5-year study. This is concerning, given that the adverse effects of many of these conditions can be ameliorated if discovered in a timely fashion. Further studies must evaluate the implications of screening practices and more timely identification of comorbidities on clinical outcomes.

Low bone turnover and low bone density in a cohort of adults with Down syndrome

Increased incidence of osteoporosis in Down syndrome has been reported, but etiology is not established. We report low bone turnover markers and bone mineral density (BMD) in a cohort of people with Down syndrome without consistent clinical risk factors. Our results should guide future studies and treatments for this common problem.

INTRODUCTION

To better understand the etiology for osteoporosis in Down syndrome (DS), we measured bone density by dual-energy X-ray absorptiometry (DXA) and circulating biochemical markers of bone formation and resorption in a cohort of 30 community-dwelling DS adults.

METHODS

Seventeen males and 13 females followed in the University of Arkansas Down Syndrome Clinic were evaluated by DXA to estimate BMD and underwent phlebotomy to measure serum procollagen type-1 intact N-terminal propeptide (P1NP) to evaluate bone formation, and serum C-terminal peptide of type-I collagen (CTx) to evaluate bone resorption.

RESULTS

Seven of 13 DS females and 12 of 17 DS males had low bone mass at one of measured sites (z≤-2.0). When data were grouped by age, males had apparent osteopenia earlier than females. The mean P1NP in the normal group was 19.2±5.2 ng/ml vs. 2.2±0.9 ng/ml in the DS group (P=0.002). Serum CTx levels in the normal group were 0.4±0.1 ng/ml vs. 0.3±0.1 ng/ml (P=0.369).

CONCLUSIONS

Low BMD in adults with DS is correlated with a significant decrease in bone formation markers, compared to controls without DS, and is independent of gender. These data suggest that diminished osteoblastic bone formation and inadequate accrual of bone mass, with no significant differences in bone resorption, are responsible for the low bone mass in DS. These observations question the use of antiresorptive therapy in this population and focus attention on increasing bone mass by other interventions.

Update on the keratoconus genetics

Keratoconus (KC) is one of the leading causes for keratoplasty. While the genetic aetiology of more and more corneal dystrophies is revealed, KC falls behind. And it is not because of lack of effort. The diversity in the many published results from over two decades is discussed in relation to the present knowledge in molecular biology. Results that at first appear to be in conflict with each other make sense when placed in the right context. Ophthalmologists often refer to KC as a heterogeneous disease. This review demonstrates that it truly is a multifactorial disease. Despite the many attempts to reveal the aetiology of KC, the pathological mechanism(s) still remain to be solved.

Hospitalizations among people with Down syndrome: a nationwide population-based study in Denmark

Most persons with Down syndrome (DS) now survive to adulthood, but their health care needs beyond childhood are not well described. We followed a national cohort of 3,212 persons with DS and a reference cohort of persons without DS through the Danish National Hospital Register from January 1, 1977, to May 31, 2008. Poisson regression was used to calculate rate ratios for numbers of overnight hospital admissions and hospital days. During the study period, persons with DS had more than twice the rate of hospital admissions and nearly three times as many bed-days as the population as a whole. Malformations, diseases of the respiratory system, and diseases of the nervous system or sensory organs were the principal indications for hospital admissions. The higher rate ratios for hospital admissions were seen especially among persons less than 20 years of age. Hospitalizations for neoplasms or for diseases of the musculoskeletal system or connective tissue were much less frequent among adults with DS. As survival among persons with DS continues to improve, these findings are likely to be useful for health care planning, although the potential utility may be different for different health care systems.

Health self-advocacy training for persons with intellectual disabilities

BACKGROUND

People with intellectual disabilities (ID) have unequal access to health care. While systemic efforts are addressing health inequalities, there remains a need to demonstrate that persons with ID can increase their health self-advocacy skills.

METHOD

A randomised control design with up to 6-month follow-up was used to evaluate the 3Rs (Rights, Respect and Responsibility) health self-advocacy training program for persons with ID (n = 31). Training involved teaching participants to recognise and redress health rights violations in the context of respect and responsibility. Training materials included PowerPoint slides and interactive video scenarios illustrating health rights, respect and responsibility problem and non-problems. Two-hour training sessions were conducted twice a week in a group format where participants played a game and answered questions.

RESULTS

The health rights training group made significantly more correct responses on post training and follow-up tests than the control group. Training effects generalised to untrained scenarios and in situ health interviews.

CONCLUSIONS

The results of this study suggest that persons with ID can learn complex skills related to health self-advocacy. More research is needed to improve in situ generalisation.

Neurological phenotypes for Down syndrome across the life span

This chapter reviews the neurological phenotype of Down syndrome (DS) in early development, childhood, and aging. Neuroanatomic abnormalities in DS are manifested as aberrations in gross brain structure as well as characteristic microdysgenetic changes. As the result of these morphological abnormalities, brain circuitry is impaired. While an intellectual disability is ubiquitous in DS, there is a wide range of variation in cognitive performance and a growing understanding between aberrant brain circuitry and the cognitive phenotype. Hypotonia is most marked at birth, affecting gait and ligamentous laxity. Seizures are bimodal in presentation with infantile spasms common in infancy and generalized seizures associated with cognitive decline observed in later years. While all individuals have the characteristic neuropathology of Alzheimer's disease (AD) by age 40 years, the prevalence of dementia is not universal. The tendency to develop AD is related, in part, to several genes on chromosome 21 that are overexpressed in DS. Intraneuronal accumulation of β-amyloid appears to trigger a cascade of neurodegeneration resulting in the neuropathological and clinical manifestations of dementia. Functional brain imaging has elucidated the temporal sequence of amyloid deposition and glucose metabolic rate in the development of dementia in DS. Mitochondrial abnormalities contribute to oxidative stress which is part of AD pathogenesis in DS as well as AD in the general population. A variety of medical comorbidities threaten cognitive performance including sleep apnea, abnormalities in thyroid metabolism, and behavioral disturbances. Mouse models for DS are providing a platform for the formulation of clinical trials with intervention targeted to synaptic plasticity, brain biochemistry, and morphological brain alterations.

Adults with Rubinstein-Taybi syndrome

Information in the medical literature regarding adults with genetic syndromes is limited, making the care of these patients challenging. We conducted a questionnaire study of adults with Rubinstein-Taybi syndrome that addressed medical problems, education, independence, and behavior. The most common medical problems included short stature, obesity, visual difficulties, keloids, eating problems, spine curvature, and joint problems. The adults had typically moderate mental retardation, but most achieved some independence in self-care and communication; many participated in supported work situations. However, approximately one-third were said to have some decreased abilities over time. Behavior problems were common and often worsened with age. Very few of the study participants were seeing a geneticist as an adult. Long-term involvement of geneticists and education of adult primary care providers may help with many of the challenges facing adults with RTS and their families.

Non-psychiatric health problems among psychiatric inpatients with intellectual disabilities

BACKGROUND

Physical distress resulting from medical problems has been found to cause increased behaviour problems in patients with intellectual disabilities (ID). Despite this fact, little has been documented on the medical problems of individuals with ID admitted for inpatient psychiatric care. We conducted an exploratory investigation based on a retrospective chart review of the medical problems and medications for 198 people with ID who had been admitted to a specialised inpatient psychiatric unit. Most patients were referred for admission because of aggressive, disruptive and self-injurious behaviours. The average length of stay was 17.6 days.

METHODS

We tallied the total number of medical problems and medications listed in the patients' discharge summaries. Because longer stays are disruptive, costly and associated with greater overall impairment, we examined the relationship between length of stay and frequency of discharge medical diagnoses. We also assessed whether or not the number of psychoactive medications correlated with the number of medical diagnoses. The effects of other demographic and diagnostic variables on rates of medical diagnoses and medications were also evaluated, including gender, age group (16-25, 26-45, 46-60, >60), level of ID (mild, moderate or severe ID) and diagnosis of an autism spectrum disorder or Down syndrome (DS).

RESULTS

Inpatients with a higher number of medical diagnoses had longer lengths of stay (Spearman r = +0.32, P < 0.0001). There was a significant correlation between number of psychoactive medications and number of medical problems (Spearman r = +0.32, P < 0.0001). The most frequent medical comorbidity was constipation, reported in 60% of the inpatients (n = 118), while gastro-esophageal reflux disease was identified in 38% (n = 75). Older inpatients had an increased number of medical problems, as might be expected, but a diagnosis of an autism spectrum disorder, gender and level of ID had no detectible effect on rates of either medical diagnoses or medications. There were only 13 inpatients with DS; in this modest sample, it was found that they had higher rates of osteoarthritis, cardiac problems, hearing loss, hypothyroidism and sleep apnoea than peers without DS, as is consistent with previous findings on overrepresented conditions in this trisomy.

CONCLUSIONS

In the present study, individuals with ID admitted for inpatient psychiatric care exhibited high rates of medical problems, and these were associated with duration of inpatient stay. Based on these findings, further investigation of the effects of medical problems on behaviour among individuals with ID admitted for inpatient psychiatric care is warranted.