Health-related quality of life in people with intellectual disability who use long-term antipsychotic drugs for challenging behaviour

Challenging behaviour, the application of restrictive measures and psychotropic drug prescription in people with intellectual disabilities

BACKGROUND

Prescribing of psychotropic drugs (PDs) and applying restrictive measures are both frequently used in managing challenging behaviour of people with intellectual disabilities (ID), which is not always according to guidelines or good clinical practice.

AIMS

This study aimed to investigate the potential triangular relationship between challenging behaviour, the application of restrictive measures and PD prescription.

METHODS AND PROCEDURES

In this cross-sectional study, data on challenging behaviour, PD prescription and restrictive measures were collected. We defined and compared four mutually exclusive groups of participants.

OUTCOMES AND RESULTS

Challenging behaviour in the group in whom one or more PD were prescribed as a restrictive measures (PDRM) was more severe than in the other three groups. More severe challenging behaviour, a higher number of antipsychotics, antidepressants and anxiolytics/hypnotics prescriptions, a lower dosage, and more application of domotics as restrictive measure was shown in the PDRM compared to the group in whom PDs were prescribed according to guidelines (PDNRM).

CONCLUSIONS AND IMPLICATIONS

We did not find indications for a triangular relationship of challenging behaviour, the application of restrictive measures and PD prescriptions. Future longitudinal research is needed to better understand this complex relationship and should investigate the indication and the effect of treatment. WHAT THIS PAPER ADDS?: This study is a first exploration of the potential triangular relationship between symptoms of challenging behaviour, psychotropic drug (PD) prescription, and the application of restrictive measures. Prescribing PDs and applying restrictive measures are two interventions which are commonly used to manage challenging behaviour in people with intellectual disabilities. Both have been subject of research separately in recent years. However, it is conceivable that the PD prescription in treatments for challenging behaviour could be a substitute for another form of a restrictive measure, for example a physical or mechanical restraint. For this purpose, we defined and compared four mutually exclusive groups of participants. We found no indication for this triangular relationship. On the other hand, we found the highest severity of challenging behaviour in the group who used PDs as restrictive measure next to other restrictive measures. Our results may suggest that both prescribing PDs and applying non-pharmacological restrictive measures are used simultaneously in managing challenging behaviour, are not sufficiently implemented or effective.

A Scoping Review of the Intersectionality of Autism and Intellectual and Developmental Disability with Social Inequity on Diagnosis and Treatment of Youth

Objective: To describe how the intersectionality of race, ethnicity, and language with autism and intellectual and developmental disability (IDD) impacts mental health inequities in psychopharmacological management of youth. Method: This was a scoping review in which a series of searches were conducted in PubMed, Web of Science, Google Scholar, and manual review of the articles collected. Results: Although autism and/or IDD increases the risk for poor physical and mental health, social determinants of health such as race, ethnicity, and language account for approximately a third of poor outcomes. Minoritized children with autism/IDD experience significantly greater delays to diagnosis and misdiagnosis and are less likely to receive appropriate services. Access to psychological testing and psychosocial services is often limited by availability, skilled practitioners, a shortage of non-English-language providers or interpreters, and poor reimbursement. Conclusion: The intersectionality of autism and/or IDD with race, ethnicity, and language compounds the health inequities associated with either of these challenges independently.

Emotional Reactions of Professionals to Challenging Behaviors in People with Intellectual and Developmental Disability

Professionals working with people with intellectual and developmental disability (IDD) can be exposed to challenging behaviors (CBs), which may result in professionals exhibiting emotional reactions that can impact their practices. This study examined these reactions and analyzed how they are influenced by the individual characteristics of people with IDD (gender, age, and level of IDD) and the variables related to CB (type of behavior and its frequency and behavioral function). A total of 125 professionals assessed 293 people with IDD who exhibited CBs. The professionals were asked to complete the Behavior Problems Inventory-Short Form, the Emotional Reactions to Challenging Behavior Scale, and the Questions About Behavior Function measure. It was revealed that positive emotional reactions predominated over negative ones. Significant results were found regarding the level of disability and the age of people with IDD. Emotional reactions were related to the severity of CBs, especially self-injurious and aggressive/destructive behavior, as well as certain behavioral functions. The severity of CBs and the age of people with IDD emerge as key predictors of the emotional reactions of professionals. In short, these reactions vary according to different variables, highlighting the importance of interventions that address professionals' emotional needs.

Co-Occurring Mental Illness and Behavioral Support Needs in Adults with Intellectual and Developmental Disabilities

People with intellectual and developmental disabilities (IDD) have higher incidences of mental health conditions and behavioral support needs than people without IDD but may not receive needed care from community providers. We examined rates of co-occurring conditions in a representative sample of adults with IDD who use state funded services in Virginia. Using data from two datasets, we identified four categories of mental health and behavioral conditions. We used these categories to examine differences in individual- and system-level factors in people with and without co-occurring conditions. We found high rates of co-occurring conditions in our sample. We found important disability factors and system-level characteristics that were associated with having a diagnosed mental health condition or behavioral support needs. Differing patterns of diagnosis and treatment for co-occurring conditions suggests more work needs to be done to support people with IDD and co-occurring mental health conditions living in the community.

Difficulties in Addressing Diagnostic, Treatment and Support Needs in Individuals with Intellectual Disability and Persistent Challenging Behaviours: A Descriptive File Study of Referrals to an Expertise Centre

Service providers may experience difficulties in providing appropriate care to optimize the functioning of individuals with intellectual disability and challenging behaviour. External consultation to identify and address the unmet support needs underlying the behaviour may be beneficial. Applying the multidimensional American Association Intellectual and Developmental Disabilities (AAIDD) model may facilitate this approach. We aimed to describe the content and outcomes of consultation for individuals with intellectual disability and challenging behaviour referred to the Dutch Centre for Consultation and Expertise in relation to the AAIDD model. Interventions were based on the clients' diagnostic, treatment, and support needs and were categorized according to the five dimensions of the AAIDD model. Outcomes of the consultations were assessed based on reports in the file and rated as 'clear improvement', 'improvement' or 'no improvement or deterioration'. In two-thirds of the 104 studied files, consultees were satisfied with the improvement in functioning. Interventions targeted the difficulties of the service providers in supporting their clients and were most often applied within the Health and Context dimensions of the AAIDD model. We may conclude that consultation of an expert team may be valuable to support the care providers, and the use of the AAIDD model may be helpful to address the unmet needs to improve the functioning of individuals with challenging behaviour.

Preferred outcome measures in treatments for challenging behaviour in individuals with intellectual disabilities: Results of an inclusive Delphi method

BACKGROUND

Interventions for challenging behaviours in individuals with intellectual disabilities benefit from outcome monitoring that takes clients' preferences into account. We determined clients' and representatives' preferred outcome domains and measures to secure their involvement in treatment decisions for challenging behaviours.

METHOD

We used an inclusive Delphi method. A focus group of individuals with mild intellectual disabilities and representatives of those with moderate and severe intellectual disabilities prepared the first round by assisting us in collecting possible outcomes. Panels of individuals with intellectual disabilities and representatives were composed to achieve consensus on instruments for preferred outcome domains.

RESULTS

Preferred outcome domains were behaviour, side-effects of psychotropic drugs, quality of life, daily functioning, caregiver burden and family quality of life. Corresponding outcome measures included self-report, interview and proxy-scales, including spoken versions.

CONCLUSION

Including the preferred domains on outcomes of interventions for challenging behaviours is recommended. Research on corresponding outcome measures is necessary.

Uso de psicofármacos en personas con discapacidad intelectual en Extremadura, España

El uso de psicofármacos es frecuente en adultos con discapacidad intelectual, a menudo por conductas desafiantes en ausencia de diagnóstico de trastorno mental. Investigaciones previas cuestionan la eficacia de estos tratamientos a falta de una enfermedad psiquiátrica, y destacan sus efectos secundarios. El objetivo de esta investigación es analizar el uso de psicofármacos en función del diagnóstico de enfermedad mental y conducta desafiante, así como la distribución de la población según el uso de psicofármacos en 569 adultos con discapacidad intelectual que presentan enfermedad mental o conductas desafiantes. Los datos acerca de la elevada prescripción de psicofármacos y, especialmente, de antipsicóticos alertan sobre la necesidad de una profunda revisión de la práctica clínica que permita reducir el uso de esta medicación en el tratamiento de la conducta y los trastornos mentales en esta población, para garantizar una atención de calidad y el respeto de los derechos de estas personas.

Withdrawing Antipsychotics for Challenging Behaviours in Adults with Intellectual Disabilities: Experiences and Views of Prescribers

International current best practice recommends the discontinuation of antipsychotics for challenging behaviours in people with intellectual disabilities (ID), due to lack of evidence of efficacy and risks of harmful side-effects. In clinical practice, discontinuation may be difficult. The aim of this study was to gain insight into prescribers' practice by investigating their experiences with the discontinuation of long-term antipsychotics for challenging behaviour. From professionals' associations thirty-four registered ID physicians, psychiatrists and specialist mental healthcare nurses were recruited who completed an online questionnaire in this survey-study. Almost all participants had attempted to deprescribe antipsychotics for their patients with ID. Sixty-five percent of participants achieved complete discontinuation in 0-25% of their patients, but none in over 50%. Barriers were a lack of non-pharmaceutical treatments for challenging behaviours and caregivers' and/or family concern. Seventy percent of participants indicated that their institutions had encouraged implementing their discontinuation policies in line with the new Dutch Act on Involuntary care and a new Dutch multidisciplinary guideline on problem behaviour in adults with ID. Support and facilitation of clinicians from institutions' managers and political and professional bodies may be helpful in further implementation of best practice in the treatment of challenging behaviour in people with ID.

The adverse effects of long-term exposure to antipsychotics among older people with intellectual disabilities: a scoping review

Background Antipsychotics are among the medications most prescribed to older adults with intellectual disabilities despite limited evidence to support their safety and efficacy in this population. Antipsychotics are associated with a significant burden of long-term adverse effects including movement disorders, metabolic and cardiovascular adverse effects, sedation and anticholinergic effects. This scoping review aims to evaluate the current extent of the literature relating to adverse effects of long-term antipsychotic use in older adults with intellectual disabilities and identify any existing gaps.  Methods The review was conducted in line with the framework for scoping reviews proposed by Arksey and O’Malley. A systematic literature search was carried out, including searches of PubMed, Cochrane Library, ScienceDirect, Embase, PsycINFO and grey literature databases. Reference lists of studies were also reviewed as part of the search. Studies were included in the review if they related to adults over 40 years of age with an intellectual disability who had been taking antipsychotic medication for at least 3 months. Results A total of 13 studies were identified for inclusion in the review. These included retrospective reviews,observational studies, case reports, cohort studies and cross-sectional studies. Adverse effects reported include extrapyramidal symptoms, cardiovascular and metabolic effects, and case reports of rhinorrhoea, hypothermia and ischaemic colitis. Increasing age was associated with a greater burden of adverse effects in some studies. Conclusion The available evidence on the adverse effects of long-term antipsychotic use in older adults with intellectual disabilities is weak and conflicting. The studies included were generally of poor quality with numerous limitations including small sample sizes and lack of control groups. More research is needed to inform understanding of adverse effects associated with long-term antipsychotic use in this population.

Process evaluation in intellectual disability research: A case study and the need for adaptation of frameworks

BACKGROUND

Involving adults with cognitive impairments, and specifically intellectual disability, in research is critical to developing appropriate and effective interventions but is highly challenging. Our aim was to examine where complexities lie in delivering research in underrepresented and hard to reach populations using an exemplar process evaluation conducted as part of a drug reduction trial.

METHODS

Quantitative methods were used to assess recruitment, adherence to the intervention and safety data. Qualitative interviews examined non-efficacy based barriers to drug reduction in clinical practice.

RESULTS

Feasibility of carrying out a drug reduction trial was limited by a lack of exploration of acceptability. Barriers to successful delivery included concerns around wider care team co-operation and consent procedures.

CONCLUSIONS

It is important to consider interventions involving adults with cognitive impairment, and particularly intellectual disability, as complex. Current process evaluation frameworks require further adaptation to guide research and innovation in these populations.

Psychometric properties of a brief self-reported health-related quality of life measure (HRQoL-IDD) for persons with intellectual and developmental disabilities

Background

To encourage self‐determination and address health disparities among persons with intellectual and developmental disabilities, clinicians and researchers rely on self‐reported measures like health‐related quality of life (HRQoL). This study evaluated the psychometric properties of a theory‐driven self‐reported HRQoL measure for adults requiring mild to moderate support related to intellectual and developmental disabilities.

Method

224 volunteers completed 42 quality of life items developed with extensive input from persons with intellectual and developmental disabilities, family members/caregivers, and providers. The 5‐point Likert scale format with visual images of fluid‐filled cups represented the range of responses.

Results

Exploratory and Unrestricted Factor Analyses yielded 16 HRQoL items with 4 subscales: Functional Well‐Being, Emotional Well‐Being, Social Well‐Being, and Healthy Decision‐making. The HRQoL‐IDD explained 62.8% of variance, had satisfactory internal consistency (0.73–0.83), stability of reponses, and reading level (2nd grade, ages 7‐8).

Conclusions

The HRQoL‐IDD is a promising measure of self‐reported HRQoL for use in community‐based settings for persons requiring mild to moderate support related to intellectual and developmental disabilities.

UK psychiatrists' experience of withdrawal of antipsychotics prescribed for challenging behaviours in adults with intellectual disabilities and/or autism

BACKGROUND

A high proportion of adults with intellectual disabilities are prescribed off-licence antipsychotics in the absence of a psychiatric illness. The National Health Service in England launched an initiative in 2016, 'Stopping over-medication of people with a learning disability [intellectual disability], autism or both' (STOMP), to address this major public health concern.

AIMS

To gain understanding from UK psychiatrists working with adults with intellectual disabilities on the successes and challenges of withdrawing antipsychotics for challenging behaviours.

METHOD

An online questionnaire was sent to all UK psychiatrists working in the field of intellectual disability (estimated 225).

RESULTS

Half of the 88 respondents stated that they started withdrawing antipsychotics over 5 years ago and 52.3% stated that they are less likely to initiate an antipsychotic since the launch of STOMP. However, since then, 46.6% are prescribing other classes of psychotropic medication instead of antipsychotics for challenging behaviours, most frequently the antidepressants. Complete antipsychotic discontinuation in over 50% of patients treated with antipsychotics was achieved by only 4.5% of respondents (n = 4); 11.4% reported deterioration in challenging behaviours in over 50% of patients on withdrawal and the same proportion (11.4%) reported no deterioration. Only 32% of respondents made the diagnosis of psychiatric illness in all their patients themselves. Family and paid carers' concern, lack of multi-agency and multidisciplinary input and unavailability of non-medical psychosocial intervention are key reported factors hampering the withdrawal attempt.

CONCLUSIONS

There is an urgent need to develop national guidelines to provide a framework for systematic psychotropic drug reviews and withdrawal where possible.

Feasibility and reliability of the Assessing Levels of Physical Activity health-related fitness test battery in adults with intellectual disabilities

BACKGROUND

People with intellectual disabilities (IDs) seem to have a lower physical fitness (PF) than their peers without disabilities, which coincides with reduced autonomy, life expectancy and quality of life. To assess PF in these individuals, it is necessary to use appropriate tools that permit the assessment of their physical capacities taking into account their specific characteristics. The aim of this work is to study the feasibility and reliability of the Assessing Levels of Physical Activity (ALPHA)-Fit test battery for adults in a group of men and women with mild to moderate ID.

METHODS

Forty-one adults with ID of both sexes, ranging in age from 20 to 60 years old, participated in the study. To identify the feasibility and reliability of the ALPHA-Fit test battery for adults, two complete assessments were done for each one of the tests included in the battery. The assessments were performed for a period of no more than 2 weeks (test-retest). An intraclass correlation coefficient was used to determinate test-retest reliability, and a mixed analysis of variance factorial was used for each of the dependent variables. Bland-Altman plots were also used to assess consistency between the two measurements. Feasibility was calculated as the percentage of people who were able to perform the tests correctly (not feasible <50%, fairly feasible 50%-75% and feasible >75%). In order to determine other psychometric properties, minimal detectable change and standard error of measurement (SEM) were also calculated.

RESULTS

Of the 10 tests in the ALPHA-Fit test battery, eight were shown to be feasible. High reliability was obtained (>0.90) for the variables related to body composition. In the hand-grip test, reliability was high in the men's group but low in the women's group. Good reliability results were also found (0.80-0.89) in the dynamic sit-up test for women, but not for men. Fair reliability (0.70-0.79) was found in jump-and-reach and neck-shoulder mobility tests. The variables in the 2-km walk and agility tests indicated poor reliability. All tests showed SEM values related to high variability. However, Bland-Altman plots showed results related to lack of consistency.

CONCLUSIONS

The feasibility and reliability calculations, as well as the SEM values, confirm that not all the tests of the ALPHA-Fit Test Battery for Adults are suitable for the assessment of PF in adults with ID, probably because of the complexity of the motor fitness tests. The authors emphasise the necessity of making adaptations to the protocols used or of using other tests more appropriate to the characteristics of people with mild to moderate ID.

Processes of consent in research for adults with impaired mental capacity nearing the end of life: systematic review and transparent expert consultation (MORECare_Capacity statement)

BACKGROUND

Involving adults lacking capacity (ALC) in research on end of life care (EoLC) or serious illness is important, but often omitted. We aimed to develop evidence-based guidance on how best to include individuals with impaired capacity nearing the end of life in research, by identifying the challenges and solutions for processes of consent across the capacity spectrum.

METHODS

Methods Of Researching End of Life Care_Capacity (MORECare_C) furthers the MORECare statement on research evaluating EoLC. We used simultaneous methods of systematic review and transparent expert consultation (TEC). The systematic review involved four electronic databases searches. The eligibility criteria identified studies involving adults with serious illness and impaired capacity, and methods for recruitment in research, implementing the research methods, and exploring public attitudes. The TEC involved stakeholder consultation to discuss and generate recommendations, and a Delphi survey and an expert 'think-tank' to explore consensus. We narratively synthesised the literature mapping processes of consent with recruitment outcomes, solutions, and challenges. We explored recommendation consensus using descriptive statistics. Synthesis of all the findings informed the guidance statement.

RESULTS

Of the 5539 articles identified, 91 met eligibility. The studies encompassed people with dementia (27%) and in palliative care (18%). Seventy-five percent used observational designs. Studies on research methods (37 studies) focused on processes of proxy decision-making, advance consent, and deferred consent. Studies implementing research methods (30 studies) demonstrated the role of family members as both proxy decision-makers and supporting decision-making for the person with impaired capacity. The TEC involved 43 participants who generated 29 recommendations, with consensus that indicated. Key areas were the timeliness of the consent process and maximising an individual's decisional capacity. The think-tank (n = 19) refined equivocal recommendations including supporting proxy decision-makers, training practitioners, and incorporating legislative frameworks.

CONCLUSIONS

The MORECare_C statement details 20 solutions to recruit ALC nearing the EoL in research. The statement provides much needed guidance to enrol individuals with serious illness in research. Key is involving family members early and designing study procedures to accommodate variable and changeable levels of capacity. The statement demonstrates the ethical imperative and processes of recruiting adults across the capacity spectrum in varying populations and settings.

Changes in Health-Related Quality of Life in People With Intellectual Disabilities Who Discontinue Long-Term Used Antipsychotic Drugs for Challenging Behaviors

Health-related quality of life in people with intellectual disabilities can be affected by challenging behaviors and side effects of antipsychotics. The aim of this study was to evaluate the effect of discontinuation antipsychotic drugs on health-related quality of life, including data from 2 discontinuation trials: an open-label trial of various antipsychotic drugs and a double-blind trial of risperidone. In both studies, antipsychotics were discontinued in 14 weeks, with steps of 12.5% of the baseline dosage every 2 weeks. Health-related quality of life was measured at baseline and at 16 weeks, and 40 weeks after baseline, by means of the RAND-36 (domains on physical well-being, role limitations caused by physical or emotional problems, vitality, pain, mental well-being, social functioning, general health, and changes in health). Participants who had completely discontinued antipsychotics according to the scheduled discontinuation and were still free of use at 40 weeks were compared with those who had incompletely discontinued. Physical well-being showed an increase in the group that had achieved complete discontinuation. Social functioning showed a decrease in the group that incompletely discontinued, which recovered at follow-up. Mental well-being decreased at 16 weeks but recovered at follow-up, regardless of complete or incomplete discontinuation. To conclude, discontinuation of antipsychotics had a positive effect on physical well-being when complete discontinuation was possible. When complete discontinuation was not possible, there was a negative effect on health-related quality-of-life domains. However, none of the unfavorable effects were irreversible.