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de Kuijper G, Fokkema T, Jansen M, Hoekstra PJ, de Bildt A. 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. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6365. [PMID: 37510597 PMCID: PMC10378833 DOI: 10.3390/ijerph20146365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/23/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023]
Abstract
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.
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Affiliation(s)
- Gerda de Kuijper
- GGZ Drenthe/Department Centre for intellectual Disability and Mental Health, Middenweg 19, 9404 LL Assen, The Netherlands
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Tryntsje Fokkema
- GGZ Drenthe/Department Centre for intellectual Disability and Mental Health, Middenweg 19, 9404 LL Assen, The Netherlands
| | - Martine Jansen
- Centre for Consultation and Expertise, Australielaan 14, 3526 AB Utrecht, The Netherlands
| | - Pieter J Hoekstra
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Accare Child Study Center, Groningerstraat 352, 9402 LT Assen, The Netherlands
| | - Annelies de Bildt
- Department of Child and Adolescent Psychiatry, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Accare Child Study Center, Groningerstraat 352, 9402 LT Assen, The Netherlands
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Sandberg M, Axmon A, Ahlström G, Kristensson J. Predictors of specialist somatic healthcare utilization among older people with intellectual disability and their age-peers in the general population: a national register study. BMJ Open 2023; 13:e072679. [PMID: 37407048 DOI: 10.1136/bmjopen-2023-072679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVES To compare somatic healthcare usage among older people with intellectual disabilities (ID) to that of their age-peers in the general population, taking into account health and demographic factors, and to identify predictors for somatic healthcare usage among older people with ID. PARTICIPANTS Equally sized cohorts, one with people with ID and one referent cohort, one-to-one-matched by sex and year of birth, were created. Each cohort comprised 7936 people aged 55+ years at the end of 2012. DESIGN Retrospective register-based study. SETTING All specialist inpatient and outpatient healthcare clinics in Sweden. OUTCOME MEASURES Data regarding planned/unplanned and inpatient/outpatient specialist healthcare were collected from the Swedish National Patient Register for 2002-2012. Diagnoses, previous healthcare usage, sex, age and cohort affiliation was used to investigate potential impact on healthcare usage. RESULTS Compared with the referent cohort, the ID cohort were more likely to have unplanned inpatient and outpatient care but less likely to have planned outpatient care. Within the ID cohort, sex, age and previous use of healthcare predicted healthcare usage. CONCLUSIONS Older people with ID seem to have lower risks of planned outpatient care compared with the general population that could not be explained by diagnoses. Potential explanations are that people with ID suffer from communication difficulties and experience the healthcare environment as unfriendly. Moreover, healthcare staff lack knowledge about the particular needs of people with ID. Altogether, this may lead to people with ID being exposed to discrimination. Although these problems are known, few interventions have been evaluated, especially related to planned outpatient care.
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Affiliation(s)
- Magnus Sandberg
- Department of Health Sciences, Lunds Universitet, Lund, Sweden
| | - Anna Axmon
- EPI@LUND (Epidemiology, Population studies and Infrastructures at Lund University), Division of Occupational and Environmental Medicine, Lunds University, Lund, Sweden
| | - Gerd Ahlström
- Department of Health Sciences, Lunds Universitet, Lund, Sweden
| | - Jimmie Kristensson
- Department of Health Sciences, Lunds Universitet, Lund, Sweden
- Institute for Palliative Care, Lund University, Region Skåne, Lund, Sweden
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Deutsch SI, Burket JA. Psychotropic medication use for adults and older adults with intellectual disability; selective review, recommendations and future directions. Prog Neuropsychopharmacol Biol Psychiatry 2021; 104:110017. [PMID: 32544599 DOI: 10.1016/j.pnpbp.2020.110017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022]
Abstract
A growing expert consensus has emerged to guide prescribing behavior and monitoring of psychotropic medications in adults and older adults with intellectual disability (ID). However, there is little empirically-derived evidence to inform physician selection of specific categories of psychotropic medication for treatment of "challenging" behaviors in this vulnerable population (such as aggression to self, others and objects; self-injurious behaviors; repetitive stereotypic behaviors; and hyperactivity). Difficulties with application of formal definitional diagnostic criteria and reliable assignment of psychiatric diagnoses to adults with ID, which is often difficult due to their poor communication skills, contribute to confusion and uncertainty surrounding medication selection. Long-term administration of antipsychotic medications are commonly prescribed for challenging behaviors in spite of their questionable long-term efficacy, leading some to suggest that their "episodic" short-term administration for imminent dangerousness to self and others or when difficult-to-find residential placements are threatened is preferred to their long-term administration. Further, literature supports engagement of interdisciplinary treatment teams to seek causes for challenging behaviors, formulate non-pharmacological psychosocial and behavioral plans for their amelioration and, if medications are initiated, convene regular medication monitoring to identify "drug-related problems". Medication monitoring is important because medication-related adverse events cause or contribute to challenging behaviors, which can sometimes be improved by dose reduction, medication discontinuation and/or elimination of polypharmacy and co-pharmacy. Importantly, medications themselves may interfere with self-reported measures of Quality of Life. The data clearly highlight the need for well-designed randomized controlled clinical trials in samples that are homogeneous with respect to severity of ID and residential setting; moreover, they should include a wider variety of clinical and safety outcome measures. Preclinical studies have suggested novel pharmacological strategies to prevent progressive worsening of adaptive function in adults with Down syndrome in particular, and improvement of cognition in adults with ID in general, irrespective of the etiopathogenesis of the ID. Translational clinical trials to address pathogenic mechanisms of ID, as well as challenging behaviors, are anticipated but raise societal issues pertaining to protection of this vulnerable population enrolling in clinical trials and prioritization of urgent therapeutic targets (e.g., amelioration of challenging behaviors versus improving or preserving intellectual functioning).
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Affiliation(s)
- Stephen I Deutsch
- Department of Psychiatry and Behavior Sciences, Eastern Virginia Medical School, 825 Fairfax Avenue, Suite 710, Norfolk, Virginia 23507, USA.
| | - Jessica A Burket
- Department of Molecular Biology and Chemistry, Christopher Newport University, 1 Avenue of the Arts, Newport News, Virginia 23606, USA; Program in Neuroscience, Christopher Newport University, 1 Avenue of the Arts, Newport News, Virginia 23606, USA
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McMahon M, Hatton C, Bowring DL. Polypharmacy and psychotropic polypharmacy in adults with intellectual disability: a cross-sectional total population study. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2020; 64:834-851. [PMID: 32902029 DOI: 10.1111/jir.12775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 08/25/2020] [Accepted: 08/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Adults with intellectual disability (ID) are prescribed high levels of medication, with polypharmacy and psychotropic polypharmacy common. However, reported rates vary between studies, and there has been an over-reliance on obtaining data from convenience samples. The objective of this study was to determine the prevalence of medication use and polypharmacy in a population-level sample of adults with IDs. Factors associated with polypharmacy and psychotropic polypharmacy are explored. METHODS We used a total population sample of 217 adults with IDs known to services in Jersey (sampling frame n = 285). The Anatomical Therapeutic Chemical classification system was used to categorise medications that participants were currently taking on a regular basis. We examined associations of polypharmacy and psychotropic polypharmacy with socio-economic status, health and demographic variables using univariate and multivariate analyses. RESULTS A total of 83.4% of participants were prescribed medication, with high doses common. Of the participants, 38.2% were exposed to polypharmacy while 23% of participants were exposed to psychotropic polypharmacy. After controlling for demographic, health and socio-economic characteristics, polypharmacy was significantly associated with older age, increased severity of ID, living in a residential setting and having increased comorbidities. Psychotropic polypharmacy was associated with being male, being aged 50+ years and having had a psychiatric diagnosis over the life course. Being prescribed psychotropic drugs above the defined daily dose was not associated with having had a psychiatric diagnosis over the life course, suggesting the possibility of 'off label' prescribing. CONCLUSIONS Our results indicate that medication use, in high doses, alongside polypharmacy and psychotropic polypharmacy are highly prevalent in adults with ID. The exposure to multiple medications increases the risk of developing adverse drug events, drug-drug interactions and medication-related problems. Future population-level, prospective cohort studies should examine the prevalence of polypharmacy and psychotropic polypharmacy using standardised definitions and consider the potential impact of adverse drug events, drug-drug interactions and medication-related problems in this population.
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Affiliation(s)
- M McMahon
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
- Health and Community Services, Government of Jersey, Saint Helier, Jersey
| | - C Hatton
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - D L Bowring
- CEDAR, University of Warwick, Coventry, UK
- Health and Community Services, Government of Jersey, Saint Helier, Jersey
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Peña-Salazar C, Arrufat F, Santos JM, Fontanet A, González-Castro G, Más S, Roura-Poch P, Valdés-Stauber J. Underdiagnosis of psychiatric disorders in people with intellectual disabilities: Differences between psychiatric disorders and challenging behaviour. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2020; 24:326-338. [PMID: 30185101 DOI: 10.1177/1744629518798259] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to assess the level of mental disorders and challenging behaviour in individuals with intellectual disability (ID) supported by specialized services, but without a prior psychiatric diagnosis, and to compare the levels of different disorders depending on the severity of ID. METHODS This is a cross-sectional study (N = 142) of population with ID. Inclusion criteria were the following: adult patients with ID and with no previous psychiatric diagnosis prior to this survey. The Wechsler Adults Intelligence Scale-II, the Psychiatric Assessment Schedule for Adults with Developmental Disability checklist and clinical interview, the Diagnostic Assessment for the Severely Handicapped scale and the Inventory for Client and Agency Planning were the assessment tools. RESULTS A previously undiagnosed mental disorder was found in 29.6% of the sample. The most prevalent mental disorders were major depressive and anxiety disorders. An association between psychiatric comorbidity and challenging behaviour was found only for mild/moderate ID, especially for affective disorders. CONCLUSIONS The presence of a psychiatric as well as a medical comorbidity is associated with severe ID, unlike challenging behaviour. Clinical limitations of the study have been discussed.
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Affiliation(s)
- Carlos Peña-Salazar
- Hegau-Bodensee-Klinikum Singen, Germany; Universitat de Vic - Central University of Catalonia, Spain
| | | | - Josep Manel Santos
- Universitat de Vic - Central University of Catalonia, Spain; Associació Sant Tomás, Spain
| | | | | | - Silvia Más
- Germanas Hospitalarias Benito Menni, Spain
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Lundqvist LO, Hultqvist J, Granvik E, Minton L, Ahlström G. Psychometric properties of the Neuropsychiatric Inventory for adults with intellectual disability. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2020; 33:1210-1220. [PMID: 32367679 DOI: 10.1111/jar.12741] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 11/25/2019] [Accepted: 03/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Problem behaviours are common among people with intellectual disabilities (ID), but psychometrically evaluated instruments for assessing such behaviours are scarce. The present study evaluated the psychometric properties of the Neuropsychiatric Inventory-Intellectual Disability (NPI-ID). METHOD We assessed 108 residents with intellectual disabilities living in group-homes using the NPI-ID, which included the 12 symptoms of the original NPI-Nursing Home and two supplementary symptoms: self-injurious behaviour and impulsive risk-taking behaviour. RESULTS The NPI-ID showed adequate internal consistency (α = 0.76) and test-retest reliability (intraclass correlation coefficient = 0.88). Exploratory factor analysis revealed five factors accounting for 64.1% of the variance. Cluster analysis revealed that residents were clustered in three groups with distinctly different symptom profiles. CONCLUSIONS The psychometric properties were satisfactory, supporting the use of the NPI-ID as a screening tool for people with intellectual disabilities. Additional research is needed to further evaluate the utility of the NPI-ID among people with intellectual disabilities.
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Affiliation(s)
- Lars-Olov Lundqvist
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
| | - Jenny Hultqvist
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Eva Granvik
- Clinical Memory Research Unit, Lund University, Malmö, Sweden
| | - Lennart Minton
- Clinical Memory Research Unit, Lund University, Malmö, Sweden
| | - Gerd Ahlström
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Sappok T, Diefenbacher A, Winterholler M. The Medical Care of People With Intellectual Disability. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:809-816. [PMID: 31888794 PMCID: PMC6947689 DOI: 10.3238/arztebl.2019.0809] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 05/22/2019] [Accepted: 09/13/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND An estimated 1.5 million persons in Germany are intellectually disabled. Persons with intellectual disability (ID) are especially vulnerable to somatic and mental illnesses. METHODS This review is based on pertinent literature retrieved by selective searches in PubMed and the Cochrane Library. RESULTS Genetic abnormalities are a frequent cause of diseases that affect multiple organs and need interdisciplinary treatment. A number of somatic diseases are more common in persons with ID than in the general population, including epilepsy (30-50% in persons with severe or very severe ID, vs. 0.5% in the general popu- lation) and dementia (five times more common than in the general population). Patients with Down syndrome are 20 times more likely than the general population to develop acute lymphoblastic leukemia. Some mental illnesses, too, are more common in persons with ID, e.g., autism spectrum disorders (7.5-15% vs. 1% in the general population). The history and the findings of the physical and psychiatric examination are assessed in accordance with the biopsychosocial model of disease, and in the light of the patient's mental developmental age. Structured instruments for behavioral evaluation and diagnosis are an important additional component of the diagnostic assessment. A holistic approach is required that takes multiple life areas into account and involves the patient's familial and social environment, while obeying the rules of simple language. Psychotherapeutic and psychosocial measures must be adapted to the patient's cognitive abilities and mental developmental age. CONCLUSION Intellectually disabled persons can be treated in a multimodal, multiprofessional approach. As of early 2019, there were 38 medical centers for adults with intellectual disability or severe multiple disabilities in Germany (Medizinische Behandlungszentren für Erwachsene mit geistiger Behinderung oder schweren Mehrfachbehinderungen, MZEB), where they can be cared for with due attention to their special needs.
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Affiliation(s)
- Tanja Sappok
- Berlin Treatment Center for adults with intellectual disabilities (ID) and mental disorders, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin
| | - Albert Diefenbacher
- Department of Psychiatry, Psychotherapy and Psychosomaticsk, Evangelisches Krankenhaus Königin Elisabeth Herzberge, Berlin
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