Healthcare and guidelines: a population-based survey of recorded medical problems and health surveillance for people with Down syndrome

Parents' perspectives on provided health care for adults with Down syndrome: A qualitative interview study

BACKGROUND

A comprehensive multidisciplinary medical guideline for adults with Down syndrome is lacking in the Netherlands. In this study, we aim to explore parents' views on multidisciplinary care and identify which aspects of health care they find most important in the context of developing such a guideline.

METHOD

This qualitative study used semi-structured interviews. Nineteen interviews were conducted with parents of adults with Down syndrome. The main themes and subthemes were identified from the transcripts by using the framework method.

RESULTS

Four main themes were identified which should be addressed in the guideline according to the parents: parents' support in medical care, patient-centred care, important medical topics and the organisation of medical care.

CONCLUSIONS

This study provides insights into parents' opinions about medical care for adults with Down syndrome. These insights are used in the construction of a guideline to improve medical care for adults with Down syndrome.

Vision Impairments in Young Adults with Down Syndrome

People with Down syndrome have more visual problems than the general population. They experience premature ageing, and they are expected to also have an acceleration in worsening visual function. A prospective observational study which includes visual acuity, refractive error, accommodation, binocular and colour vision was performed on young adults with (n = 69) and without (n = 65) Down syndrome and on a senior group (n = 55) without Down syndrome. Results showed significant differences in visual acuity between groups (p < 0.001), and it can be improved with a new prescription in 40% of the participants with Down syndrome. Regarding the accommodative state, no significant differences were found between groups of young people. Concerning binocular vision, 64.7% of strabismus was observed in the group with Down syndrome (p < 0.001). Visual abnormalities are significant in young adults with Down syndrome and are different from those of older people without Down syndrome, some of which can be improved by providing the optimal prescription as well as regular eye examinations.

Service Use Patterns by Children With Down Syndrome in a Canadian Region

Children with Down syndrome require services from different sectors over time to optimize health and development, however, there is little information on longitudinal, cross-sector service use. Parents of children with Down syndrome attending a Canadian children's hospital participated in semistructured interviews covering life-time multiple sector service use. Five key service patterns were identified: (1) primary care physicians playing a circumscribed role; (2) a marked shift in public habilitative service receipt from development agencies in the preschool years to exclusive school delivery after school entry; (3) families obtaining private services to address gaps from public sector services; (4) a prominent role for parents to identify additional services; and (5) service variability as a function of timing and severity of medical comorbidity.

Susceptibility to COVID-19 Diagnosis in People with Down Syndrome Compared to the General Population: Matched-Cohort Study Using Primary Care Electronic Records in the UK

BACKGROUND

During the COVID-19 pandemic, people with Down syndrome (DS) have experienced a more severe disease course and higher mortality rates than the general population. It is not yet known whether people with DS are more susceptible to being diagnosed with COVID-19.

OBJECTIVE

To explore whether DS is associated with increased susceptibility to COVID-19.

DESIGN

Matched-cohort study design using anonymised primary care electronic health records from the May 2021 release of Clinical Practice Research Datalink (CPRD) Aurum.

SETTING

Electronic health records from approximately 1400 general practices (GPs) in England.

PARTICIPANTS

8854 people with DS and 34,724 controls matched for age, gender and GP who were registered on or after the 29th January 2020.

MEASUREMENTS

The primary outcome was COVID-19 diagnosis between January 2020 and May 2021. Conditional logistic regression models were fitted to estimate associations between DS and COVID-19 diagnosis, adjusting for comorbidities.

RESULTS

Compared to controls, people with DS were more likely to be diagnosed with COVID-19 (7.4% vs 5.6%, p ≤ 0.001, odds ratio (OR) = 1.35; 95% CI = 1.23-1.48). There was a significant interaction between people with DS and a chronic respiratory disease diagnosis excluding asthma and increased odds of a COVID-19 diagnosis (OR = 1.71; 95% CI = 1.20-2.43), whilst adjusting for a number of comorbidities.

CONCLUSION

Individuals with DS are at increased risk for contracting COVID-19. Those with underlying lung conditions are particularly vulnerable during viral pandemics and should be prioritised for vaccinations.

Age and gender-related differences in quality of life of Bangladeshi patients with Down Syndrome: A cross-sectional study

Currently available screening instruments for evaluation of individuals with intellectual disabilities do not capture all the complications associated with Down Syndrome (DS). Here, we examined age and gender-specific variability revolving around major challenges related to ophthalmologic and auditory health, social integration, daily life, and behavioral problems in 468 (age: 2–84 years) individuals with DS living in all eight divisions of Bangladesh. More than half of the children presented with significant difficulty in walking or other targeted movements compared with 37.9% of adolescents (p = 0.03). Nearly 70% of children exhibited communication difficulties, particularly revolving around the understanding of speech, comprehending or learning tasks or new materials, and in expressing thoughts in words or behaviors (p = 0.003–0.006). Uncontrolled urination was frequent and predominantly found among children (p = 0.04). No significant differences were present in females vs. males except for concern about physical appearance (females: 58.5% vs. males: 47.5%; p = 0.02). The severity of DS was associated with intellectual performance, communication difficulties, and self-sufficiency (i.e., uncontrolled micturition or bowel movements) but not with psychotic, ophthalmologic, auditory, or motor skills-related problems. Increased awareness of DS phenotypic profiles among professionals and caregivers can foster earlier detection and counselling and help formulate appropriate interventions to reduce long-term sequelae and enhance cognitive and behavioral developmental outcomes.

Prevalence and incidence of physical health conditions in people with intellectual disability - a systematic review

OBJECTIVE

To synthesize evidence on the prevalence and incidence of physical health conditions in people with intellectual disability (ID).

METHODS

We searched Medline, PsycInfo, and Embase for eligible studies and extracted the prevalence, incidence, and risk of physical health conditions in people with ID.

RESULTS

Of 131 eligible studies, we synthesized results from 77 moderate- to high-quality studies, which was mainly limited to high-income countries. The highest prevalence estimates were observed for epilepsy, ear and eye disorders, cerebral palsy, obesity, osteoporosis, congenital heart defects, and thyroid disorders. Some conditions were more common in people with a genetic syndrome. Compared with the general population, many health conditions occur more frequently among people with ID, including asthma and diabetes, while some conditions such as non-congenital circulatory diseases and solid cancers occur at the same or lower rate. The latter associations may reflect under-detection.

CONCLUSIONS

People with ID have a health profile more complex than previously known. There is a pressing need for targeted, evidence-informed population health initiatives including preventative programs for this population.

Sleep Disorders in Adults with Down Syndrome

Sleep disorders, despite being very frequent in adults with Down syndrome (DS), are often overlooked due to a lack of awareness by families and physicians and the absence of specific clinical sleep guidelines. Untreated sleep disorders have a negative impact on physical and mental health, behavior, and cognitive performance. Growing evidence suggests that sleep disruption may also accelerate the progression to symptomatic Alzheimer’s disease (AD) in this population. It is therefore imperative to have a better understanding of the sleep disorders associated with DS in order to treat them, and in doing so, improve cognition and quality of life, and prevent related comorbidities. This paper reviews the current knowledge of the main sleep disorders in adults with DS, including evaluation and management. It highlights the existing gaps in knowledge and discusses future directions to achieve earlier diagnosis and better treatment of sleep disorders most frequently found in this population.

Epilepsy in Down Syndrome: A Highly Prevalent Comorbidity

Individuals with Down syndrome (DS) have an increased risk for epilepsy during the whole lifespan, but especially after age 40 years. The increase in the number of individuals with DS living into late middle age due to improved health care is resulting in an increase in epilepsy prevalence in this population. However, these epileptic seizures are probably underdiagnosed and inadequately treated. This late onset epilepsy is linked to the development of symptomatic Alzheimer's disease (AD), which is the main comorbidity in adults with DS with a cumulative incidence of more than 90% of adults by the seventh decade. More than 50% of patients with DS and AD dementia will most likely develop epilepsy, which in this context has a specific clinical presentation in the form of generalized myoclonic epilepsy. This epilepsy, named late onset myoclonic epilepsy (LOMEDS) affects the quality of life, might be associated with worse cognitive and functional outcomes in patients with AD dementia and has an impact on mortality. This review aims to summarize the current knowledge about the clinical and electrophysiological characteristics, diagnosis and treatment of epileptic seizures in the DS population, with a special emphasis on LOMEDS. Raised awareness and a better understanding of epilepsy in DS from families, caregivers and clinicians could enable earlier diagnoses and better treatments for individuals with DS.

Attention Bias and Prodromal Anxiety Symptoms in Toddlers With Fragile X Syndrome and Down Syndrome

Early identification of behavioral risk markers for anxiety is essential to optimize long-term outcomes in children with neurodevelopmental disorders. This study analyzed attentional avoidance and its relation to anxiety and autism spectrum disorder (ASD) symptomatology during social and nonsocial fear conditions in toddlers with fragile X syndrome (FXS) and Down syndrome (DS). Toddlers with FXS and DS exhibited increased nonsocial attentional avoidance relative to typically developing (TD) toddlers. Attentional avoidance was not related to anxiety symptom severity in any group; however, higher ASD symptom severity was related to more social attentional avoidance in the FXS and TD groups. Findings suggest that there may be different underlying mechanisms driving attentional avoidance across neurodevelopmental disorders.

Navigating the Ghanaian health system: stories from families of children with intellectual and developmental disabilities

This study explored the experiences of families in navigating the Ghanaian health system to address the general health needs of their children with intellectual and developmental disabilities (IDD). The sample involved 22 primary caregivers of children with IDD aged 3-18 years who participated in a semi-structured interview. The interviews were analyzed using the constant comparison analytical method. The findings highlighted key enablers and barriers related to three overarching themes: entry into the health system; consultation with health professionals; and service coordination. The findings showed that the families and their children gained entry into the health system in many health facilities. However, the families revealed that some facilities denied the children services, either because the children had difficulties following entry processing protocols or there were no health professionals willing to address the children's needs. Although health professionals perform their duties professionally during consultation and care administration in many cases, the families reported on some challenges. Service coordination was seamless in some facilities; however, the families reported on other facilities they accessed where service coordination was not seamless. The study findings illustrate that the experiences of families and their children with IDD in the Ghanaian health system may be mixed.

Low Rates of Preventive Healthcare Service Utilization Among Adolescents and Adults With Down Syndrome

INTRODUCTION

People with Down syndrome have health risks that require specific lifelong preventive health care. With increasing life expectancy, people with Down syndrome also face health conditions typical of their unaffected peers and thus need coordinated health care. The purpose of this study is to describe rates of age/sex- and Down syndrome-specific preventive healthcare activities among adolescents and adults with Down syndrome.

METHODS

Using Medicaid claims (2006-2010) in California, Colorado, Michigan, and Pennsylvania, the cohort was defined as people with Down syndrome aged ≥12 years seen by primary care providers and enrolled in Medicaid for ≥45 of 60 months without dual Medicare enrollment (n=3,501). Age focus-consistent primary care providers were defined as having a focus concordant with a patient's age: 12-17 years, child or mixed-focus; ≥26 years, adult or mixed-focus; 18-25 years, any focus. Differences in healthcare activities were evaluated using Pearson's chi-square, Fisher's exact, and Kruskal-Wallis tests. Analyses were performed in 2015-2017.

RESULTS

Of the cohort, 79% had an age focus-consistent primary care provider. However, 40% of adults aged ≥26 years received care from a child-focused primary care provider. Only 43% with an age focus-consistent provider had ≥1 well examination (age focus-inconsistent primary care provider: 35%, p<0.001). Most preventive activities had poor rates (<50%) regardless of age focus consistency between provider and patient age or whether they were age/sex- or Down syndrome-specific (well examinations; vaccinations; sleep apnea; hearing; and breast, cervical, and colon cancer screenings). Lipids, vision, and thyroid screenings reached moderate levels (50% to <80%).

CONCLUSIONS

Rates of age/sex- and Down syndrome-specific preventive recommendations were low among adolescents and adults with Down syndrome, regardless of the age focus consistency of their primary care provider. This represents a significant opportunity to improve primary care in this vulnerable population.

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.

Health care utilisation among older people with Down syndrome compared to specific medical guidelines for health surveillance: a Swedish national register study

Background

Specific medical guidelines for health surveillance exist for people with Down syndrome (DS) since 25 years but knowledge of adherence to the guidelines is lacking. The guidelines were developed to avoid unnecessary suffering from preventable conditions. The aims of the study were to investigate 1) planned health care visits in relation to the co-morbidities described in specific medical guidelines as a measure of adherence, 2) unplanned health care visits as a measure of potentially unmet health care needs and 3) gender differences in health care utilisation among older people with DS.

Methods

This register-based study includes people with DS (n = 472) from a Swedish national cohort of people with intellectual disability (n = 7936), aged 55 years or more, and with at least one support according to the disability law, in 2012. Data on inpatient and outpatient specialist health care utilisation were collected from the National Patient Register for 2002–2012.

Results

A total of 3854 inpatient and outpatient specialist health care visits were recorded during the 11 years, of which 54.6% (n = 2103) were planned, 44.0% (n = 1695) unplanned and 1.4% (n = 56) lacked information. More than half of the visits, 67.0% (n = 2582) were outpatient health care thus inpatient 33% (n = 1272). Most planned visits (29.4%, n = 618) were to an ophthalmology clinic, and most unplanned visits to an internal medicine clinic (36.6%, n = 621). The most common cause for planned visits was cataract, found at least once for 32.8% in this cohort, followed by arthrosis (8.9%), epilepsy (8.9%) and dementia (6.6%). Pneumonia, pain, fractures and epilepsy each accounted for at least one unplanned visit for approximately one-fourth of the population (27.1, 26.9, 26.3 and 19.7% respectively). Men and women had similar numbers of unplanned visits. However, women were more likely to have visits for epilepsy or fractures, and men more likely for pneumonia.

Conclusions

Increased awareness of existing specific medical guidelines for people with DS is vital for preventive measures. The relatively few planned health care visits according to the medical guidelines together with a high number of unplanned visits caused by conditions which potentially can be prevented suggest a need of improved adherence to medical guidelines.

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.

Scope of occupational therapy practice for adults with both Down syndrome and dementia: A cross-sectional survey

INTRODUCTION

Dementia in adults with Down syndrome causes a progressive decline in daily occupations impacting both persons with Down syndrome and their informal caregivers. This study aimed to explore the scope of occupational therapy practice for adults with both Down syndrome and dementia and their informal caregivers living in their homes.

METHODS

A survey was conducted with occupational therapists having clinical experience in providing interventions for adults with Down syndrome. A web-based survey was developed to explore occupational therapy practice for this group of people with Down syndrome and their informal caregivers. Responses to closed-ended questions were analysed descriptively, and inductive content analysis was used for open-ended questions.

RESULTS

Forty-three occupational therapists from Australia, Canada, United Kingdom and the United States of America participated in the survey. Two-thirds were from the United Kingdom, most of whom were employed in the public sector and had at least 10 years of clinical experience. Over 90% of respondents received one or more referrals in a typical month for adults with Down syndrome having dementia, 68% of which were for a decline in activities of daily living. Home environment and activities of daily living were frequently assessed areas, and the commonest interventions were compensatory strategies and environmental modifications. Only half the respondents provided interventions for informal caregivers. Risk and safety and manual handling were frequently addressed domains for informal caregivers. Collaboration and developing clinical expertise were the two key perceived enablers for providing effective occupational therapy services. Fragmentation of services and a lack of client-centred care were the common perceived barriers.

CONCLUSION

Occupational therapists often address decline in activities of daily living for individuals with both Down syndrome and dementia. To support participation in meaningful occupations for these people and support the needs of their informal caregivers, it is essential that services are offered in a collaborative approach.

Health comorbidities and cognitive abilities across the lifespan in Down syndrome

BACKGROUND

Down syndrome (DS) is associated with variable intellectual disability and multiple health and psychiatric comorbidities. The impact of such comorbidities on cognitive outcomes is unknown. We aimed to describe patterns of physical health and psychiatric comorbidity prevalence, and receptive language ability, in DS across the lifespan, and determine relationships with cognitive outcomes.

METHODS

Detailed medical histories were collected and cognitive abilities measured using standardised tests for 602 individuals with DS from England and Wales (age range 3 months to 73 years). Differences in prevalence rates between age groups and between males and females were determined using chi-squared or Fisher's exact tests. In adults, rates for psychiatric comorbidities were compared to expected population rates using standardised morbidity ratios (SMRs). Adapted ANCOVA functions were constructed to explore age and sex associations with receptive language ability across the lifespan, and regression analyses were performed to determine whether the presence of health comorbidities or physical phenotypes predicted cognitive abilities.

RESULTS

Multiple comorbidities showed prevalence differences across the lifespan, though there were few sex differences. In adults, SMRs were increased in males and decreased in females with DS for schizophrenia, bipolar disorder, and anxiety. Further, SMRs were increased in both males and females with DS for dementia, autism, ADHD, and depression, with differences more pronounced in females for dementia and autism, and in males for depression. Across the lifespan, receptive language abilities increasingly deviated from age-typical levels, and males scored poorer than females. Only autism and epilepsy were associated with poorer cognitive ability in those aged 16-35 years, with no relationships for physical health comorbidities, including congenital heart defects.

CONCLUSIONS

Our results indicate the prevalence of multiple comorbidities varies across the lifespan in DS, and in adults, rates for psychiatric comorbidities show different patterns for males and females relative to expected population rates. Further, most health comorbidities are not associated with poorer cognitive outcomes in DS, apart from autism and epilepsy. It is essential for clinicians to consider such differences to provide appropriate care and treatment for those with DS and to provide prognostic information relating to cognitive outcomes in those with comorbidities.

Anesthetic Management of Elderly Patients With Down Syndrome: A Case Report

In 1930, the life expectancy of patients with Down syndrome was about 10 years; today, their life expectancy is more than 60 years. With aging, there is an increased need for anesthesia and surgery. There is, however, no published information regarding the anesthetic management of older adults with Down syndrome. In this report, we described the anesthetic management of a 50-year-old woman with Down syndrome undergoing major cervical spine surgery. Components of the anesthetic that we thought would be difficult such as intravenous line placement and endotracheal intubation were accomplished without difficulty. Despite our best efforts, our patient nevertheless experienced both emergence delirium and postoperative vomiting. We advocate that physicians, advanced practice providers, and registered nurses be aware of the unique perianesthesia needs of older patients with Down syndrome.

Diminished Blood Pressure Profiles in Children With Down Syndrome

This study sought to analyze blood pressure trends in children with Down syndrome at multiple centers. A multicenter, retrospective, cross-sectional study was performed. All patients were <18 years and had a diagnosis of Down syndrome. Existing comorbidities were nonexclusionary. For each patient, 3 blood pressure recordings were obtained from routine clinic visits. In total, 887 patients with 2661 total blood pressure recordings were included in this study. The average blood pressure percentile for patients was 38.87 with a median percentile of 31.5. Age, sex, and race were not predictive of blood pressure percentile. Compared with established data from the National Heart Lung and Blood Institute and National Health and Nutrition Examination Survey cohort (ages 8-18 years), blood pressure in our Down syndrome population was statistically lower by 6.1 percentile points (P<0.001), with the greatest difference at higher blood pressure percentiles (P<0.001). Only 10% of all Down syndrome cohort blood pressure recordings were greater than the National Heart Lung and Blood Institute/National Health and Nutrition Examination Survey 70th percentile, with no patients meeting criteria for prehypertension or hypertension. Additional comparisons against American Academy of Pediatrics data were similar and statistically significant. In children with Down syndrome, there is a 12 percentile point reduction in baseline blood pressure compared with age- and height-matched controls reported in the National Heart Lung and Blood Institute/National Health and Nutrition Examination Survey and American Academy of Pediatrics cohorts. This data can potentially be utilized in the evaluation and care of persons with Down syndrome in their pediatric medical homes.

Hospitalisation of adults with Down syndrome: lesson from a 10-year experience from a community hospital

BACKGROUND

Life expectancy of individuals with Down syndrome (DS) has improved significantly over the past decades. However, there are sparse data documenting the co-morbidities and hospitalisation of adult patients with DS in the literature. The aim of this study was to characterise the co-morbidities and pattern of hospitalisation in adult patients with DS during a 10-year period at the community hospital as well as to compare hospitalisation parameters with the general adult population during the same years.

METHOD

We reviewed the medical records of 81 hospitalisations from 37 patients with DS aged 21 to 68 years at Metrowest Medical Center during a 10-year period and compared with those of the general adult population during the same time. Co-morbidities were also described.

RESULTS

Adults with DS had a mean age at admission of 48.6 ± 8.8 years with the median length of stay of 3 days (interquartile range 4 days). Male patients were hospitalised longer than female patients (mean 5.0 vs. 2.8 days; P < 0.05), and patients who lived at home were admitted at earlier ages than those who came from residential healthcare facility (mean 41.5 vs. 52.2 years; P < 0.001). The most common cause of hospitalisation was pneumonia/aspiration syndrome (29.6%), and the most common co-morbidity was gastroesophageal reflux disease (GERD)/dysphagia (70.3%). Presence of GERD/dysphagia or seizure disorder was significantly associated with multiple admission and readmission within 1 month (P < 0.05). The mortality rate was 4.9%, and the rate of intensive care unit admission was 8.6%.

CONCLUSIONS

Our cohort did not show statistically significant different hospitalisation parameters such as inpatient mortality and average length of stay when compared with general adult population hospitalised at the same years. The care of adult patients with DS presents challenges in internal medicine due to its unique co-morbid profile and signifies the importance of multidisciplinary approach. In order to improve the care of this patient population, their co-morbidities, particularly GERD/dysphagia and seizure disorder, should be optimally managed and comprehensively addressed when patients are hospitalised.

Dementia in Down syndrome: unique insights for Alzheimer disease research

Virtually all adults with Down syndrome (DS) show the neuropathological changes of Alzheimer disease (AD) by the age of 40 years. This association is partially due to overexpression of amyloid precursor protein, encoded by APP, as a result of the location of this gene on chromosome 21. Amyloid-β accumulates in the brain across the lifespan of people with DS, which provides a unique opportunity to understand the temporal progression of AD and the epigenetic factors that contribute to the age of dementia onset. This age dependency in the development of AD in DS can inform research into the presentation of AD in the general population, in whom a longitudinal perspective of the disease is not often available. Comparison of the risk profiles, biomarker profiles and genetic profiles of adults with DS with those of individuals with AD in the general population can help to determine common and distinct pathways as well as mechanisms underlying increased risk of dementia. This Review evaluates the similarities and differences between the pathological cascades and genetics underpinning DS and AD with the aim of providing a platform for common exploration of these disorders.

The Prevalence of OSA Among an Adult Population With Down Syndrome Referred to a Medical Clinic

Obstructive sleep apnea (OSA) is a common sleep disorder affecting approximately 16% of adults (24% of men and 9% of women), and, if untreated, it can cause significant complications ( Young, 2009 ). This study evaluates 56 adult patients with Down syndrome and analyzed retrospective data to determine the: (1) prevalence of OSA, (2) severity of OSA, and (3) association between body mass index (BMI) and OSA. Of those participants that had polysomnography (PSG) testing available, 82.1% were diagnosed with OSA, divided by severity into mild (45.7%), moderate (15.2%), and severe (39.1%) levels. Because of the high prevalence of OSA among our study population, we recommend that all adults with DS be screened for OSA with PSG.

Evaluation of Pediatrician Adherence to the American Academy of Pediatrics Health Supervision Guidelines for Down Syndrome

The American Academy of Pediatrics's guideline on health supervision for children with Down syndrome (DS) offers pediatricians guidance to improve detection of comorbid conditions. Pediatrician adherence has not yet been comprehensively evaluated. Medical records of 31 children with DS who received primary care at two urban academic clinic sites from 2008-2012 were reviewed. Data was extracted on adherence to age-specific individual guideline components for each subject by year-of-life (total 84 years-of-life). Overall adherence across all components was 83% (2001 guideline) and 67% (2011 guideline). Adherence to thyroid, hearing, vision, and developmental components was >85%, and anticipatory guidance regarding atlantoaxial instability and sexuality was <35%. Overall adherence was higher when a subject was younger and when a provider was an attending-level pediatrician.

Adherence to health management guidelines for children with Down’s syndrome at the Bustamante Hospital for Children, Jamaica

Health surveillance of children with Down’s syndrome may be inadequate. We aimed to assess adherence to health management guidelines at the main paediatric hospital in Jamaica. Ours was a retrospective descriptive study over a five-year period. Data on demographics, co-morbidities, investigations, referrals and interventions were recorded. Of 41 children included in the study, 85% were diagnosed in the neonatal period. Congenital heart disease in 29 (76%) and ophthalmological disorders in 13/24 (54%) were the most common co-morbidities. Evaluations in accordance with the American Academy of Pediatrics guidelines were carried out in only 46% of the children for echocardiography, 48% for ophthalmology, 30% for hearing evaluation and 10% for neonatal thyroid screening. Thus, the recommended guidelines were not carried out in a timely manner in the majority of the children. Education of healthcare providers and caregivers along with the provision of adequate resources may help to resolve this inadequacy.

Disparities in Health Supervision for Children With Down Syndrome

Increasing evidence suggests children with Down syndrome do not receive recommended health care services. We retrospectively assessed adherence to the 2001 American Academy of Pediatrics health supervision guidelines for 124 children with Down syndrome. Cervical spine radiographs were completed for 94% of children, often preoperatively. Adherence to complete blood count recommendations was 55% (95% CI 44% to 66%); lower for males ( P = .01) and children with private medical insurance ( P = .04). Adherence to thyroid function recommendations was 61% (95% CI 54% to 67%); higher for children seen by a pediatrician ( P = .002) and with known thyroid disease ( P < .0001). Adherence to audiology and ophthalmology recommendations was 33% (95% CI 27% to 40%) and 43% (95% CI 37% to 50%), respectively. Adherence rates were higher for children referred to an otolaryngologist ( P = .0002) and with known eye disease ( P < .0001). Future efforts should identify barriers to care and improve adherence to recommended screening.

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.

Relationship-Based Care for Newborns With Down Syndrome and Endocardial Cushion Defect

Down syndrome with endocardial cushion defect is a challenging diagnosis for parents as well as members of the health care team. Utilizing a framework of relationship-based care, nurses are in a position to positively affect parents' experience by providing education, advocacy, and support from initial diagnosis through discharge. The plan of care is multidisciplinary and focuses on critical developmental needs, such as bonding and feeding. Because Down syndrome is associated with multiple anomalies, anticipatory guidance is needed to assist parents with establishing a health maintenance plan for their child after discharge.

Catatonia in Down syndrome; a treatable cause of regression

OBJECTIVE

The main aim of this case series report is to alert physicians to the occurrence of catatonia in Down syndrome (DS). A second aim is to stimulate the study of regression in DS and of catatonia. A subset of individuals with DS is noted to experience unexplained regression in behavior, mood, activities of daily living, motor activities, and intellectual functioning during adolescence or young adulthood. Depression, early onset Alzheimer's, or just "the Down syndrome" are often blamed after general medical causes have been ruled out. Clinicians are generally unaware that catatonia, which can cause these symptoms, may occur in DS.

STUDY DESIGN

Four DS adolescents who experienced regression are reported. Laboratory tests intended to rule out causes of motor and cognitive regression were within normal limits. Based on the presence of multiple motor disturbances (slowing and/or increased motor activity, grimacing, posturing), the individuals were diagnosed with unspecified catatonia and treated with anti-catatonic treatments (benzodiazepines and electroconvulsive therapy [ECT]).

RESULTS

All four cases were treated with a benzodiazepine combined with ECT and recovered their baseline functioning.

CONCLUSION

We suspect catatonia is a common cause of unexplained deterioration in adolescents and young adults with DS. Moreover, pediatricians and others who care for individuals with DS are generally unfamiliar with the catatonia diagnosis outside schizophrenia, resulting in misdiagnosis and years of morbidity. Alerting physicians to catatonia in DS is essential to prompt diagnosis, appropriate treatment, and identification of the frequency and course of this disorder.

Variability of the aging process in dementia-free adults with Down syndrome

The aim of this cross-sectional study was to analyze the typical aging process in adults with Down syndrome, focusing on its variability. The sample comprised 120 adults with Down syndrome who were free of dementia. Ages ranged from 20 to 69 years. Each participant was assessed on cognitive functioning and social adaptation, and was checked for the presence of psychopathological disorders. Results revealed an age-related deterioration in both cognitive and social adaptation skills, the extent of this decline depending on the dimension under scrutiny, and interindividual variability in aging profiles.

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.

Epidemiology of respiratory symptoms in children with Down syndrome: a nationwide prospective web-based parent-reported study

Background

Children with Down syndrome suffer from recurrent respiratory tract and ear-nose-throat complaints that influence daily life. Little is known about the frequency of these complaints, as well as their relation to co-morbidity and ageing.

Methods/design

A prospective web-based parent-reported observational study was designed for parents having a child with Down syndrome (age 0 to 18 years). Upon registration, parents receive an email containing a link to a weekly questionnaire regarding respiratory symptoms during two consecutive years. Additionally, at the beginning, after one year and at the end of the study they receive an extended questionnaire concerning baseline data, daily activities and medical history. The data will be compared to the ongoing “child-is-ill” study, which collects weekly data in an identical fashion in children that are considered to be “normal as to being ill” by their parents.

Discussion

This study will provide important data on the epidemiology of respiratory symptoms in children with Down syndrome, which will be useful for further studies on treatment options. Also, this study will gain insight in healthcare usage and work absence due to the child’s illnesses.

The triple challenges associated with age-related comorbidities in Down syndrome

BACKGROUND

Major increases in the survival of people with Down syndrome during the last two generations have resulted in extended periods of adulthood requiring specialist care, which in turn necessitates greater understanding of the nature, timing and impact of comorbidities associated with the disorder.

METHOD

The prevalence of five comorbidities reported as common in adults with Down syndrome, visual impairment, hearing impairment, epilepsy, thyroid disorders and dementia was assessed by decade of life.

RESULTS

From early adulthood, people with Down syndrome are at enhanced risk of developing new comorbidities and they may present with multiple conditions. Three specific challenges are identified and discussed: are comorbidities detected in a timely manner, is the clinical progress of the disorder adequately understood, and who is responsible for the provision of care?

CONCLUSIONS

Further detailed investigations into the development and treatment of comorbidities across the lifespan are needed for a successful longitudinal approach to healthcare in people with Down syndrome. Implementation of this approach will better inform healthcare providers to ensure continuity of care with advancing age.

Significant impact of recurrent respiratory tract infections in children with Down syndrome

OBJECTIVE

Parents and health professionals believe that recurrent respiratory tract infections (RRTI) have a large impact on children with Down syndrome (DS). We studied the relation between parent-reported RRTI and development, behaviour and health-related quality of life (HRQoL) in 8-year-old children with DS.

METHOD

During a 3-year period, 325 children with DS were recruited for inclusion in this observational study. Parents were asked to fill in the Child Behavior Checklist and TNO-AZL Children's Quality of Life Parent Form. A psychological assistant administrated the McCarthy Scales of Children's Abilities. The children were divided into a group with presence of RRTI (RRTI (+) ) and a group without RRTI (RRTI (-) ), on the basis of parental report. Linear regression analyses were performed to assess the effect of RRTI, while correcting for the influence of confounders.

RESULTS

Compared with RRTI (-) children (n = 176), RRTI (+) children (n = 149, 46%) showed decreased mental and motor development (mean developmental age 3.67 vs. 4.08 years), more behavioural problems and lower scores on most HRQoL scales (P < 0.05). Moreover, school enrolment is less favourable in RRTI (+) children.

CONCLUSION

In 8-year-olds with DS, the children with parent-reported RRTI show more delayed development, more behavioural problems and lower HRQoL compared with the children without RRTI. Although this association does not prove a causal relationship, further studies should focus on this, because RRTI are potentially preventable.

The French version of the Reiss Screen for Maladaptive Behavior: factor structure, point prevalence and associated factors

The main aims of the present study were to examine the factor structure and the internal consistency of the factors in the French version of the Reiss Screen of Maladaptive Behavior in a French-speaking European sample. The prevalence of psychopathology and the influence of associated factors were also examined. The Reiss Screen was administered to 467 adults (age range: 18-73) with intellectual disability living in the French-speaking regions of Switzerland and Belgium. A confirmatory factor analysis was performed to replicate the original factor structure. Internal consistency was examined by using Cronbach's alpha. Analyses of variance were computed to study the influence of gender, age and Down syndrome etiology. The original factor structure of the Reiss Screen was replicated. The overall rate of psychopathology in the sample was 37%. No linear relationship between age and psychopathology was found. However, adults aged less than 26 years had lower scores than older adults on several psychopathological domains. Males had higher scores than females on the Autism and the Avoidant Disorder subscales. Participants with Down syndrome had lower scores on all domains, with the exception of the Autism subscale. The results of this study suggest that the French version of the Reiss Screen can be a useful tool to detect psychopathology in adults with intellectual disability.

Prevalence and incidence of myocardial infarction and cerebrovascular accident in ageing persons with intellectual disability

BACKGROUND

Epidemiological information on age-related cardiovascular disease in people with intellectual disability (ID) is scarce and inconclusive. We compared prevalence and incidence of cerebrovascular accident and myocardial infarction over age 50 in a residential population with ID to that in a general practice population.

METHOD

A retrospective descriptive study was conducted, based on medical records of 510 persons with ID and 823 general practice patients, aged 50 years and over.

RESULTS

Lifetime prevalences after age 50 were similar in both populations: 5.7% (95% CI 4.0-8.1%) in persons with ID and 4.4% (95% CI 3.1-6.0%) in the general population (Pearson chi-square 1.17, P = 0.279). Incidence per gender was similar between cohorts (men P = 0.86, women P = 0.36). There was no difference in incidence rates between the ID and control groups [relative risk = 1.5 (95% CI 0.9-2.4)].

CONCLUSION

Prevalence and incidence of myocardial infarction and cerebrovascular accident in ageing persons with ID do not appear different from those in the general population. It has to be taken into account that underdiagnosis and selection bias towards a more disabled group may have lead to underestimation of age-related cardiovascular morbidity, and the higher age and underrepresentation of Down syndrome to overestimation.

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.

Contributions of a specialty clinic for children and adolescents with Down syndrome

We investigated what added value, if any, a Down syndrome specialty clinic brings to the healthcare needs of children and adolescents with Down syndrome. For this quality improvement study, we performed a retrospective chart review of 105 new patients with Down syndrome, ages 3 and older, seen during the inaugural year of our specialty clinic. We asked how many of our patients were already up-to-date on the healthcare screenings recommended for people with Down syndrome. We further analyzed what tests we ordered, which referrals we suggested, and, ultimately, what new diagnoses of co-occurring medical conditions were made. Only 9.8% of our patients were current on all of the recommended Down syndrome healthcare screenings. Parents came to clinic with a variety of concerns, and after laboratory tests, radiologic studies, and subspecialty referrals, we made many new diagnoses of gastrointestinal conditions (e.g., constipation and celiac disease), seasonal allergies, dermatologic conditions (e.g., xerosis), behavioral diagnoses (e.g., autism spectrum disorder and disruptive behavior not otherwise specified), and clarifications of neurologic conditions. A Down syndrome specialty clinic can identify and address many healthcare needs of children and adolescents with Down syndrome beyond that which is provided in primary care settings.

Older adults with intellectual disability

PURPOSE OF REVIEW

Improvements in health and social care for people with intellectual disability have led to a dramatic increase in the life expectancy of this population, resulting in a large and growing number of older adults with intellectual disability. They are at risk of age-related mental disorders such as dementia and continue to present with high rates of mental illness.

RECENT FINDINGS

Recent research with older adults with intellectual disability has included physical health issues that may affect mental well being, and biological and clinical features of dementia in people with Down syndrome. Two key clinical trials of memantine and antioxidants for dementia in Down syndrome showed that these treatment options were ineffective in the short term. Other research focussed on environmental and psychosocial issues (including carer issues) and end-of-life care.

SUMMARY

Improved mental well being requires effective management of mental illness and co-morbid physical health problems as well as consideration of environmental and social issues. Biological research has identified potential treatments for age-related decline, which has led to the development of medication trials. Despite disappointing results, two recent medication trials showed that randomized controlled trials are feasible in older people with intellectual disabilities - a group who are often excluded from trials.