Medical concerns in people with severe learning difficulties: report on a vision week and symposium at the Royal College of Physicians and Surgeons of Glasgow, Scotland, 8-12 March 1993

Comprehensive health assessments during de-institutionalization: an observational study

BACKGROUND

People with intellectual disability (ID) leaving institutions pass through a transition stage that makes them vulnerable to inadequate health care. They enter into community care under general practitioners (GPs) who are often untrained and inexperienced in their needs. Specifically designed health reviews may be of assistance to both them and their new GPs as they go through that phase.

METHODS

This research aimed to investigate the effectiveness of a specially designed health review, the comprehensive health assessment program (CHAP) health review, in a group of adults as they transitioned out of the care of the last institution for people with ID in Tasmania. There were 25 residents reviewed by their GPs.

RESULTS

The CHAP reviews picked up a number of health conditions and stimulated health promotion activities. Some of the findings were: a high number of abnormal Body Mass Indexes (19/23), immunizations given (13/23), vision impairment reported (2/23), mental health issues recorded (4/23) and skin abnormalities described (17/23). There were 22 referrals made to other health professionals (Australian Hearing Service 4, dentists 3, optometrists 3, psychiatrists 2, neurologists 2, ophthalmologist 1, urologist 1, ultrasound 1, mammogram 1, family planning 1, physiotherapist 1, continence nurse 1 and respiratory physician 1). These were in addition to various requests for pathology.

CONCLUSIONS

The CHAP health review was effective in identifying a number of health issues in the population of people with ID as they transitioned out of institutional care into the general community.

Medical needs of people with intellectual disability require regular reassessment, and the provision of client- and carer-held reports

BACKGROUND

Previous work has indicated a wide range of unmet medical health needs in people with intellectual disability (ID).

METHODS

A profile of recorded medical needs was produced for 589 people with ID through a detailed search of individual medical and nursing case records. Specialist optometric and audiological assessments were offered, and reports were provided in technical and plain English terms. A Health Watch project delivered folders with copies of the plain English reports to 60 individuals and carers.

RESULTS

The case record review indicated a wide range of medical disorders; however, exact diagnoses and counselling regarding underlying neurological conditions were seldom recorded. Assessed levels of hearing and vision loss were much greater than had been previously recognized. The Health Watch reports were welcomed by the clients and carers.

CONCLUSIONS

If satisfactory healthcare is to be achieved for people with ID, medical needs must be monitored, regular specialist reassessments offered, access to specialist services facilitated and reports clearly explained to carers.

Prevalence of visual and hearing impairment in a Dutch institutionalized population with intellectual disability

A screening of hearing and visual function was performed using clinical assessment methods in a Dutch institutionalized population of 672 people with mild to profound intellectual disability (ID). Because the studied population was not comparable to the total Dutch population with ID, subgroups were distinguished according to level of ID, age younger and older than 50 years, and the presence or absence of Down's syndrome (DS). The prevalences of both hearing and visual impairment were considerably increased in all subgroups, as compared with the general population. In the least affected group, i.e. those < 50 years with a mild or moderate ID by other causes than DS, the prevalences of hearing and visual impairment were 21% and 4%, respectively (as opposed to 2-7% and 0.2-1.9% in the general Dutch population <50 years, respectively). The prevalence of hearing impairment showed a sharp and highly significant increase in individuals with DS and subjects > or = 50 years. To a lesser extent, young adults with severe or profound ID had an increased risk of hearing impairment. Visual impairment and blindness were specifically highly prevalent in people with severe or profound ID (51% < 50 years of age). Down's syndrome and an age > or = 50 years were also significant risk factors for visual impairment. There was an alarmingly high prevalence of combined sensory impairment, especially in those with severe or profound ID (20%). Although hearing impairment had been diagnosed prior to this screen in 138 people and visual impairment in 65 individuals, a first diagnosis of hearing impairment was made in 128 subjects and of visual impairment in 90 cases. This highlights the tendency for sensory impairments to go unnoticed in people with ID, which is not restricted to those with severe or profound ID. Therefore, the present authors stress the importance of regular screening as outlined in the existing IASSID international consensus statement.

Vision care requirements among intellectually disabled adults: a residence-based pilot study

Intellectually disabled adults have an high incidence of visual problems and they are often unable to communicate their visual difficulties. At Lennox Castle and Waverley Park Hospitals, vision care is through referral by medical and nursing staff to designated optometrists and ophthalmologists. This practice has provided a good service when visual difficulties are noticed. The vision care requirements of all residents had not been comprehensively assessed and a new interdisciplinary procedure developed at Waverley Park Hospital had drawn attention to the fact that only 11% had been offered vision assessment within the previous 5 years. In this study, 63 residents without specific referral received a comprehensive visual and medical assessment. The residents ranged from age 20 to 85 years and included the full range of disabilities. Objective assessments, ophthalmoscopy and retinoscopy were generally successful for all levels of disability. Visual acuity and visual fields were tested using methods suitable for nonverbal subjects. Success rates for these subjects were generally good, except in the profoundly disabled group where less than 30% were able to respond. A high prevalence of visual impairment, refractive error, squint and other ocular conditions was found. Visual impairment was most common in the severe and profoundly disabled groups because of optic nerve or cortical dysfunction. New spectacles were recommended for 23 residents (seven others had adequate correction). Nine residents were referred for ophthalmologic consultation, mainly for cataract. Three required monitoring for visual conditions. Thirty-one residents (49%) required no immediate action beyond documentation of the visual status. This study has shown a high prevalence of visual difficulties which were not previously detected. Routine biennial vision assessment of all residents is recommended to allow timely intervention to correct vision problems, and also to provide the necessary information about vision to plan appropriate programmes of activity.