Mental and physical health and ageing in mental handicap: a review

Appropriateness of psychopharmacological therapies to psychiatric diagnoses in persons with autism spectrum disorder with or without intellectual disabilities: a cross-sectional analytic study

BACKGROUND

Observational studies highlighted high rates of psychotropic medication in persons with autistic spectrum disorder (ASD) with or without intellectual disability, which seems to be associated with the management of problem behaviors more than co-occurrent psychiatric disorders. The purpose of the study is to investigate psychopharmacology use and diagnoses of co-occurrent psychiatric disorder (PD) in persons with ASD attending a public mental health service in Emilia Romagna, Italy.

METHODS

The present study is a multicenter, cross-sectional study.

RESULTS

275 persons out of 486 (56.5%) resulted to receive at least one psychotropic drug, compared to 74 persons (15.2%) that were diagnosed with a PD. 63.6% were on poly-pharmacotherapy (2-10 compounds), with 37.8% receiving 3 or more medications. Antipsychotics were the most frequently prescribed class of psychotropic drugs (89%), followed by antiepileptics/mood stabilizers/lithium (42.1%) and anxiolytics (BDZ) (38.5%). Most common psychiatric disorders were psychotic disorders (29.7%), followed by anxiety disorders (17.5%), bipolar disorders (12.2%), and depressive disorders (9.4%).

CONCLUSIONS

Our findings support earlier research showing that many individuals with ASD receive pharmacotherapy without being diagnosed with a co-occurring psychiatric disorder, indicating that the main reasons for prescription and the type of compound frequently have little to no link with specific psychopathology.

Prevalence estimation of intellectual disability using national administrative and household survey data: The importance of survey question specificity

Background

Variability in prevalence estimation of intellectual disability has been attributed to heterogeneity in study settings, methodologies, and intellectual disability case definitions. Among studies based on national household survey data specifically, variability in prevalence estimation has partly been attributed to the level of specificity of the survey questions employed to determine the presence of intellectual disability.

Specific aims & method

Using standardised difference scoring, and ‘intellectual disability’ survey data from the 2007 Northern Ireland Survey on Activity Limitation and Disability (NISALD) (N=23,689) and the 2011 Northern Ireland Census (N=1,770,217) the following study had two aims. First, we aimed to demonstrate the effects of survey question specificity on intellectual disability prevalence estimation. Second, we aimed to produce reliable estimates of the geographic variation of intellectual disability within private households in Northern Ireland while also assessing the socio-demographic, health-related and disability characteristics of this population.

Findings

Prevalence estimates generated using the more crudely classified intellectual disability Census data indicated a prevalence of 2% for the overall population, 3.8% for children aged between 0 and 15 years, and 1.5% for citizens aged 16 years or older. Intellectual disability prevalence estimates generated using the more explicitly defined 2007 NISALD data indicated a population prevalence of 0.5% for the overall population, 1.3% for children aged between 0 and 15 years, and 0.3% for citizens aged 16 years or older. The NISALD estimates were consistent with most recent international meta-analysis prevalence estimates. According to the NISALD data, the majority of those with an intellectual disability were male, lived outside Belfast, and experienced severe intellectual disability, with multiple comorbid health conditions.

Discussion

The current findings highlight the importance of survey question specificity in the estimation of intellectual disability prevalence and provide reliable prevalence estimates of intellectual disability in Northern Ireland. The findings also demonstrate the utility of administrative data for detecting and understanding intellectual disability, and inform recommendations on how to maximise use of future intellectual disability Census data

Psychiatric illness and learning disability: a dual diagnosis

The prevalence of moderate to profound learning disability is roughly 3 per 1000 and of mild learning disability about 3 per hundred (Abramowicz & Richardson, 1975). There are estimated to be more than 120 million people with learning disability worldwide.

Primary health care provision for people with learning disabilities: a survey of general practitioners

The delivery of primary health care to people with learning disabilities living in the community has come under increasing scrutiny. Concerns have been raised over both the current quality of this care and its future organization. A postal questionnaire was sent to 153 general practitioners (GPs) to elicit their views and opinions concerning the delivery of primary health care to people with learning disabilities; the response rate was 57% (88 responses). The majority of respondents appeared to have no idea of the number of patients they had with learning disabilities. There was no consensus as to the workload generated by this population group. Most GPs claimed to undertake health promotion activities for their patients with learning disabilities. Many GPs' knowledge of health needs affecting people with learning disabilities appeared inadequate, and this was reflected in their degree of confidence in meeting medical needs. Many GPs felt that the lead responsibility for dealing with the general medical needs of people with learning disabilities did not belong with them. These findings support difficulties identified elsewhere in the literature: less frequent surgery attendance of people with learning disabilities, people with learning disabilities do not mention their symptoms to carers/GPs, lack of interest/knowledge of GPs, and a difficulty for GPs in reaching a diagnosis. There was a broad acknowledgement of a problem within primary care, but little consensus as to a solution.

Planning ahead

Despite the acknowledged increase in the number of older people with intellectual disabilities (ID) in the UK, the age-related health and social care needs of this population have yet to be fully understood and addressed. Although there is some evidence of positive development, the current picture of service provision is characterized by fragmentation and limited choice of resources and specialist care. Policy aims are variably met and inconsistently applied. Research suggests that service planning is often incoherent, that many older people with ID and their carers receive poor quality non-specialist care and that staff are inadequately trained to manage the often multiple and complex needs of this user group. There is a considerable co-joined service development and research challenge in this emerging field. If older people with ID and their carers are to receive quality provision, a coherent and well-funded service planning system is required which is underpinned by articulated agency partnerships, informed by good practice developments in the fields of ID, gerontology and dementia care, and linked to evidence about effective models of care and services. The incorporation of the perspectives of users and carers in the planning process is an essential pre-requisite as is a commitment to the development of effective support across the life course of all individuals with ID.

Exploring the attitudes and knowledge of support workers towards individuals with intellectual disabilities

BACKGROUND

The aim of this study is to explore support workers' attitudes and knowledge towards individuals with intellectual disabilities (IDs) to see whether a new attitude scale needs to be developed.

METHOD

Support workers from a charitable organization located in the West Midlands in the United Kingdom participated in one of four focus groups conducted in late 2013. Thematic analysis was then conducted which identified the emergent themes from the focus groups.

RESULTS

Five themes emerged from the analysis, namely, discrimination of people with IDs, attitude change, impacts of integration, their role as a carer and the impact of training. Only one theme, 'the impacts of integration', is clearly represented in current attitude scales; 'their role as a carer' and 'discrimination of people with IDs' are partially represented.

CONCLUSION

These results suggest that current attitude scales do not accurately measure the attitudes of support workers; therefore, a modified attitude scale could be developed to incorporate findings from this study.

The association between behavioural and emotional problems and age in adults with Down syndrome without dementia: Examining a wide spectrum of behavioural and emotional problems

The literature on the association between behavioural and emotional problems and ageing in adults with Down syndrome (DS) without dementia is limited and has generally not reported on a wide range of behavioural and emotional problems. This research aimed to extend the field by examining the associations between age and a wide spectrum of behavioural and emotional problems in adults with DS without dementia. A preliminary analysis of the association between potential covariates and behavioural and emotional problems was also undertaken. Parents and caregivers completed a questionnaire on behavioural and emotional problems for 53 adults with DS aged between 16 and 56 years. Twenty-eight adults with DS and their caregivers were part of a longitudinal sample, which provided two time points of data approximately four years apart. Additionally, 25 participants with DS and their caregivers were from a cross sectional sample, which provided one time point of data. Random effects regression analyses were used to examine the patterns in item scores for behavioural and emotional problems associated with age. No significant associations between age and the range or severity of any behavioural and emotional items were found. This suggested a more positive pattern for ageing adults with DS than has been previously described. Given that behavioural and emotional problems were not associated with age, investigation into other factors that may be associated with the behavioural and emotional difficulties for adults with DS is discussed.

Behaviour disorders in adults with learning disabilities: Effect of age and differentiation from other psychiatric disorders

Objective: To clarify the effect of age on behaviour disorders in adults with learning disabilities, and the differentiation of behaviour disorders from other psychiatric disorders.

Method: Detailed assessments, measuring maladaptive behaviours, psychiatric disorders and demographic factors were completed on 93.7% of all people with learning disabilities aged 65 years and over, living in Leicestershire, UK (n = 134), and also a random sample of adults with learning disabilities aged 20-64 years (n = 73). Behaviour disorders were distinguished from other psychiatric disorders. Descriptive and inferential statistics were calculated.

Result: Equal rates (15%) and types of behaviour disorder were found in the two groups. The presence of behaviour disorder was associated with the severity of learning disabilities, but age was not associated, and nor was presence of epilepsy or gender. In many cases, positive scores on the behavioural assessment, which carers attributed to challenging behaviour/ behaviour disorder, were actually symptoms of psychiatric illness.

Conclusion: Behaviour disorders persist into old age, and therefore require management from the appropriate services. This need will increase, due to increasing lifespan. The accurate interpretation of behaviour scales requires that a comprehensive psychiatric assessment is also undertaken, particularly in elderly people where rates of psychiatric disorders are higher than for younger adults.

People with intellectual disability: what do we know about adulthood and life expectancy?

Increases in the life expectancy of people with Intellectual Disability have followed similar trends to those found in the general population. With the exception of people with severe and multiple disabilities or Down syndrome, the life expectancy of this group now closely approximates with that of the general population. Middle and old age, which until 30 years ago were not recognized in this population, are now important parts of the life course of these individuals. Older adults with Intellectual Disabilities form a small, but significant and growing proportion of older people in the community. How these persons grow older and how symptoms and complications of the underlying cause of the Intellectual Disability will influence their life expectancy is of the utmost importance.

Ageing and health status in adults with intellectual disabilities: results of the European POMONA II study

BACKGROUND

POMONA II was a European Commission public health-funded project. The research questions in this article focus on age-specific differences relating to environmental and lifestyle factors, and the 17 medical conditions measured by the POMONA Checklist of Health Indicators (P15).

METHOD

The P15 was completed in a cross-sectional design for a stratified sample of 1,253 adults with ID across 14 European member states.

RESULTS

Older people (55+) were more likely to live in larger residential homes. Rates of smoking and use of alcohol were lower than in the general population but were higher with older age. More than 60% of older adults had a sedentary lifestyle. Cataract, hearing disorder, diabetes, hypertension, osteoarthritis/arthrosis, and osteoporosis were positively associated with advancing age; allergies and epilepsy, negatively associated.

CONCLUSIONS

Some evidence of health disparities was found for older people with ID, particularly in terms of underdiagnosed or inadequately managed preventable health conditions.

Early onset ageing and service preparation in people with intellectual disabilities: institutional managers' perspective

Although longevity among older adults with intellectual disabilities is increasing, there is limited information on their premature aging related health characteristics and how it may change with increasing age. The present paper provides information of the institutional manager's perception on early onset aging and service preparation for this population. We used purposive sampling to recruit 54 institutional managers who care for people with intellectual disabilities in Taiwan. The present study employed a cross-sectional design using a self-administrative structured questionnaire that was completed by the respondents in November 2009. The results showed that more than 90% of the respondents agreed with earlier onset aging characteristics of people with ID. However, nearly all of the respondents expressed that the government policies were inadequate and the institution is not capable of caring for aging people with ID, and more than half of them did not satisfy to their provisional care for this group of people. With regard to the service priority of government aging policy for people with ID, the respondent expressed that medical care, financial support, daily living care were the main areas in the future policy development for them. The factors of institutional type, expressed adequacy of government's service, respondent's job position, age, and working years in disability service were variables that can significantly predict the positive perceptions toward future governmental aging services for people with ID (adjusted R(2) = 0.563). We suggest that the future study strategy should underpin the aging characteristics of people with intellectual disabilities and its differences with general population to provide the useful information for the institutional caregivers.

People with learning disabilities who have cancer: an ethnographic study

BACKGROUND

Cancer incidence among people with learning disabilities is rising. There have been no published studies of the needs and experiences of people with learning disabilities and cancer, from their own perspective.

AIM

To provide insight into the experiences and needs of people with learning disabilities who have cancer.

DESIGN OF STUDY

Prospective qualitative study, using ethnographic methods.

SETTING

Participants' homes, hospitals, nursing homes, and hospices in London and surrounding areas.

METHOD

The participants were 13 people with learning disabilities ranging from mild to severe, who had a cancer diagnosis. The main method of data collection was participant observation (over 250 hours). The median length of participation was 7 months.

RESULTS

Participants' cancer experiences were shaped by their previous experience of life, which included deprivation, loneliness, and a lack of autonomy and power. They depended on others to negotiate contact with the outside world, including the healthcare system. This could lead to delayed cancer diagnosis and a lack of treatment options being offered. Most participants were not helped to understand their illness and its implications. Doctors did not make an assessment of capacity, but relied on carers' opinions.

CONCLUSION

Urgent action is warranted by findings of late diagnosis, possible discrimination around treatment options, and lack of patient involvement and assessment of capacity in decision making. There are significant gaps in knowledge and training among most health professionals, leading to disengaged services that are unaware of the physical, emotional, and practical needs of people with learning disabilities, and their carers.

Risk of fall for individuals with intellectual disability

Our aim was to identify risk factors for falling and establish a method to assess risk for falls in adults with intellectual disabilities. In a cross-sectional survey of 144 Japanese adults, we found that age, presence of epilepsy, and presence of paretic conditions were independent risk factors. The Tinetti balance and gait instrument was successfully administered to this population and resulted in high diagnostic accuracy (sensitivity 88.9%, specificity 91.9%) for identifying individuals at risk when the cutoff score was set at 25. Participants whose balance and gait deteriorated showed a decrease in the Tinetti score of at least 2 points per year. Thus, the Tinetti instrument may be an effective tool to detect an increased risk of fall in this population.

Variation in health conditions among groups of adults with disabilities in primary care

The literature on the health of adults with disabilities focuses on one disability compared to a comparison group. This study allows cross disability comparisons with the hypothesis. Adults with disabilities had higher odds of having common health conditions, compared to adults without disability in the same practice. A retrospective record review of 1449 patients with disability and 2084 patients without disability included individuals with sensory impairments (n = 117), developmental disabilities (n = 692), trauma-related impairments (n = 155) and psychiatric impairments (n = 485). The only two health conditions with statistically significantly increased odds for all groups with disabilities were dementia and epilepsy. Patients with developmental disabilities were less likely to have coronary artery disease, cancer, and obesity. Those with sensory impairments had increased odds for congestive heart failure, diabetes, transient ischemic attacks and death. Patients with trauma disabilities had increased odds for chronic obstructive pulmonary disease, and depression. Finally, psychiatric patients had increased odds for most of the investigated condition. In conclusion, there were many similarities in the risk for common health conditions such as asthma, cancer, coronary artery disease, depression, hypertension, and obesity, among patients with and without disability. Some of the conditions with increased odds ratios, including depression, seizures, and dementia are secondary to the primary disability.

Cardiovascular disease prevalence and risk factors of persons with mental retardation

This paper reviews the recent literature on cardiovascular disease (CVD) prevalence, CVD-related mortality, physiological CVD risk factors, and behavioral CVD risk factors in adults with mental retardation (MR). The literature on the potential influences of modifiable behavioral CVD risk factors and the physiological CVD risk factors are also reviewed. Adults with mild to moderate MR residing in community settings appear to have an elevated disease prevalence, elevated CVD-related mortality, more adverse physiological CVD risk factors, and elevated behavioral risk compared to others with and without MR. Preliminary evidence supports the benefits of participating in the recommended physical activity levels and consuming the recommended diets to reduce the risk for CVD. The lack of large-scale longitudinal or experimental research indicates a gap in the research. The development of research-based, appropriate, primary prevention programs and intervention strategies aimed at lowering the risk for CVD is highly recommended. Programs should focus on educating individuals with MR along with direct care providers and family members on the importance of appropriate dietary concepts, physical activity habits, and regular health screenings by physicians. Programs should be individualized to regional and cultural issues.

Aging among persons with intellectual disability in Israel in relation to type of residence, age, and etiology

This study was conducted to compare aging phenomena of persons with intellectual and developmental disability (ID) aged 40 years and older living in community residence (N = 65) with those living with their families (N = 43) in Jerusalem, Israel. All 108 persons and care givers were interviewed to ascertain health problems, sensory impairment, activity of daily living (ADL), cognitive skills, and leisure activities. Health problem had already developed by age 40 years. The most frequent were visual (33%), hearing impairments (20%) and dental problems (30%). The community residence group displayed more medical problems, whereas individuals living at home had more dental problems. Health problems in persons with Down syndrome were significantly higher. ADL functioning for all participants was high, but persons with Down syndrome and cerebral palsy had more dependence. A decline in functioning in both residential groups was observed concerning leisure time, but scores for social life leisure activities were better for the community residential group. The data provided in this study can serve as information to develop geriatric services for persons with ID and provide a basis for comparison with peers in the general population in Israel. Dental service to persons with ID living at home should be improved.

Ageing and intellectual disability in Israel: a study to compare community residence with living at home

The present study was conducted to compare ageing phenomena in people with intellectual disabilities aged 40 years and above living in community residences (n = 29) with those living with their families (n = 31). The goals were to compare the health status between the two types of settings, to compare the health status between the study sample and the general Israeli population of the same age group, and to investigate whether deterioration occurs among the participants in activities of daily living (ADLs), cognitive ability and leisure activity. Health problems had already appeared by 40 years of age among the participants. The most frequent problems were visual impairment (33%), hearing impairments (20%) and heart problems (20%). Dental problems were found in 30%. The community-based residence group displayed more medical problems than people living at home, whereas individuals living at home had more dental problems. The functioning of the participants in the ADL areas was high, with no evident decline reported during the previous 5 years. Concerning leisure time, a decline in functioning in both residential groups was observed, and interestingly, the scores for social life and leisure activities were better for the community-based residential group. There is a need for better dental service provision for people with intellectual disabilities living at home. The data provided in the current study can serve as a preliminary base for the development of geriatric services for older adults with intellectual disabilities in the community and also provide a basis for further comparison with peers in the general population.

The quality of health care for adults with developmental disabilities

OBJECTIVE

The purpose of this study was to determine the health status of adults with developmental disabilities residing in community settings and the quality of the preventive, medical, dental, and psychiatric services they receive.

METHODS

Data were collected on a sample of 353 adults residing in Los Angeles, California, in 1997. Historical data were obtained from study subjects or caregivers, physical and dental examinations were performed, blood was drawn for analysis, and a psychiatrist reviewed medical records for reports of psychiatric diagnoses and consultations.

RESULTS

Health markers, such as rates of obesity, and laboratory test results of routine screening panels including blood cell counts, hemoglobin, and hematocrits; blood concentrations of liver enzymes and other enzymes, cholesterol, and tryglycerides; and urinalyses were within normal limits for an adult population. However, preventive services were notably lacking, especially for individuals living at home. Fewer than half of the study subjects had received influenza vaccine; only a third of those living alone or with family or friends had received this vaccination. Chart audits revealed that about a third received psychotropic medications, but only 24% of these individuals had psychiatric consultations noted in their record. Further, 36% of this medicated group received psychotropic drugs without any identifiable diagnosis, and simultaneous receipt of two or more antipsychotics was not uncommon.

CONCLUSIONS

Given that the U.S. health care system fails to ensure the provision of preventive services for all people, including the developmentally disabled, a systematic overhaul is necessary to establish an effective quality assurance program that will provide preventive medical, dental, and psychiatric services for people with developmental disabilities.

Behavioural symptoms among people with severe and profound intellectual disabilities: a 26-year follow-up study

BACKGROUND

Very little is known about the natural history of challenging behaviour and psychiatric disorder in people with severe and profound degrees of intellectual disability.

AIMS

To clarify the natural history of challenging behaviour and psychiatric disorder in this population through a longterm prospective cohort study over a 26-year period.

METHOD

One hundred individuals with severe or profound intellectual disability were randomly selected in 1975. Their behaviour was recorded through carer and psychiatrist ratings using the Modified Manifest Abnormality Scale of the Clinical Interview Schedule. The presence and severity of psychiatric disorder were also recorded. The study was repeated in 1981/82 and 1992/93. We repeated the study again in 2001, supplementing the original observational data with the Checklist of Challenging Behaviour.

RESULTS

Behavioural symptomatology is remarkably persistent, particularly stereotypy, emotional abnormalities, eye avoidance and overactivity, although the severity of overall psychiatric disorder does show some abatement through time.

CONCLUSIONS

These findings influence the prospects of success in relocating adults with severe and profound degrees of intellectual disability back into the community.

The influence of intellectual disability on life expectancy

BACKGROUND

To date, relatively few representative data have been available to health planners and advocacy groups on the life expectancy of people with intellectual disability. A study of trends in the survival profiles of people with intellectual disability was undertaken to assist in the planning of appropriate medical and support services.

METHODS

Since 1953, the Disability Services Commission of Western Australia has maintained a database of persons diagnosed with intellectual disability. The database was used to calculate survival probabilities on a total of 8724 individuals, 7562 of whom were still alive at the time of sampling in December 2000.

RESULTS

Kaplan-Meier survival plots showed a strong negative association between severity of intellectual disability and survival, with median life expectancies of 74.0, 67.6, and 58.6 years for people with mild, moderate, and severe levels of handicap. Significant negative associations also were observed with male gender, Indigenous Australian parentage, and individuals diagnosed with a specific genetic disorder.

CONCLUSIONS

The findings indicate a major and expanding increase in the service requirements of this aging, intellectually disabled population during the past two generations.

A prospective study of menopause in women with Down's syndrome

The present study prospectively examined the age at menopause of 92 women with Down's syndrome (DS) and the influence of hypothyroidism on the age of menopause. Three methods were used to determine the distribution and median age at onset of menopause: (1) Kaplan-Meier life tables; (2) Cox proportional hazards modelling; and (3) maximum likelihood logistic regression. All three methods provided distributions and similar estimates of the median age at menopause, which was approximately 46 years. The presence of hypothyroidism did not influence age at menopause. The earlier-than-expected age at onset of menopause suggests that women with DS are at an increased risk for post-menopausal health disorders.

Persons with intellectual disability receiving psychiatric treatment

Determinants of (1) referral to psychiatric services and (2) the amount of mental health care consumed were analysed in a population of individuals with intellectual disability, using data from a cumulative mental health case register in a defined geographical area. Associations between level of disability, gender, age and social environment on the one hand, and psychiatric referral and service consumption on the other were expressed as odds ratios (ORs). Being older (OR = 1.9; 95% CI = 1.5-2.5), having milder intellectual disability (OR = 1.4; 95% CI = 0.9-2.3) and living alone (OR = 5.8; 95% CI = 2.8-11.9) predicted a higher probability of receiving psychiatric treatment. Living alone (OR = 15.3; 95% CI = 1.7-136.1) was also associated with higher level of mental health service consumption.

People with intellectual disability in general practice: case definition and case finding

In a general practice database containing data on 62,000 patients, those with intellectual disability (ID) were traced. Health problems in this database were recorded according to the International Classification of Health Problems in Primary Care (ICPC) code. By using selected codes, 318 people with ID (0.65% of the study population) were found; the sample contained nearly as many false positives. Adding up the percentage of people with ID living in residential facilities, the total prevalence of people with ID was estimated as 0.82%. Documentation on the cause and level of ID was available in about half of the cases. The demographic characteristics of the people with ID were significantly different from the general population: there was a higher percentage of males and a lower percentage of people over 50 years of age among those with ID. Information about the use of home care was virtually non-existent in the general practice data. The results are compared with those of other studies. The discussion deals with reasons for complete documentation of cases with ID in general practice and the role of the general practitioner in health care supply to people with ID.

The epidemiology of Alzheimer disease in intellectual disability: results and recommendations from an international conference

Among adults with intellectual disability, virtually everyone with Down's syndrome (DS) over the age of 40 years has neuropathology currently viewed to be consistent with a diagnosis of Alzheimer disease (AD), while other adults with intellectual disability without DS display an increased prevalence of Alzheimer-type neuropathology after they reach the age of 65. This paper presents the results of discussions by an epidemiology workgroup, formed at an international conference convened to discuss AD among people with intellectual disability, concerning: (1) the incidence and prevalence of clinical dementia in adults with intellectual disability; (2) risk factors for the development of AD in adults with intellectual disability; and (3) a minimum data set that would be of great utility for future research on AD in adults with intellectual disability.

Prevalence and incidence of health problems in people with intellectual disability

The objective of this study was to determine the prevalence and incidence of the most frequent chronic health problems in relation to age in people with intellectual disabilities living in residential facilities in the Netherlands. A prospective cohort study was done with four data collections, each with an interval of one year. Data were collected by means of questionnaires which were completed by each person's physician. Striking results included the reported high prevalence and incidence of visual and hearing impairment, which was even more pronounced in people with Down's syndrome than in people with intellectual disability resulting from other causes. Gastrointestinal problems also appeared to have high incidence rates. Dementia was frequently reported in people with Down's syndrome aged 40 years and older. The results reflect the need for a more predictive policy which can anticipate health problems in people with intellectual disability.

Comorbidity in people with Down's syndrome: a criteria-based analysis

The aims of this study were to review what is currently known about comorbidity in people with Down's syndrome and to determine if their relative risk for certain disorders was increased. Analysis was carried out on the published literature from 1982 through 1994. In order to be included in this study, articles had to meet predetermined criteria. The strengths and weaknesses of the selected articles were considered in this review. The estimation of relative risks was done by calculating the odds ratio (OR). Odds ratios of > 2 or < 0.5 were found in more than one article for congenital heart defects, hypothyroidism, hearing impairment and hepatitis B. Only one article indicated an OR within this range for all of the following disorders: obesity, epilepsy, degenerative spine disorders and a wide atlanto-axial distance. The results were unclear in the areas of hyperthyroidism, visual disorders, dementia and psychiatric disorders. The concept of comorbidity, i.e. establishing the relationships between the various conditions in one person and understanding the implications for medical care, seems promising, especially for people with intellectual disability. Further work in this area may well improve the quality of care offered to these people.

Validity of the schizophrenia diagnosis of the psychiatric assessment schedule for adults with developmental disability (PAS-ADD)

BACKGROUND

First rank symptoms are central to the diagnosis of schizophrenia, but their complexity makes it difficult to validly detect them in people with learning disability. This report investigates ability of PAS-ADD to detect schizophrenia, validated against expert clinical opinion.

METHOD

The sample consisted of 98 patients with learning disabilities and a key informant for each sample member. Clinical opinions of the referring psychiatrists were sought using a symptom checklist. Reportage of remission, and the number of core schizophrenia symptoms identified, were used to estimate level of symptom activity at time of interview.

RESULTS

The proportion of schizophrenia cases detected by PAS-ADD increases with the number of active core symptoms identified by the referrer. Where two or more core symptoms were indicated, PAS-ADD detected 71% cases. The most frequently fulfilled criterion was third-person auditory hallucinations. Six schizophrenia diagnoses disagreed with the clinician, four of which were referred as being hypomania. Overall symptom frequency detected by PAS-ADD was positively correlated with IQ.

CONCLUSIONS

Results suggest there may be scope for modifying the ICD-10 diagnostic algorithm for use with learning disability, particularly in relation to the delusions and negative symptoms criteria.

Behaviour symptoms among severely and profoundly mentally retarded patients. A 16-18 year follow-up study

BACKGROUND

Little is known about the natural history and evolution of behaviour symptoms and patterns in severely and profoundly mentally retarded adults. This paper reports a cohort study of 100 such adults.

METHOD

Abnormal behaviour symptoms and patterns have been followed, using a carer rating scale and the modified Manifest Abnormality Scale of Goldberg's Clinical Interview Schedule (1970) by the same two consultant psychiatrists in 1975, 1981 and 1992.

RESULTS

Emotional withdrawal, stereotypes and eye avoidance are particularly persistent. Carer ratings of noisiness and social withdrawal, and psychiatrist ratings of suspiciousness, overactivity and hostile irritability, are also persistent but to a lesser degree. Overall ratings of psychiatric disorder are persistent and act against successful community placement.

CONCLUSIONS

Abnormal behaviour patterns in severely and profoundly mentally retarded adults show only a modest degree of abatement over time. Care staff need a good understanding of clinical psychiatric and behaviour management techniques.