Dementia in older people with intellectual disability: symptoms of physical and mental illness, and levels of adaptive behaviour

Psychiatric diagnoses in older people with intellectual disability in comparison with the general population: a register study

AIMS

To describe the occurrence of psychiatric diagnoses in a specialist care setting in older people with intellectual disability (ID) in relation to those found in the same age group in the general population.

METHOD

A cohort of people with ID (n = 7936), aged 55 years or more in 2012, was identified, as was an age and sex-matched cohort from the general population (n = 7936). Information regarding psychiatric diagnoses during 2002-2012 was collected from the National Patient Register, which contains records from all inpatient care episodes and outpatient specialist visits in Sweden. The mean age at the start of data collection (i.e. January 1st, 2002) was 53 years (range 44-85 years).

RESULTS

Seventeen per cent (n = 1382) of the people in the ID cohort had at least one psychiatric diagnosis recorded during the study period. The corresponding number in the general population cohort was 10% (n = 817), which translates to an odds ratio (OR) of 1.84. The diagnoses recorded for the largest number of people in the ID cohort were 'other' (i.e. not included in any of the diagnostic groups) psychiatric diagnoses (10% of the cohort had at least one such diagnosis recorded) and affective disorders (7%). In the general population cohort, the most common diagnoses were affective disorders (4%) and alcohol/substance-abuse-related disorders (4%). An increased odds of having at least one diagnosis was found for all investigated diagnoses except for alcohol/substance-abuse-related disorders (OR = 0.56). The highest odds for the ID cohort was found for diagnosis of psychotic disorder (OR = 10.4) followed by attention deficit/hyperactive disorder (OR = 3.81), dementia (OR = 2.71), personality disorder (OR = 2.67), affective disorder (OR = 1.74) and anxiety disorder (OR = 1.36). People with ID also had an increased odds of psychiatric diagnoses not included in any of these groups (OR = 8.02). The percentage of people with ID who had at least one diagnosis recorded during the study period decreased from more than 30% among those aged 55-59 years in 2012 (i.e. born 1953-1957) to approximately 20% among those aged 75+ years in 2012 (i.e. born in or before 1937).

CONCLUSIONS

Older people with ID seem to be more likely to have psychiatric diagnoses in inpatient or outpatient specialist care than their peers in the general population. If this is an effect of different disorder prevalence, diagnostic difficulties or differences in health care availability remains unknown. More research is needed to understand the diagnostic and treatment challenges of psychiatric disorders in this vulnerable group.

A comparison of reports of caregiver burden between foster family care providers and staff caregivers in other settings

There has been increasing concern about the impact of dementia symptoms on the lives and on the care being provided for persons with intellectual disability (ID) in out-of-home settings. One such setting that has received little attention is foster family care homes. These settings in the USA replicate family living and while some supports and resources are provided, they are not designed to meet intensive care needs. As a preliminary step in understanding family experiences and to expand the range of interest in Alzheimer’s disease (AD) in persons with ID beyond traditional out-of-home settings, a pilot study was initiated that included aging persons with ID and symptoms of AD who were living in foster family care settings in two regions of New York State as well as more traditional out-of-home care subjects. Comparisons of matched samples on subjective and objective burden measures suggest that there are few differences in experiences. The limitations of these findings are considered and recommendations made for future, related research.

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.

Alzheimer's dementia in persons with Down's syndrome

The aim of this study was to investigate the amount of time formal caregivers spend addressing activities of day-to-day care activities for persons with Down's syndrome (DS) with and without Alzheimer's dementia (AD). Caregivers completed for 63 persons with DS and AD, and 61 persons with DS without AD, the Caregiving Activity Survey-Intellectual Disability (CAS-ID). Data was also gathered on co-morbid conditions. Regression analysis was used to understand predictors of increased time spent on day-to-day caregiving. Significant differences were found in average time spent in day-to-day caregiving for persons with and without AD. Mid-stage and end-stage AD, and co-morbid conditions were all found to predict increased time spent caregiving. Nature and tasks of day-to-day caregiving appeared to change as AD progressed. The study concluded that staff time to address day-to-day caregiving needs appeared to increase with onset of AD and did so most dramatically for persons with moderate intellectual disability. Equally, while the tasks for staff were different, time demands in caring for persons at both mid-and end-stage AD appeared similar.

Prevalence of Behavioural and Psychological Symptoms of Dementia in Individuals with Learning Disabilities

A review of 23 studies investigating the prevalence of Behavioural and psychological symptoms of dementia (BPSD) in the general and learning disability population and measures used to assess BPSD was carried out. BPSD are non-cognitive symptoms, which constitute as a major component of dementia regardless of its subtype Research has indicated that there is a high prevalence of BPSD in the general dementia population. There are limited studies, which investigate the prevalence of BPSD within individuals who have learning disabilities and dementia. Findings suggest BPSDs are present within individuals with learning disabilities and dementia. Future research should use updated tools for investigating the prevalence of BPSD within individuals with learning disabilities and dementia.

Dementia in people with intellectual disability: insights and challenges in epidemiological research with an at-risk population

The population with intellectual disability (ID) is ageing, but age-related health concerns such as dementia have received little research attention thus far. We review evidence regarding the prevalence and incidence of dementia in people with ID, and discuss some possible explanations for an increased risk, such as shared genetic risk factors, co-morbid physical and mental disorders, lifestyle factors, trauma, and lowered brain reserve. We discuss practical and theoretical challenges facing researchers in this field, before highlighting the implications of findings to date for future research and clinical care. Research on dementia in this at-risk population has the potential to help us understand dementia in general and to improve services for this group of vulnerable individuals.

Incontinence in individuals with Angelman syndrome: a comparative study

Frequency and type of incontinence and variables associated with incontinence were assessed in individuals with Angelman syndrome (AS; n=71) and in a matched control group (n=69) consisting of individuals with non-specific intellectual disability (ID). A Dutch version of the "Parental Questionnaire: Enuresis/Urinary Incontinence" (Beetz, von Gontard, & Lettgen, 1994) was administered and information on primary caretakers' perspectives regarding each individual's incontinence was gathered. Results show that diurnal incontinence and fecal incontinence during the day more frequently occurred in the control group than in the AS group. In both groups, nocturnal enuresis was the most common form of incontinence. More incontinence was seen in individuals with AS who were younger, had a lower level of adaptive functioning and/or had epilepsy. Individuals with AS were able to stay dry for longer periods of time than the controls and often showed both in-toilet urination and urinary accidents during the day, whereas accidents and correct voids during the day were more set apart in the control group. Also, persons with AS had a lower micturition frequency implying possible voiding postponement. Both groups showed high rates of LUTS (lower urinary tract symptoms) possibly indicative of functional bladder disorders such as voiding postponement, dysfunctional voiding, or even an underactive bladder. In general, most primary caretakers reported severe intellectual disability as the main cause for urinary incontinence. Based on these results incontinence does not appear to be part of the behavioral phenotype of Angelman syndrome. Therefore, pediatric or urologic diagnostics and treatment are recommended for all persons with incontinence and intellectual disability. Further implications for practice and research are given.

Incontinence in Individuals with Rett Syndrome: A Comparative Study

Frequency and type of incontinence and its association with other variables were assessed in females with Rett Syndrome (RS) (n = 63), using an adapted Dutch version of the 'Parental Questionnaire: Enuresis/Urinary Incontinence' (Beetz et al. 1994). Also, incontinence in RS was compared to a control group consisting of females with non-specific (mixed) intellectual disability (n = 26). Urinary incontinence (UI) (i.e., daytime incontinence and nocturnal enuresis) and faecal incontinence (FI) were found to be common problems among females with RS that occur in a high frequency of days/nights. UI and FI were mostly primary in nature and occur independent of participants' age and level of adaptive functioning. Solid stool, lower urinary tract symptoms and urinary tract infections (UTI's) were also common problems in females with RS. No differences in incontinence between RS and the control group were found, except for solid stool that was more common in RS than in the control group. It is concluded that incontinence is not part of the behavioural phenotype of RS, but that there is an increased risk for solid stool in females with RS.

Psychometric evaluation of the Italian version of the AADS questionnaire: a caregiver-rated tool for the assessment of behavioral deficits and excesses in persons with intellectual disabilities and dementia

BACKGROUND

The aim of this study was to verify the reliability and validity of the Italian version of the Assessment for Adults with Developmental Disabilities (AADS-I), the only available measure specifically designed to assess the frequency, management difficulties and impact on the quality of life (QoL) of positive and negative non-cognitive symptoms in persons with intellectual disabilities (ID) and dementia.

METHODS

AADS-I was administered to professional carers of 63 aging ID individuals. We computed the internal consistency separately of the frequency, management difficulty and effect on the QoL subscales of Behavioral Excesses and Behavioral Deficits and their inter-rater and test-retest reliabilities.

RESULTS

Homogeneity of AADS-I was found to range from good to excellent: Cronbach's α coefficients were 0.77, 0.83 and 0.82, respectively for frequency, management difficulty and effect on the QoL of Behavioral Excesses, and 0.82, 0.76 and 0.79 of Behavioral Deficits. Intraclass correlation coefficients (ICC) between two independent carers were 0.67, 0.79 and 0.73 and 0.67, 0.67 and 0.67 for frequency, management difficulty and effect on the QoL of Behavioral Excesses and Deficits, respectively. Corresponding ICC for test-retest reliability were 0.80, 0.75, 0.78 and 0.70, 0.81, 0.81. Age, gender and typology of ID did not correlate with the AADS-I subscale scores, whereas the severity of ID related only with the frequency subscale of Behavioral Deficits. This subscale also correlated with the Dementia Questionnaire for Persons with Intellectual Disabilities. Behavioral deficits are more frequent in subjects with dementia.

CONCLUSIONS

These results confirm the reliability and validity of the Italian version of AADS.

The needs of people with learning disabilities who develop dementia: A literature review

People with learning disabilities are living longer and are increasingly developing age related conditions including dementia. If this occurs, their medical and social needs pose many challenges for services. A literature review was undertaken of articles published between 1996— 2006. Data was collected relating to the needs of people with learning disabilities and dementia, their carers and their peers. The primary medical need is for timely and accurate diagnosis. There is a multitude of diagnostic tools and advice is available as to which are most suitable for different client groups. The needs of carers are intertwined with those of people with learning disabilities and dementia and meeting their needs for education, training and increased staff numbers, has proved beneficial. Although multiple services will be responsible for the needs of this client group, there is a consensus that learning disability services should be at the heart of service provision.

Supporting persons with Down syndrome and advanced dementia

Aim: To understand staff perceptions of critical issues in caring for persons with intellectual disability (ID) and advanced dementia. Background: There has been growing interest in addressing resource, training, and service redesign issues including an increase in collaborative practices in response to the growing incidence of dementia among persons with ID. Most recently this has included consideration of the specific issues in advanced dementia.

Method: Thirteen focus group interviews were held involving staff in six ID services and one specialist palliative care provider in Ireland. A qualitative descriptive approach was taken to analysis.

Results: Staff identified three key themes: (1) readiness to respond to end of life needs, (2) the fear of swallowing difficulties, and (3) environmental concerns and ageing in place.

Discussion: Four underlying issues that emerged in this study offer clues to solutions: (a) differences in staff preparation associated with settings, (b) lack of understanding and lack of collaboration with palliative care services, (c) uncertainties about the ability to transfer existing palliative care models to persons with ID and dementia and (d) the need to develop training on end stage dementia and related care approaches.

Health co-morbidities in ageing persons with Down syndrome and Alzheimer's dementia

BACKGROUND

Consideration of the relationship between physical and mental health co-morbidities in ageing persons with Down syndrome (DS) and Alzheimer's dementia (AD) is of clinical importance both from a care and resource perspective. AIM To investigate and measure health co-morbidities in ageing persons with Down syndrome with and without AD.

METHODS

Recorded physical and mental health needs were ascertained for 124 persons with DS>35 years through a systematic and detailed search of individual medical and nursing case records. Differences in persons with and without AD were investigated, by stage of dementia and by level of intellectual disability (ID). A summed score for health co-morbidities was created and compared using t-tests.

RESULTS

Persons with AD had significantly higher co-morbidity scores than persons without AD (t=-8.992, d.f.=121, P<0.0001). There was also a significant difference in summed co-morbidity scores for persons at end-stage vs. persons at mid-stage AD (t=-6.429, d.f.=56, P<0.0001). No differences were found by level of ID.

CONCLUSIONS

Increasing health co-morbidities in persons with DS and AD have important implications for care and resources. Appropriate environmental supports combined with competent skilled staff are crucial and will have an important impact on the quality of life for this increasingly at risk population.

Ageing and learning disability

BACKGROUND

Ageing is a continuation of the developmental process and is influenced by genetic and other biological factors as well as personal and social circumstances.

AIMS

To identify some key biological, psychological and social issues relevant to how ageing might particularly effect people with learning disabilities.

METHOD

This selected review considers the extent to which there are similarities and differences relative to people without learning disabilities.

RESULTS

There is a convergence, in later life, between people with a learning disability and those without, owing to the reduced life expectancy of people with more severe disabilities. People with Down's syndrome have particular risks of age-related problems relatively early in life.

CONCLUSIONS

The improved life expectancy of people with learning disabilities is well established. There is a lack of a concerted response to ensure that the best possible health and social care is provided for people with learning disabilities in later life.

Determinants of aggression, and adaptive and maladaptive behaviour in older people with Down's syndrome with and without dementia

In a cross-sectional study of aggression, and adaptive and maladaptive behaviour in 128 subjects with Down's syndrome (DS), 29 of whom had dementia, the current authors found that the presence of dementia was not predictive of aggression or maladaptive behaviour. However, the level of adaptive behaviour was shown to be lower in subjects with dementia, and in those with lower levels of cognitive functioning, as measured on a rating instrument, the Test for Severe Impairment. Although the presence of aggressive behaviours is not higher in subjects with dementia and DS on cross-sectional review, it remains to be seen whether aggression will increase in individual cases with the onset or progression of dementia. The decline in adaptive behaviour shown in the present study confirms the findings of previous studies and indicates a direction for service development for persons with the dual diagnosis of dementia and DS.