Caregiver experiences of supporting adults with intellectual disabilities in pain

Natural history in Malan syndrome: survey of 28 adults and literature review

BACKGROUND

Malan syndrome (MALNS), previously referred to as "Sotos syndrome 2" due to its resemblance to Sotos syndrome (SS), is an ultra-rare neurodevelopmental disorder characterized by overgrowth, typical craniofacial features, intellectual disability (ID), and a range of psychobehavioral, musculoskeletal, vision and neurological signs. As MALNS and SS partly overlap, it is essential to more accurately profile their clinical presentations and highlight their differences in order to improve syndrome specific management. An increasing number of individuals with MALNS reach adult-age though the natural history of the disorder is poorly characterized due to the small number of adult individuals described so far. As a consequence, current guidelines are limited to the pediatric population. Further delineation of MALNS is essential to optimize care in adulthood.

RESULTS

A mixed approach based on cross-sectional data collection with a survey disseminated to caregivers of adults with molecularly confirmed MALNS and literature review was conducted. Twenty-eight caregivers completed the survey. Clinical presentation in adulthood is multisystemic and defined by psychobehavioral comorbidities (96%), musculoskeletal involvement (96%), vision impairment (96%) and neurological complications (86%). The most common signs were anxiety (79%), hypotonia (75%), movement difficulty (75%), scoliosis (64%), problems with coordination (61%), strabismus (57%), constipation (54%), breastbone abnormalities (54%) and advanced bone age during childhood (54%). Impaired vision was complicated by vision decline (36%) and optic atrophy (32%). We report some previously unidentified features, including high pain threshold (46%), incontinence (25%), tremors (21%), muscle hypoplasia (18%) and tics (18%).

CONCLUSIONS

This survey in the adult population has allowed a more complete description of the natural history of MALNS. Our findings will contribute to the development and improvement of standards of care for adults with MALNS to assure optimal health monitoring and treatment of evolutive complications. We propose additional recommendations to the previous dataset of clinical evaluations specifically applied to adults. The comparison of MALNS and SS adult presentation highlights significant differences in terms of prevalence and severity of ID, behavioral issues, and vision problems, confirming that a proper differential diagnosis between the two conditions is indispensable to guide physicians and mental health professionals to syndrome specific management.

The recognition, assessment and perceptions of total pain in people with profound intellectual disabilities: A mixed methods systematic review

BACKGROUND

People with profound intellectual disabilities are a population with complex comorbidities. Total pain recognises the interconnectedness of aspects of pain; social, psychological, physical, emotional, spiritual. Pain is under-recognised due to communication challenges and carers perceptions. This review's purpose is to synthesise current literature and provide guidance for future research and care.

METHODS

Five databases were searched in this mixed methods systematic review (Cinahl, Medline, Psycinfo, Web of Science, Scopus). Articles retrieved were reported via a PRISMA flow diagram. Quality appraisal utilised the mixed methods appraisal tool (MMAT). A convergent qualitative design was the method of data synthesis.

RESULTS

Data from 16 included articles generated four themes; Absent voices, reductionist assessment, pain intensity, valuing expertise. Data included physical pain only.

CONCLUSION

Multifaceted pain needs inclusion in research. Assessment must consider the unique expressions of pain by individuals with profound intellectual disabilities. A sharing of expertise may improve pain care.

Actions taken and barriers encountered by professionals working with adults with intellectual disabilities who experience grief: a qualitative approach

Experience of grief has increased among people with intellectual disability because of their longer life expectancy. Professionals supporting this population are often critical of the lack of adequate tools for dealing with this situation. The objective of this study was to identify the strategies and barriers that these professionals are confronted with when dealing people with intellectual disability who are going through the grieving process. A qualitative study was conducted involving 20 professionals working with people with intellectual disability. Four themes were extracted using thematic analysis: Exclusion of clients from end-of-life and grief processes, Strategies to support the client's grief process, Emotional and personal difficulties faced by the professionals, and Coping and regulation of the professional's grief process. Barriers identified by these professionals include not having the specific skills to support clients in their grief and the emotional impact of the death of a client.

Reliable assessment of pain behaviour in adults with profound intellectual and multiple disabilities: The development of an instruction protocol

BACKGROUND

Persons with profound intellectual and multiple disabilities (PIMD) are vulnerable when it comes to experiencing pain. Reliable assessment of pain-related behaviour in these persons is difficult. Aim To determine how pain items can be reliably scored in adults with PIMD.

METHODS

We developed an instruction protocol for the assessment of pain-related behaviour in four phases. We used videos of 57 adults with PIMD during potentially painful situations. The items were assessed for inter-rater reliability (Cohen's kappa or percentage of agreement).

RESULTS

The developed instruction protocol appeared to be adequate. Twelve items had satisfactory inter-rater reliability (n = 9: .30-1.00; n = 3: 85%-100%).

DISCUSSION

Calibrating and adjustments to the instructions and item set appeared to be crucial to reliably score 12 items in adults with PIMD. Further research should focus on creating an assessment instrument based on these reliably scored items.

[Challenges in pain assessment and management among individuals with intellectual and developmental disabilities : German version]

INTRODUCTION

Intellectual and developmental disabilities (IDD) include conditions associated with physical, learning, language, behavioural, and/or intellectual impairment. Pain is a common and debilitating secondary condition compromising functional abilities and quality of life.

OBJECTIVES

This article addresses scientific and clinical challenges in pain assessment and management in individuals with severe IDD.

METHODS

This Clinical Update aligns with the 2019 IASP Global Year Against Pain in the Vulnerable and selectively reviews recurring issues as well as the best available evidence and practice.

RESULTS

The past decade of pain research has involved the development of standardized assessment tools appropriate for individuals with severe IDD; however, there is little empirical evidence that pain is being better assessed or managed clinically. There is limited evidence available to inform effective pain management practices; therefore, treatment approaches are largely empiric and highly variable. This is problematic because individuals with IDD are at risk of developing drug-related side effects, and treatment approaches effective for other populations may exacerbate pain in IDD populations. Scientifically, we are especially challenged by biases in self-reported and proxy-reported pain scores, identifying valid outcome measures for treatment trials, being able to adequately power studies due to small sample sizes, and our inability to easily explore the underlying pain mechanisms due to compromised ability to self-report.

CONCLUSION

Despite the critical challenges, new developments in research and knowledge translation activities in pain and IDD continue to emerge, and there are ongoing international collaborations.

Evaluating and Handling the Pain of People With Intellectual Disability

Anecdotal reports have suggested people with intellectual disabilities experience more pain than the general population due to additional co-morbidities and secondary conditions. This multicenter comparative cross-sectional study aimed to evaluate the prevalence, factors, and treatment modalities in people with intellectual disabilities (PID) as observed by their caregivers and reported through distributed questionnaires. The study sample included 130 PID users of centers in Ciudad Real (Spain). Variables related to sociodemographic characteristics, health problems, problem behaviors, and pain were collected. Among participants, 78 (60%) of PID were males, and their mean age was 43.8 years (SD = 13.57). Pain was identified in 29 PID (22.3%; 95% confidence interval [CI] 14.99-29.81), and drugs for pain were administered to 33 PID (26.4%; 95%CI 19-34). The prevalence of pain in the sampled PID, its severity, and the analgesic administration rate were lower than those in the general population. This situation may be aggravated for PID with communication problems.

Validity of the Rotterdam Elderly Pain Observation Scale for institutionalised cognitively impaired Dutch adults

BACKGROUND

The Rotterdam Elderly Pain Observation Scale (REPOS) has not yet been validated for institutionalised cognitively impaired adults. To fill this gap of knowledge, we tested psychometric properties of the REPOS when used for pain assessment in this population.

METHODS

In this multicentre observational study, residents were filmed during a possibly painful moment and at rest. Healthcare professionals were asked to rate residents' pain by means of a Numeric Rating Scale (NRS)-proxy. Two researchers assessed pain with the REPOS and the Chronic Pain Scale for Non Verbal Adults with Intellectual Disabilities (CPS-NAID) from video-recordings.

RESULTS

In total, 168 observations from 84 residents were assessed. Inter-observer reliability between the two researchers was good, with Cohen's kappa 0.72 [95% confidence interval (CI) 0.64 to 0.79]. Correlation between the REPOS and CPS-NAID for a possibly painful moment was 0.73 (95% CI 0.65 to 0.79). Sensitivity (85%) and specificity (61%) for the detection of pain were calculated with REPOS ≥ 3 and NRS ≥ 4 as a reference value. Item response theory analysis shows that the item grimace displayed perfect discrimination between residents with and without pain.

CONCLUSION

The REPOS is a reliable and valid instrument to assess pain in cognitively impaired individuals.

Self-esteem, self-efficacy, self-concept and intimate image diffusion among deaf adolescents: A structural equation model analysis

This study aimed to assess the role of self-esteem, self-efficacy and self-concept on intimate image diffusion among in-school deaf adolescents in Lagos, Nigeria. The theory of planned behaviour served as a framework for the study. Data was collected through structured questionnaire from 276 (male = 39.5%; female = 60.5%) in-school deaf adolescents from five senior secondary (3 integrated and 2 inclusive). Data generated were analysed with IBM SPSS 22 and IBM AMOS 26.0 packages. Mean age of participants was ±16.5, all participants use WhatsApp while 71.7% had Facebook profile. It was observed that all the fit measures of the SEM fell within the acceptable range (χ2 = 104.34, df = 39, χ2/df = 2.67, GFI = 0.92, CFI = 0.91, NFI = 0.93, IFI = 0.91 and RMSEA = 0.54). According to the findings, self-esteem and self-efficacy had a positive and direct relationship with intimate image diffusion while a negative but direct link exists between self-concept and intimate image diffusion among deaf adolescents. Based on the finding, an appropriate recommendation was made.

Challenges in pain assessment and management among individuals with intellectual and developmental disabilities

Pain is common for individuals with intellectual and developmental disabilities, and we need to accelerate the use of evidence-based approaches to assess and manage pain.

Introduction:

Intellectual and developmental disabilities (IDD) include conditions associated with physical, learning, language, behavioural, and/or intellectual impairment. Pain is a common and debilitating secondary condition compromising functional abilities and quality of life.

Objectives:

This article addresses scientific and clinical challenges in pain assessment and management in individuals with severe IDD.

Methods:

This Clinical Update aligns with the 2019 IASP Global Year Against Pain in the Vulnerable and selectively reviews recurring issues as well as the best available evidence and practice.

Results:

The past decade of pain research has involved the development of standardized assessment tools appropriate for individuals with severe IDD; however, there is little empirical evidence that pain is being better assessed or managed clinically. There is limited evidence available to inform effective pain management practices; therefore, treatment approaches are largely empiric and highly variable. This is problematic because individuals with IDD are at risk of developing drug-related side effects, and treatment approaches effective for other populations may exacerbate pain in IDD populations. Scientifically, we are especially challenged by biases in self-reported and proxy-reported pain scores, identifying valid outcome measures for treatment trials, being able to adequately power studies due to small sample sizes, and our inability to easily explore the underlying pain mechanisms due to compromised ability to self-report.

Conclusion:

Despite the critical challenges, new developments in research and knowledge translation activities in pain and IDD continue to emerge, and there are ongoing international collaborations.

Access to primary and community health-care services for people 16 years and over with intellectual disabilities: a mapping and targeted systematic review

Background

In 2015, approximately 2.16% of adults were recorded as having intellectual disabilities. UK government policy is that adults with intellectual disabilities should access mainstream health services. However, people with intellectual disabilities experience challenges when accessing primary and community health services that can lead to inequalities and shorter life expectancy.

Objectives

To map and review the evidence on access to primary and community health-care services for adults with intellectual disabilities and their carers. To identify influencing factors for gaining access to primary and community health-care services. To determine which actions, interventions or models of service provision improve entry access to these services for people with intellectual disabilities and their carers. Finally, to identify the gaps in evidence and provide implications for health care and recommendations for research.

Data sources

MEDLINE, The Cochrane Library, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Applied Social Sciences Index and Abstracts (ASSIA) and Education Resources Information Center (ERIC) were searched from 2002 to 2018.

Review methods

The mapping review methodology included an extensive literature search, article selection and data extraction of relevant abstracts. Findings from the mapping review informed the scope of the targeted systematic review. Methodology for the targeted systematic review included an extensive literature search informed by the mapping review, article selection, data extraction, quality appraisal and narrative synthesis.

Results

The mapping review included 413 studies with data extraction completed on abstracts. The targeted systematic review synthesised the evidence from 80 studies reported in 82 publications. During the review process, the team identified three key points at which people with intellectual disabilities potentially interacted with primary and community health-care services: identifying needs, accessing services and interaction during a consultation. In addition, there were a number of papers about interventions or innovations to improve access. Evidence from the studies was synthesised within the four clusters. Influencing factors were identified: staff knowledge/skills, joint working with learning disability services, service delivery model, uptake, appointment making, carer/support role, relationship with staff, time, accessible information and communication. The influencing factors were cross-cutting through the literature, with certain factors having more importance in certain clusters.

Limitations

The main limitation was the weak evidence base. The studies generally had small samples, had study designs that were open to potential biases and measured only short-term outcomes.

Conclusions

Health checks were found to help identify health needs and improve the care of long-term conditions. Important factors for accessing health services for adults with intellectual disabilities were consistency of care and support, staff training, communication skills and time to communicate, and provision of accessible information. Health professionals need to ensure that there is joint working between different services, clear communication and accurate record-keeping. Future research questions centre on the need to develop and value creative study designs capable of addressing the complex issues identified in the findings of the review for this complex population.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 5. See the NIHR Journals Library website for further project information.

Understanding pain physiology and its application to person with intellectual disability

The issue of pain warrants attention as, by virtue of having an intellectual disability, a person may have associated medical or physical conditions and associated factors increasing their risk of pain disorders. People with intellectual disability experiencing pain need to be provided with the best possible care. The focus of this article is on the exploration of pain: physiology and types; manifestations and responses in the context of intellectual disability in order to promote effective, knowledgeable assessment and management of pain for this client group. Pain is a subjective, complex, physiological and psychological phenomenon that can be acute or chronic and may be classified according to its cause. Within the experience of pain, the concept of total pain describes the physical, psychological, social and spiritual factors that influence the experience of pain.

Self-Reported Presence and Experience of Pain in Adults with Down Syndrome

Objective

The aim was to examine whether the presence of pain (based on physical conditions and participants' report) and self-reported pain experience in adults with Down syndrome (DS) differ from general population controls.

Design

Cross-sectional study of 224 adults with DS (mean age = 38.1 years, mild-severe intellectual disabilities) and 142 age-matched controls (median age = 40.5 years, mean estimated IQ = 105.7) in the Netherlands.

Methods

File-based medical information was evaluated. Self-reported presence and experience of pain were assessed in rest and after movement during a test session (affect with facial affective scale (FAS: 0.04-0.97), intensity assessed with numeric rating scale (NRS: 0-10).

Results

Compared with controls, more DS participants had physical conditions that may cause pain and/or discomfort ( p  = .004, 50% vs 35%), but fewer DS participants reported pain during the test session ( p  = .003, 58% vs 73%). Of the participants who indicated pain and comprehended self-reporting scales ( n  = 198 FAS, n  = 161 NRS), the DS group reported a higher pain affect and intensity than the controls ( p  < .001, FAS: 0.75-0.85 vs 0.50-0.59, NRS: 6.00-7.94 vs 2.00-3.73).

Conclusions

Not all adults with DS and painful/discomforting physical conditions reported pain. Those who did indicated a higher pain experience than adults from the general population. Research into spontaneous self-report of pain, repeated pain assessment, and acute pain is needed in people with DS for more insight into pain experience and mismatches between self-report and medical information.

Assessing quality of life in Welsh carers with and without back pain

BACKGROUND

The author aimed to study the prevalence and characteristics of care provision in Welsh adults with and without back pain, as well as their quality of life. The study used a country-wide and population-based setting from an independent dataset.

METHOD

Data were retrieved from and analysed in the Welsh Health Survey 2013. Information on demographics, lifestyle factors, regular care provision, and quality of life was obtained from household interviews. Chi-square tests, t-tests, and survey-weighted multinomial regression modelling were performed.

RESULTS

Of 15,007 Welsh adults aged 16 years and above, 2751 (18.3%) reported they had been caring for a sick, disabled, or frail person. The carers tended to be between 40-74 years, female, had not obtained a bachelor's degree, with a body mass index>25, physically active, smokers, and living in indoor secondhand smoke households. People who lived in mid and western Wales tended to give care, compared with those who lived in southeast and north Wales. Carers with back pain experienced slight physical health and emotional problems, whereas carers without back pain experienced worse physical health and emotional problems, which could disrupt normal life.

CONCLUSION

Nearly one in five Welsh adults, with or without back pain, have provided care for other people. Future socioeconomic structure, health policy, and nursing programmes to reinvest in long-term care, such as a national psychiatric care initiative, should be encouraged, to lessen mental suffering alongside chronic pains and to optimise adult mental health and quality of life in all people, with or without back pain.