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Badger S, Watkins LV, Bassett P, Roy A, Eyeoyibo M, Sawhney I, Purandare K, Wood L, Pugh A, Hammett J, Sheehan R, Tromans S, Shankar R. The relationship between clinical presentation and the nature of care in adults with intellectual disability and epilepsy - national comparative cohort study. BJPsych Open 2024; 10:e94. [PMID: 38686441 PMCID: PMC11060072 DOI: 10.1192/bjo.2024.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND A quarter of People with Intellectual Disabilities (PwID) have epilepsy compared with 1% of the general population. Epilepsy in PwID is a bellwether for premature mortality, multimorbidity and polypharmacy. This group depends on their care provider to give relevant information for management, especially epilepsy. There is no research on care status relationship and clinical characteristics of PwID and epilepsy. AIM Explore and compare the clinical characteristics of PwID with epilepsy across different care settings. METHOD A retrospective multicentre cohort study across England and Wales collected information on seizure characteristics, intellectual disability severity, neurodevelopmental/biological/psychiatric comorbidities, medication including psychotropics/anti-seizure medication, and care status. Clinical characteristics were compared across different care settings, and those aged over and younger than 40 years. RESULTS Of 618 adult PwID across six centres (male:female = 61%:39%), 338 (55%) received professional care whereas 258 (42%) lived with family. Significant differences between the care groups existed in intellectual disability severity (P = 0.01), autism presence (P < 0.001), challenging behaviour (P < 0.001) and comorbid physical conditions (P = 0.008). The two groups did not vary in intellectual disability severity/genetic conditions/seizure type and frequency/psychiatric disorders. The professional care cohort experienced increased polypharmacy (P < 0.001) and antipsychotic/psychotropic use (P < 0.001/P = 0.008).The over-40s cohort had lower autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) comorbidity (P < 0.001/P = 0.007), increased psychiatric comorbidity and challenging behaviour (P < 0.05), physical multimorbidity (P < 0.001), polypharmacy (P < 0.001) and antipsychotic use (P < 0.001) but reduced numbers of seizures (P = 0.007). CONCLUSION PwID and epilepsy over 40 years in professional care have more complex clinical characteristics, increased polypharmacy and antipsychotic prescribing but fewer seizures.
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Affiliation(s)
- Sarah Badger
- Cornwall Partnership NHS Foundation Trust, Truro, UK
| | - Lance V Watkins
- University of South Wales, Pontypridd, UK; Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK; and Swansea Bay University Health Board, Port Talbot, UK
| | | | - Ashok Roy
- Coventry and Warwickshire Partnership NHS Trust, Coventry, UK
| | | | - Indermeet Sawhney
- Hertfordshire Partnership University NHS Foundation Trust, St Albans, UK
| | - Kiran Purandare
- Central and Northwest London NHS Foundation Trust, London, UK
| | - Laurie Wood
- Swansea Bay University Health Board, Port Talbot, UK
| | - Andrea Pugh
- Swansea Bay University Health Board, Port Talbot, UK
| | | | - Rory Sheehan
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Samuel Tromans
- SAPPHIRE Group, Department of Population Health Sciences, University of Leicester, Leicester, UK; and Adult Learning Disability Service, Leicestershire Partnership NHS Trust, Leicester, UK
| | - Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Truro, UK; and Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
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Sun JJ, Watkins L, Henley W, Laugharne R, Angus-Leppan H, Sawhney I, Shahidi MM, Purandare K, Eyeoyibo M, Scheepers M, Lines G, Winterhalder R, Perera B, Hyams B, Ashby S, Shankar R. Mortality risk in adults with intellectual disabilities and epilepsy: an England and Wales case-control study. J Neurol 2023:10.1007/s00415-023-11701-6. [PMID: 37022478 PMCID: PMC10078066 DOI: 10.1007/s00415-023-11701-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/07/2023]
Abstract
BACKGROUND People with epilepsy (PWE) and people with intellectual disabilities (ID) both live shorter lives than the general population and both conditions increase the risk of death further. We aimed to measure associations between certain risk factors for death in PWE and ID. METHODS A retrospective case-control study was conducted in ten regions in England and Wales. Data were collected on PWE registered with secondary care ID and neurology services between 2017 and 2021. Prevalence rates of neurodevelopmental, psychiatric and medical diagnoses, seizure frequency, psychotropic and antiseizure medications (ASM) prescribed, and health activity (epilepsy reviews/risk assessments/care plans/compliance etc.) recorded were compared between the two groups. RESULTS 190 PWE and ID who died were compared with 910 living controls. People who died were less likely to have had an epilepsy risk assessment but had a greater prevalence of genetic conditions, older age, poor physical health, generalized tonic-clonic seizures, polypharmacy (not ASMs) and antipsychotic use. The multivariable logistic regression for risk of epilepsy-related death identified that age over 50, medical condition prevalence, antipsychotic medication use and the lack of an epilepsy review in the last 12 months as associated with increased risk of death. Reviews by psychiatrists in ID services was associated with a 72% reduction in the odds of death compared neurology services. CONCLUSIONS Polypharmacy and use of antipsychotics may be associated with death but not ASMs. Greater and closer monitoring by creating capable health communities may reduce the risk of death. ID services maybe more likely to provide this holistic approach.
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Affiliation(s)
- James J Sun
- Royal Free London NHS Foundation Trust, London, UK
| | - Lance Watkins
- Swansea Bay University Health Board, Port Talbot, UK
- University of South Wales, Pontypridd, UK
| | | | - Richard Laugharne
- Cornwall Partnership NHS Foundation Trust, Truro, UK
- University of Plymouth Peninsula School of Medicine, Truro, UK
| | | | - Indermeet Sawhney
- Hertfordshire Partnership University NHS Foundation Trust, St Albans, UK
| | | | - Kiran Purandare
- Central and North West London NHS Foundation Trust, London, UK
| | | | - Mark Scheepers
- Gloucestershire Health and Care NHS Foundation Trust, Gloucestershire Health and Care NHS Foundation Trust, Brockworth, UK
| | - Geraldine Lines
- Gloucestershire Health and Care NHS Foundation Trust, Gloucestershire Health and Care NHS Foundation Trust, Brockworth, UK
| | | | - Bhathika Perera
- Barnet, Enfield and Haringey Mental Health NHS Trust, London, UK
| | | | | | - Rohit Shankar
- Cornwall Partnership NHS Foundation Trust, Truro, UK.
- University of Plymouth Peninsula School of Medicine, Truro, UK.
- Chy Govenek, Threemilestone Industrial Estate, Highertown, Truro, TR4 9LD, Cornwall, UK.
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Paton C, Roy A, Purandare K, Rendora O, Barnes TRE. Prescribing antipsychotic medication for adults with intellectual disability: shared responsibilities between mental health services and primary care. BJPsych Bull 2022; 46:311-315. [PMID: 34308827 PMCID: PMC9813760 DOI: 10.1192/bjb.2021.72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
AIMS AND METHOD We conducted a secondary analysis of data from a Prescribing Observatory for Mental Health audit to assess the quality of requests from intellectual disability services to primary care for repeat prescriptions of antipsychotic medication. RESULTS Forty-six National Health Service Trusts submitted treatment data on 977 adults with intellectual disability, receiving antipsychotic medication for more than a year, for whom prescribing responsibility had been transferred to primary care. Therapeutic effects had been monitored in the past 6 months in 80% of cases with a documented communication indicating which service was responsible for this and 72% of those with no such communication. The respective proportions were 69% and 42% for side-effect monitoring, and 79% and 30% for considering reducing/stopping antipsychotic medication. CLINICAL IMPLICATIONS Where continuing antipsychotic medication is prescribed in primary care for people with intellectual disability, lack of guidance from secondary care regarding responsibilities for monitoring its effectiveness may be associated with inadequate review.
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Affiliation(s)
- Carol Paton
- Imperial College London, UK.,Royal College of Psychiatrists, UK
| | - Ashok Roy
- Coventry and Warwickshire Partnership NHS Trust, UK
| | - Kiran Purandare
- Imperial College London, UK.,Central and North West London NHS Foundation Trust, UK
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Watkins LV, Henley W, Sun JJ, Perera B, Angus-Leppan H, Sawhney I, Purandare K, Eyeoyibo M, Scheepers M, Lines G, Winterhalder R, Shankar R. Tackling increased risks in older adults with intellectual disability and epilepsy: data from a national multicentre cohort study. Seizure 2022; 101:15-21. [DOI: 10.1016/j.seizure.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 10/18/2022] Open
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Abraham J, Purandare K, McCabe J, Wijeratne A, Eggleston E, Oak K, Laugharne R, Roy A, Shankar R. An 8-year study of admissions and discharges to a specialist intellectual disability inpatient unit. J Appl Res Intellect Disabil 2021; 35:569-576. [PMID: 34931405 DOI: 10.1111/jar.12967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/28/2021] [Accepted: 11/19/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND In the United Kingdom, policy change has led to specialist intellectual disability inpatient bed reduction. Little evidence exists assessing the results for patients admitted to such units. This study evaluates the outcomes of a specialist intellectual disability inpatient unit. METHOD Gender/age/ethnicity/intellectual disability severity/co-morbid psychiatric/developmental disorders, treatment length and stay data were collected. The health of the nation outcome scales for people with learning disabilities (HoNOS-LD) scores at admission, treatment completion and discharge were recorded. Analysis of these multiple variables and correlations within different patient groups was investigated using various statistical tests. RESULTS Of 169/176 patients (2010-2018), admission to discharge, HoNOS-LD global and all individual items score decreased significantly, for all patient categories. Treatment completion to discharge duration was significant for the whole cohort. CONCLUSIONS This is the largest study of intellectual disability inpatient outcomes. Discharge from the hospital appears not associated with duration of treatment. Using HoNOS-LD to demonstrate treatment effectiveness is recommended.
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Affiliation(s)
- Julie Abraham
- University of Exeter Medical School, Royal Cornwall Hospital, Truro, Cornwall, UK
| | | | - Joanne McCabe
- University of Exeter Medical School, Royal Cornwall Hospital, Truro, Cornwall, UK
| | | | | | - Katy Oak
- Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall, UK
| | - Richard Laugharne
- Cornwall Intellectual Disability Epilepsy Research (CIDER), University of Plymouth Medical School, Truro, UK
| | - Ashok Roy
- Coventry and Warwickshire Partnership NHS Trust, Coventry, UK
| | - Rohit Shankar
- University of Exeter Medical School, Royal Cornwall Hospital, Truro, Cornwall, UK.,Cornwall Intellectual Disability Epilepsy Research (CIDER), University of Plymouth Medical School, Truro, UK
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Perera B, Laugharne R, Henley W, Zabel A, Lamb K, Branford D, Courtanay K, Alexander R, Purandare K, Wijeratne A, Radhakrishnan V, McNamara E, Daureeawoo Y, Sawhney I, Scheepers M, Taylor G, Shankar R. COVID-19 deaths in people with intellectual disability in the UK and Ireland: descriptive study. BJPsych Open 2020; 6:e123. [PMID: 33059790 PMCID: PMC7562776 DOI: 10.1192/bjo.2020.102] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/14/2020] [Accepted: 09/03/2020] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Rapid spread of coronavirus disease 2019 (COVID-19) has affected people with intellectual disability disproportionately. Existing data does not provide enough information to understand factors associated with increased deaths in those with intellectual disability. Establishing who is at high risk is important in developing prevention strategies, given risk factors or comorbidities in people with intellectual disability may be different to those in the general population. AIMS To identify comorbidities, demographic and clinical factors of those individuals with intellectual disability who have died from COVID-19. METHOD An observational descriptive case series looking at deaths because of COVID-19 in people with intellectual disability was conducted. Along with established risk factors observed in the general population, possible specific risk factors and comorbidities in people with intellectual disability for deaths related to COVID-19 were examined. Comparisons between mild and moderate-to-profound intellectual disability subcohorts were undertaken. RESULTS Data on 66 deaths in individuals with intellectual disability were analysed. This group was younger (mean age 64 years) compared with the age of death in the general population because of COVID-19. High rates of moderate-to-profound intellectual disability (n = 43), epilepsy (n = 29), mental illness (n = 29), dysphagia (n = 23), Down syndrome (n = 20) and dementia (n = 15) were observed. CONCLUSIONS This is the first study exploring associations between possible risk factors and comorbidities found in COVID-19 deaths in people with intellectual disability. Our data provides insight into possible factors for deaths in people with intellectual disability. Some of the factors varied between the mild and moderate-to-profound intellectual disability groups. This highlights an urgent need for further systemic inquiry and study of the possible cumulative impact of these factors and comorbidities given the possibility of COVID-19 resurgence.
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Affiliation(s)
| | - Richard Laugharne
- Cornwall Intellectual Disability and Epilepsy Research (CIDER) Centre, Cornwall Partnership Foundation NHS Trust, UK
| | | | - Abigail Zabel
- Cornwall Intellectual Disability and Epilepsy Research (CIDER) Centre, Cornwall Partnership Foundation NHS Trust, UK
| | - Kirsten Lamb
- Royal College General Practitioners special interest group for learning disability, UK
| | | | - Ken Courtanay
- Barnet Enfield and Haringey Mental Health NHS Trust, UK
| | - Regi Alexander
- Hertfordshire Partnership University NHS Foundation Trust, UK
| | | | | | | | - Eileen McNamara
- Barnet, Enfield and Haringey Mental Health trust, Barnet Learning Disability Team, UK
| | - Youshan Daureeawoo
- Barnet, Enfield and Haringey Mental Health trust, Barnet Learning Disability Team, UK
| | | | - Mark Scheepers
- Gloucestershire Health and Care NHS Foundation Trust, UK
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Perry BI, Cooray SE, Mendis J, Purandare K, Wijeratne A, Manjubhashini S, Dasari M, Esan F, Gunaratna I, Naseem RA, Hoare S, Chester V, Roy A, Devapriam J, Alexander R, Kwok HF. Problem behaviours and psychotropic medication use in intellectual disability: a multinational cross-sectional survey. J Intellect Disabil Res 2018; 62:140-149. [PMID: 29349928 DOI: 10.1111/jir.12471] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 11/06/2017] [Accepted: 12/15/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Problem behaviours (PBs) are a common cause for clinician contact in people with disorders of intellectual development and may be a common cause for the prescription of psychotropic medication. We aimed to use a large, multinational sample to define the prevalence of PBs, the associations with psychotropic medication use, and to assess for any potential 'diagnostic overshadowing' by the label of PBs in a population of people with disorders of intellectual development. METHOD A multinational, multi-setting, cross-sectional service evaluation and baseline audit was completed. Data were collected from UK hospitals, UK community settings, Sri Lanka and Hong Kong. A semi-structured questionnaire was completed by treating clinicians, capturing demographic details, prevalence rates of intellectual disability and psychotropic medication use, alongside psychiatric co-morbidity. RESULTS A sample size of 358 was obtained, with 65% of included participants treated in an inpatient setting. Psychotropic use was prevalent (90%) in our sample, particularly antipsychotics (74%). The prevalence of PB was high (83%). There was no statistically significant association between psychotropic prescription and recorded psychiatric co-morbidity, suggesting prevalent 'off-label' use for PBs, or poor recording of psychiatric co-morbidity. There was some evidence of possible diagnostic overshadowing due to the PB classification. A higher dose of psychotropic medication was associated with aggression toward others (P = 0.03). CONCLUSIONS We found evidence of prevalent potential 'off-label' use for psychotropic medication, which may be due to PBs. We also found evidence of potential diagnostic-overshadowing, where symptoms of psychiatric co-morbidity may have been attributed to PBs. Our findings provide renewed importance, across borders and health systems, for clinicians to consider a holistic approach to treating PBs, and attempting to best understand the precipitants and predisposing factors before psychotropic prescribing.
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Affiliation(s)
- B I Perry
- Division of Mental Health and Wellbeing, University of Warwick, Coventry, UK
- Coventry and Warwickshire Partnership NHS Trust, Coventry, UK
| | | | - J Mendis
- National Institute of Mental Health, Angoda, Sri Lanka
| | - K Purandare
- Central and North West London NHS Foundation Trust, London, UK
| | - A Wijeratne
- Central and North West London NHS Foundation Trust, London, UK
| | - S Manjubhashini
- South West London and St Georges Mental Health Foundation NHS Trust, London, UK
| | - M Dasari
- Humber NHS Foundation Trust, Driffield, UK
| | - F Esan
- Partnerships in Care, Diss, Diss, UK
| | | | | | - S Hoare
- Partnerships in Care, Diss, Diss, UK
| | - V Chester
- Partnerships in Care, Diss, Diss, UK
| | - A Roy
- Coventry and Warwickshire Partnership NHS Trust, Coventry, UK
| | - J Devapriam
- Leicestershire Partnership NHS Trust, Leicester, UK
| | | | - H F Kwok
- Faculty of Health Sciences, University of Macau, Zhuhai Shi, China
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Paton C, Bhatti S, Purandare K, Roy A, Barnes TRE. Quality of prescribing of antipsychotic medication for people with intellectual disability under the care of UK mental health services: a cross-sectional audit of clinical practice. BMJ Open 2016; 6:e013116. [PMID: 27920085 PMCID: PMC5168692 DOI: 10.1136/bmjopen-2016-013116] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To determine the prevalence and quality of antipsychotic prescribing for people with intellectual disability (ID). DESIGN A clinical audit of prescribing practice in the context of a quality improvement programme. Practice standards for audit were derived from relevant, evidence-based guidelines, including NICE. Data were mainly collected from the clinical records, but to determine the clinical rationale for using antipsychotic medication in individual cases, prescribers could also be directly questioned. SETTINGS 54 mental health services in the UK, which were predominantly NHS Trusts. PARTICIPANTS Information on prescribing was collected for 5654 people with ID. RESULTS Almost two-thirds (64%) of the total sample was prescribed antipsychotic medication, of whom almost half (49%) had a schizophrenia spectrum or affective disorder diagnosis, while a further third (36%) exhibited behaviours recognised by NICE as potentially legitimate targets for such treatment such as violence, aggression or self-injury. With respect to screening for potential side effects within the past year, 41% had a documented measure of body weight (range across participating services 18-100%), 32% blood pressure (0-100%) and 37% blood glucose and blood lipids (0-100%). CONCLUSIONS These data from mental health services across the UK suggest that antipsychotic medications are not widely used outside of licensed and/or evidence-based indications in people with ID. However, screening for side effects in those patients on continuing antipsychotic medication was inconsistent across the participating services and the possibility that a small number of these services failed to meet basic standards of care cannot be excluded.
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Affiliation(s)
| | - Sumera Bhatti
- Royal College of Psychiatrists Centre for Quality Improvement, London, UK
| | | | - Ashok Roy
- Coventry and Warwickshire Partnership Trust, Coventry, UK
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Gumber R, Gangavati S, Bhaumik S, Cooray S, Purandare K, Mendis J, Abeywickrema C. The WHO mhGAP Intervention Guide for people with intellectual disability: the Sri Lankan experience. BJPsych Int 2015. [DOI: 10.1192/s2056474000000805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In recognition of the treatment gap in mental health, the World Health Organization (WHO) Mental Health Gap Action Programme (mhGAP) was launched in 2008 and has proved successful. The paper describes the launch of the first mhGAP intellectual disabilities pilot project in Sri Lanka. It reports on the development of the materials and the key lessons learnt.
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