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Learning_Disabilities

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									Learning Disabilities
Dr Muhammad Iqbal FRCPsych
    Consultant Psychiatrist
            SEPT
        20.09.2011
  Learning Disabilities
 Definition/Classification
 Physical Health of pwLD
 Mental Health of pwLD
 Consent to Treatment
  (Capacity Assessment)
 Use medication for challenging behaviour
 Specific Disorders, e.g. Autism
                Definition/
           Definition
 Statistical
 Mean IQ of the general population is 100
 Standard deviation is 15
 Below two standard deviations from mean
 A person with an IQ below 70
  Classification
 Mild
     Below 2 SD from Mean (<70)
 Moderate
     Below 3 SD from Mean (<55)
 Severe
     Below 4 SD from Mean (<40)
 Profound
     Below 5 SD from Mean (<25)
  Causes of LD
 Mild   to moderate
     Pathology is not always identified


 Severe    to profound
     Brain damage
     Identified syndromes
  Learning Disabilities
 LearningDifficulties
 Mental Retardation


 Older   terms
     Imbecile, idiot, feeble minded,
      morally defective, mental handicap
  Abilities
 Mild   (<70)
     Good communication
 Moderate       (<55)
     Communication affected
 Sever   (<40)
     Minimum communication
 Profound   (<25)
     No communication
       Mild Learning Disabilities
 IQ  70-60
 Good verbal communication
 May look ordinary/ normal
 May have a voluntary/paid job
 May Read & Write
 Social skills
 relationship
 Level of Support
 IQ   60—70
     Supported/ voluntary job
     Can live on their own with support
     24 hour care if other additional disabilities


 IQ   below 55
     24 hour care
 Assessments
 Psychology
 Speech and Language
 Occupational Therapy
                Morbidity pwLD
 Higher    incidence of
     Mental Illness
       • All kinds
     Epilepsy
     Autistic Spectrum Disorder
     Challenging Behaviours
     Genetic disorders
     Physical Illness
HEALTHCARE for ALL
   Independent Inquiry
             By
   Sir Jonathan Michael
         July 2008
  Context
 Mencap     Reports:
     ‘Treat me Right’
     ‘Death by Indifference’


 Disability   Rights Commission:
     ‘Equal Treatment’
     ‘Closing the Gap’
  NHS failing pwLD
 ‘equal’   does not mean ‘same’

 ‘reasonableadjustments’
  to make services equally accessible
             Prevalence of LD
 Vary   reflecting diff in definition

 3%   children and 2% adults
     1.2 million Mild to Moderate
     210,000 severe to profound

 DoH    estimates:
     1.5 million = 2.5 % of UK pop
       GP with 2000 patients
 44 mild to moderate
 6 with severe LD
              Health of pwLD 1
 58   times more likely to die b 50

 1/3   have an ass. physical disability
     Cerebral Palsy
        • Postural deformities,
        • Chest infection
        • Eating & swallowing prblems
             Health of pwLD 2
 Osteoporosis  earlier, fractures
 Epilepsy 20 times
 SUDEP higher in children w LD


 Mental    ill health more common
     Schizophrenia 3 times
 Health    Risks
     Opportunities for life style & diet
          Health of pwLD 3
 More  difficult to identify & describe
  symptoms of illness
 Much harder to navigate the health system
  to receive treatment

 More difficult for NHS professionals to
 deliver treatment effectively
          Health of pwLD 4
 Lifeexpectancy shortest for those with
  greatest support needs
 Behaviour disturbance & disability were
  better predictors of low volume & poor
  quality primary care
 Worse for pwLD from ethnic minority
            Health of pwLD 5
 Healthreview of 181 pwLD found a new
 health need in over half
     Diabetes, Asthma
     Hypertension
     High cholesterol
     Thyroid disorders
     Dental problems
     Cardiac difficulties
     Mental health problems
         Health of pwLD 6
 The inquiry believes that the findings on
 health needs, unmet needs, & variation in
 health outcome for pwLD strongly imply
 that in addition to avoidable morbidity,
 there are deaths occurring which could be
 avoided
            Health of pwLD 7
 Less   likely to be given pain relief
     Symptoms of pain attributed to LD
 Less likely to receive palliative care
 ‘GP had not seen for 20 yrs but issued
  regular prescriptions’
 ‘40 y old pwLD with chest pain sent back
  from A/E, then died of heart attack’
              Health of pwLD 8
 Diagnostic     overshadowing:
     Tendency to attribute symptoms & behaviours
      associated with illness to LD, and for illness to
      be overlooked (e.g. pain/ distress
      communicated through behaviour, screaming,
      biting)

     Widespread
     Inquiry was very concerned
       • ‘must be addressed urgently’
           Health of pwLD 9
 Family members complained that the staff
 suggested the pwLD should be allowed ‘to
 slip away’ rather than resuscitated or
 treated
               Summary
 High  levels of unmet health needs
 pwLD receive less effective care
 Particular problems on transition from
  children’s to adult services
 Significant level of avoidable suffering due
  to untreated ill health
 Avoidable deaths are occurring
       The Legal Framework
   The Disability Discrimination Act
   The Mental Capacity Act
   The Carers Act
        Mental Health of pwLD
 Increased   rates of mental disorders
     Psychosis
     Affective disorders
     Anxiety and phobias
     Challenging behaviours
        Presentation of Psychosis
   Depends on level of Functioning

 Schizophrenia
 Paranoid Psychosis
 Psychosis NOS


       Frightened/ Paranoid
       Bizarre/ disturbed behaviour
       Agitated/ aggressive
       Auditory/ Visual hallucinations
      Presentation of Hypomania
 Depends    on level of Functioning

 Usual symptoms with IQ 70-65
 Biological symptoms only e lower IQ
     Aggression
 May   be very tricky
     Autism
     excitement
   Presentation of Depression
 Depends    on level of Functioning

 Usual symptoms with IQ 70-60
 Biological symptoms only e lower IQ


 Usually   not difficult
        Challenging Behaviours
 Any   stress may lead to
     Agitation
     Aggression


 bio-psycho-social   assessment
     Mental/ Physical Illnesses
     Changes in Routine/ Environment
     Wound up
Inappropriate Sexual Behaviour
 May   be a problem in some Autistics

 Expression    of sexual needs
     May be appropriate e IQ 70-60
     May be none for lower IQ


 Vulnerable   behaviour
      Mental Capacity Act 2005
 Came   into force in 2007
 Affects 16+
 To protect people who lack capacity
     Dementia
     Learning Disabilities
     Mental Health problems
     Stroke
     Head injuries
          Mental Capacity Act
 Five   key principles:
     Presumption of capacity
     Support to make their own decisions
     Unwise decisions
     Best interests
     Least restrictive option
          Mental Capacity Act
A   person lacks capacity if unable:
    To understand the info relevant to the
     decision
    To retain that information
    To use or weigh that information as part of the
     process of making the decision
    To communicate the decision by any means
           Mental Capacity Act
 Assessing     lack of capacity
     ‘decision specific’
     ‘time specific’
           Mental Capacity Act
 Assessing     lack of capacity
     Information given in an appropriate way
       • Simple language
       • Visual aids


     The information may be retained for a short
      period, but long enough to make the decision
           Mental Capacity Act
 Independent      Mental Capacity Advocate
 (IMCA)
     Appointed to support a person who lacks
      capacity but has no one to speak for them.
       • Serious medical treatment
       • accomodation
   Using Medication to
   Manage Behaviour
Problems in Adults with LD
                 Definition
 ‘’ Socially unacceptable Behaviour that
  causes distress, harm or disadvantage to
  the person themselves or to other people
  or property, and usually require some
  intervention. ’’

 Challenging   Behaviour, Behaviour
  Disorder.
Examples of Problem Behaviour
 Verbal Aggression
 Physical Aggression to Self (SIB)
 Physical Aggression to Others or Property
 ? Inappropriate Sexual Behaviour
       General Principles for Rx
 Assessment      and Formulation:
     Primary aim to find out underlying cause of
      the Behaviour and manage that.
     Minimise the impact of B (self, others,
      environment)
     Many factors: Internal & External
     Multi-axial formulation
     Formulation even if No psychiatric diagnosis
       General Principles for Rx
 Assessment     and Formulation:

     British Psychological Society’s (BPS)
      guidelines on the Management of Challenging
      Behaviour

     Challenging Behaviour: a unified approach
      (06) RCPsych & BPS
       General Principles for Rx
 Input   from Person, Families, Carers
     Input from the person with LD
       • Appropriate methods for communication
     Families & Carers

     At every stage of the management
      General Principles for Rx
 When    to consider medication:
     Non-medication management considered
     Medication alone or an adjunct
     Talking therapies
     Environmental changes


         circumstances (and Risk
 Individual
 Assessment)
       General Principles for Rx
 Medication:
     Lowest possible dose
     Minimum duration
     Withdrawal of medication considered at
      reviews
THANK YOU!

								
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