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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!