Transcript Learning Disabilities

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/
 Statistical
Definition
 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
 Learning
Difficulties
 Mental Retardation
 Older

terms
Imbecile, idiot, feeble minded,
morally defective, mental handicap
Abilities
 Mild

(<70)
Good communication
 Moderate

Communication affected
 Sever

(<40)
Minimum communication
 Profound

(<55)
(<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



Supported/ voluntary job
Can live on their own with support
24 hour care if other additional disabilities
 IQ

60—70
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’
 ‘reasonable
adjustments’
to make services equally accessible
Prevalence of LD
 Vary
 3%


children and 2% adults
1.2 million Mild to Moderate
210,000 severe to profound
 DoH

reflecting diff in definition
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

Schizophrenia 3 times
 Health

ill health more common
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
 Life
expectancy 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
 Health
review of 181 pwLD found a new
health need in over half


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
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

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



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Dementia
Learning Disabilities
Mental Health problems
Stroke
Head injuries
Mental Capacity Act
 Five
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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
Disorder.
Behaviour, Behaviour
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
 Individual
circumstances (and Risk
Assessment)
General Principles for Rx
 Medication:



Lowest possible dose
Minimum duration
Withdrawal of medication considered at
reviews
THANK YOU!