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The purpose of this paper is to discuss the challenges of assessment and management of psychotic symptoms in a background of intellectual disability (ID) and treatment-resistant epilepsy caused by a genetic syndrome.

Ring chromosome 20 [r(20)] syndrome is characterised by the triad of severe refractory epilepsy, mild to severe ID and behavioural problems. This paper describes the presentation of r(20) syndrome in a young woman with moderate ID and treatment-resistant epilepsy, who experiences psychotic symptoms at times of improved seizure control.

There are several diagnostic possibilities for such a presentation, including psychotic symptoms due to adverse effects of anti-epileptic medications and forced normalisation (alternating psychosis).

This paper advocates judicious use of antipsychotic medication to manage psychotic symptoms, as well as involvement of both patient and close family members throughout all stages of care. It is essential to strike a balance between control of epileptic seizures and psychiatric symptoms, providing an optimal benefit to the patients’ quality of life by meeting their complex needs through a multidisciplinary and multi-agency team input.

People with learning disabilities have high dependency needs and high prevalence of physical, psychological and social morbidities. Some studies have shown that South Asian and white populations have a similar prevalence of learning disabilities and related psychological morbidity (McGrother et al, 2002), although other studies have shown an increased prevalence of severe levels of learning disabilities in the South Asian population (Emerson et al, 1997). The aim of this study was to compare stress levels and unmet service needs in informal carers of South Asian and white adults with learning disabilities.A sample of 742 informal carers was selected from the Leicestershire Learning Disability Register. Data on carers' and subjects' demographic details, stress levels and unmet service needs were analysed and compared using chi‐square tests and logistic regression analyses. Substantial differences were observed between the two groups. Carers of South Asian adults with learning disabilities reported significantly higher levels of care provision and unmet needs. Major stress was reported in 23% of carers. This was more common in carers with poor health, in those caring for younger adults, carers of adults with psychological symptoms, and in those with an expressed need for moral support or respite care.Stress is common among informal carers of adults with learning disabilities and inequalities, in reported care given and unmet needs, exist between carers of South Asian and white adults. Practitioners need to be aware of factors associated with stress when assessing carers in this population.

The Royal College of Psychiatrists set up an interface group to look at the interface between old age psychiatry and learning disability and, as part of its work, the group commissioned a survey of learning disability and old age psychiatrists to investigate their experience of working across the boundary between the two specialities. This paper is based on the report produced. It summarises the findings of the survey and sets out eight recommendations to further the work. There was no clarity on how services should be provided to older people with a learning disability who develop a mental health problem in later life but the need for collaboration between the two specialities is compelling.

The prevalence rate of arson in offenders with intellectual disabilities (ID) has been reported to be higher than that in the general population. This retrospective study focuses on examining the characteristics of offenders with ID and the range of identified reasons for the index offence. The findings indicate a higher prevalence of arson in this population, along with the fact that the majority of people with ID who have committed arson tend to bypass the Criminal Justice System. A significant number are likely to repeat the behaviour and will also commit other offences. The most common reason for arson appears to be revenge, closely followed by suggestibility. The majority had an associated diagnosis of personality disorders along with an Axis 1 psychiatric diagnosis. Other factors include large family size, history of childhood psychiatric disorders, abuse, homelessness, unemployment and relationship difficulties.

Needs led person centred services are the hallmark of high quality intellectual disability services. Commissioning mechanisms such as Payment by Results (PbR) have been established in acute health services. An outcome focussed version of PbR will be implemented nationally from 2012 in an incremental manner in mental health services for adults and older people. Though intellectual disability services are currently excluded, it is proposed that needs led approaches would improve the quality and efficiency of specialist intellectual disability services. This paper aims to suggest that this approach could be the key to commissioning and designing personalised pathways of care.

Health needs are scoped and care pathways are defined as primarily consisting of Needs, Interventions and Outcomes. The mandated cluster groups to be used for PbR in adult mental health and older people's services are extended to cover the non overlapping needs of people with intellectual disability to provide an integrated framework of health needs usually met by specialist services. A framework of interventions is suggested and components of “assessment” and “therapeutic” activities are outlined. An outcome framework is described. A case example illustrates the application of these components to design a care pathway to provide a personalised, needs led service.

It is possible to use the principles underlying PbR to commission personalised services of high quality, improved efficiency and thus greater value.

The principles underlying PbR can be used to commission personalised pathways of care in intellectual disability services at a time when this approach is being extended to mental health services nationally.

The purpose of this paper is to identify psychotropic medication being prescribed for people with intellectual disability “as and when required” (PRN); the indications, frequency of use, rate of poly-pharmacy and contribution of PRN medication towards this. The paper also aimed to identify individual and environmental factors associated with PRN medication prescribing.

Data were collected from nursing and medical records for the 119 service users in the acute assessment and treatment unit and NHS residential care settings managed by specialist intellectual disability services covering Leicester, Leicestershire and Rutland over a month period. Data were analysed using descriptive statistics and logistic regression to calculate adjusted odds ratios for predictor variables.

In total, 72 per cent of the service users were prescribed and 25 per cent were administered PRN medication over the study period. The most common indications for PRN prescribing were aggression and agitation. Lorazepam and chlorpromazine were the most frequently prescribed PRN medications. The rate of poly-pharmacy was 41 and 38 per cent of this was attributable to PRN medication. Male gender and history of challenging behaviour were found to be significant factors associated with PRN medication prescribing.

PRN medications are commonly prescribed in people with intellectual disabilities and contribute to poly-pharmacy. Whilst PRN medication continues to remain an effective therapeutic option in situations where environmental and behavioural approaches are proving insufficient, their use should always be in conjunction with effective review mechanisms.

The diagnosis and management of cancer in people with intellectual disabilities (PWIDs) are fraught with difficulties. The purpose of this paper is to present a case study to highlight these difficulties.

The present case analysis describes the presentation of a 56-year-old man with a profound intellectual disability, who developed recurrent chest infections and died as a result of obstructive pneumonitis.

Despite a presentation over several years and numerous chest X-rays demonstrating a consistent lung abnormality, it was only on postmortem examination that a right-sided lung carcinoma was detected.

The papers have provided an update on the topic in light of recent legislations and management strategies which need to be applied to clinical practice if any improvement is to happen in the care of PWID.

The aim of the project was to evaluate the short‐term treatment outcomes of patients treated in a medium secure service for people with intellectual disability. A total of 138 patients, 77 discharged and 61 current inpatients, treated over a six‐year period were included in the audit. Information on demographic and clinical variables was collected on a pre‐designed data collection tool and analysed using appropriate statistical methods. The median length of stay for the discharged group was 2.8 years. About 90% of this group were discharged to lower levels of security and about a third went directly to community placements. None of the clinical and forensic factors examined was significantly associated with length of stay for this group. There was a ‘difficult to discharge long‐stay’ group which had more patients with criminal sections, restriction orders, history of abuse, fire setting, personality disorders and substance misuse. However, when regression analysis was done, most of these factors were not predictive of the length of stay. Clinical diagnosis or offending behaviour categories are poor predictors of length of hospital stay, and there is a need to identify empirically derived patient clusters using a variety of clinical and forensic variables. Common datasets and multi‐centre audits are needed to drive this.