Sabyasachi Bhaumik

Body Mass Index in Adults with Intellectual Disability: Distribution, Associations and Service Implications--A Population-Based Prevalence Study.

BACKGROUND Previous studies of weight problems in adults with intellectual disability (ID) have generally been small or selective and given conflicting results. The objectives of our large-scale study were to identify inequalities in weight problems between adults with ID and the general adult population, and to investigate factors associated with obesity and underweight within the ID population. METHODS We undertook a population-based prevalence study of 1119 adults with ID aged 20 and over on the Leicestershire Learning Disability Register who participated in a programme of universal health checks and home interviews with their carers. We performed a cross-sectional analysis of the register data and compared the observed and expected prevalences of body mass index categories in the ID and general populations using indirect standardisation for age. We used logistic regression to evaluate the association of a range of probable demographic, physical, mental and skills attributes with obesity and underweight. RESULTS In those aged 25 and over, the standardised morbidity ratio (SMR) for obesity was 0.80 (95% CI 0.64-1.00) in men and 1.48 (95% CI 1.23-1.77) in women. The SMR for underweight was 8.44 (95% CI 6.52-10.82) in men and 2.35 (95% CI 1.72-3.19) in women. Among those aged 20 and over, crude prevalences were 20.7% for obesity, 28.0% for overweight, 32.7% for normal weight and 18.6% for underweight. Obesity was associated with living independently/with family, ability to feed/drink unaided, being female, hypertension, Down syndrome and the absence of cerebral palsy. Underweight was associated with younger age, absence of Down syndrome and not taking medication. CONCLUSION Obesity in women and underweight in both men and women was more common in adults with ID than in the general population after controlling for differences in the age distributions between the two populations. The associated factors suggest opportunities for targeting high-risk groups within the ID population for lifestyle and behaviour modification.

Epilepsy in adults with intellectual disabilities: prevalence, associations and service implications.

STATEMENT OF THE PROBLEM The prevalence of epilepsy in people with an intellectual disability (ID) is apparently higher than in the general population. The outlook for individuals with both epilepsy and ID depends on the presence of any associated conditions. However, there have been few epidemiological studies of the prevalence of epilepsy and associated problems within a representative adult ID population to inform the development of policy. METHOD This was a population-based prevalence study using the Leicestershire Learning Disability Register. Prevalence was estimated from the number of individuals with reported epilepsy identified from structured home interviews with carers. Associations with epilepsy were investigated for a range of defined physical, mental and skill attributes. Logistic regression was done with and without adjustment for age, sex and level of understanding to identify specific and holistic links respectively. RESULTS The prevalence of epilepsy was 26%. Among those with epilepsy, 68% experienced seizures despite anti-epileptic medication. Epilepsy showed a significant association with low levels of understanding. Specific morbid associations included wetting (adjusted odds ratio 2.7), soiling (2.2), walking (2.5), daily living skills (1.6), poor speech (2.2), lack of empathy (1.5), mood swings (1.5), being uncooperative (1.6), seeking attention (1.7) and disturbing others at night (1.9). Holistic associations included a wider range of physical and mental problems and global skills deficits. CONCLUSIONS The high prevalence, associated morbidities and global skills deficits make epilepsy care for adults with ID important and complex. Specialist epilepsy services for this population need a multidisciplinary skills mix.

Psychiatric service use and psychiatric disorders in adults with intellectual disability.

BACKGROUND UK policies aim to facilitate access to general psychiatric services for adults with intellectual disability (ID). If this is to be achieved, it is important to have a clear idea of the characteristics and proportion of people with ID who currently access specialist psychiatric services and the nature and extent of psychiatric disorders in this population. METHODS A cross-sectional study was carried out on all adults with ID using specialist services in Leicestershire and Rutland, UK, between 2001 and 2006. Characteristics of individuals seen by psychiatric services and the nature and prevalence of psychiatric disorders were investigated. RESULTS Of 2711 adults identified, 1244 (45.9%) accessed specialist psychiatric services at least once during the study period. Individuals attending psychiatric services were more likely to be older and to live in residential settings; they were less likely to be south Asian or to have mild/moderate ID. The prevalence of psychiatric disorders among the total study population was 33.8%; the most common disorders were behaviour disorder (19.8%) and autistic spectrum disorders (8.8%). Epilepsy was highly prevalent (60.8%) among those attending psychiatric services without a mental health diagnosis. Behaviour disorders and autistic spectrum disorders were more common in men and in adults with severe/profound ID, whereas schizophrenia and organic disorders were more common in women and in adults with mild/moderate ID. Depression was also more common in women with ID. CONCLUSIONS Psychiatric disorders and specialist health problems are common among adults with ID and the profile of psychiatric disorders differs from that found in general psychiatry. Close collaboration between general and specialist service providers is needed if the current move towards use of general psychiatric services in this population is to be achieved. The measures should include a clear care pathway for people with ID and mental health problems to facilitate the smooth transfer of patients between specialist and generic mental health services and arrangements for joint working where input from both services is required. The commissioning framework for such processes should be in place with appropriate pooling of resources.

Neuroleptics in the treatment of aggressive challenging behaviour for people with intellectual disabilities: a randomised controlled trial (NACHBID)

OBJECTIVE(S) To assess the effects and cost-effectiveness of haloperidol, risperidone and placebo on aggressive challenging behaviour in adults with intellectual disability. DESIGN A double-blind randomised controlled trial of two drugs and placebo administered in flexible dosage, with full, independent assessments of aggressive and aberrant behaviour, global improvement, carer burden, quality of life and adverse drug effects at baseline, 4, 12 and 26 weeks, and comparison of total care costs in the 6 months before and after randomisation. At 12 weeks, patients were given the option of leaving the trial or continuing until 26 weeks. Assessments of observed aggression were also carried out with key workers at weekly intervals throughout the trial. SETTING Patients were recruited from all those being treated by intellectual disability services in eight sites in England, one in Wales and one in Queensland, Australia. PARTICIPANTS Patients from all severity levels of intellectual disability; recruitment was extended to include those who may have been treated with neuroleptic drugs in the past. EXCLUSION CRITERIA treatment with depot neuroleptics/another form of injected neuroleptic medication within the last 3 months; continuous oral neuroleptic medication within the last week; those under a section of the Mental Health Act 1983 or Queensland Mental Health Act 2000. INTERVENTIONS Randomisation to treatment with haloperidol (a typical neuroleptic drug), risperidone (an atypical neuroleptic drug) or placebo using a permuted blocks procedure. Dosages were: haloperidol 1.25-5.0 mg daily; risperidone 0.5-2.0 mg daily. MAIN OUTCOME MEASURES Primary: reduction in aggressive episodes between baseline and 4 weeks using Modified Overt Aggression Scale. Secondary: Aberrant Behaviour Checklist; Uplift/Burden Scale; 40-item Quality of Life Questionnaire; Udvalg for Kliniske Undersøgelser scale; Clinical Global Impressions scale. Economic costs recorded using a modified version of Client Service Receipt Inventory for 6 months before and after randomisation. RESULTS There were considerable difficulties in recruitment because of ethical and consent doubts. Twenty-two clinicians recruited a total of 86 patients. Mean daily dosages were 1.07 mg rising to 1.78 mg for risperidone and 2.54 mg rising to 2.94 mg for haloperidol. Aggression declined dramatically with all three treatments by 4 weeks, with placebo showing the greatest reduction (79%, versus 57% for combined drugs) (p = 0.06). Placebo-treated patients showed no evidence of inferior response in comparison to patients receiving neuroleptic drugs. An additional study found that clinicians who had not participated in clinical trials before were less likely to recruit. Mean total cost of accommodation, services, informal care and treatment over the 6 months of the trial was 16,336 pounds for placebo, 17,626 pounds for haloperidol and 18,954 pounds for risperidone. CONCLUSIONS There were no significant important benefits conferred by treatment with risperidone or haloperidol, and treatment with these drugs was not cost-effective. While neuroleptic drugs may be of value in the treatment of aggressive behaviour in some patients with intellectual disability, the underlying pathology needs to be evaluated before these are given. The specific diagnostic indications for such treatment require further investigation. Prescription of low doses of neuroleptic drugs in intellectual disability on the grounds of greater responsiveness and greater liability to adverse effects also needs to be re-examined.

Nature and quality of antipsychotic prescribing practice in UK psychiatry of intellectual disability services

BACKGROUND Antipsychotics are perceived to be over-used in the management of behavioural problems in people with an intellectual disability (ID). Published guidelines have set good practice standards for the use of these drugs for behavioural indications. We sought to identify the range of indications for which antipsychotic drugs are prescribed in people with ID and to audit clinical practice against the standards. METHOD Data were collected from the clinical records of individuals with ID who were under the care of mental health services in the UK, and prescribed an antipsychotic drug. RESULTS The sample comprised 2319 patients from 39 clinical services. Twenty-seven per cent of the patients had a diagnosis of a psychotic illness (ICD-10 F20-29) and 27% an affective illness (ICD-10 F30-39). The proportion who did not have a psychiatric diagnosis ranged from 6% of those with borderline/mild ID to 21% of those with severe/profound ID. Overall, the most common indications for prescribing an antipsychotic drug were comorbid psychotic illness, anxiety and agitation, and a range of behavioural disturbances. The prevalence of use of antipsychotic drugs to manage challenging behaviour in the absence of concomitant mental illness increased with the severity of ID and accounted for almost half of prescriptions in those with severe/profound ID. Adherence to the audit standards related to documentation of clinical indications and review of efficacy was high. Side effect monitoring was less assiduous. CONCLUSIONS In clinical practice, most prescriptions for antipsychotic drugs in people with ID are consistent with the evidence base and the overall quality of prescribing practice, as measured against recognised standards, is good, although in some patients potentially remedial side effects may not be detected and treated.

Epilepsy in adults with learning disabilities

Epilepsy is a common problem of adults with learning disabilities. Despite the high prevalence there have been few studies of the epilepsy suffered by adults with learning disabilities. The findings of a Leicestershire study are that multiple seizure types are a common presentation, and that for many (75%) the seizures remain refractory to treatment. Those who suffer tonic-clonic seizures are most likely to achieve remission, whereas for those with simple or complex partial seizures the prognosis is poor. For a significant proportion, status epilepticus, emergency admission to hospital and injuries occur on a regular basis.

A naturalistic study of the use of vigabatrin, lamotrigine and gabapentin in adults with learning disabilities

Epilepsy is a common condition in people with learning disabilities with many patients continuing to suffer from seizures despite antiepileptic drug (AED) treatment. Although the advent of newer AEDs offers hope for better treatment, there is a need to compare the efficacy of each new AED in adults with both drug-resistant epilepsy and learning disabilities. This retrospective casenote study involves the analysis of the outcome for those adults with learning disabilities treated with either vigabatrin, lamotrigine or gabapentin. The information obtained from the casenote analysis was used to both compare the efficacies of the three drugs and also the side-effects and drop-out rates, including reasons for drop-out. The total number of patients involved was 51 who underwent 71 treatment episodes. All three AEDs had similar efficacies. Although vigabatrin was found to be associated with a higher incidence of behaviour problems, behaviour problems occurred with the other drugs as well. Lamotrigine caused increased seizures in 24% of patients, especially when prescribed at a higher dose. Gabapentin appeared to be associated with fewer serious side-effects.

Psychological treatments in intellectual disability: the challenges of building a good evidence base

Psychological treatments are widely used for the management of mental health and behavioural problems in people with intellectual disabilities. The evidence base, including the cost-effectiveness of such interventions, is limited. This editorial explores the current evidence base and analyses its strengths and limitations. The editorial also highlights current problems in conducting randomised controlled trials in this area and suggests a way forward.

Overcoming the barriers experienced in conducting a medication trial in adults with aggressive challenging behaviour and intellectual disabilities

BACKGROUND Aggressive challenging behaviour in people with intellectual disability (ID) is frequently treated with antipsychotic drugs, despite a limited evidence base. METHOD A multi-centre randomised controlled trial was undertaken to investigate the efficacy, adverse effects and costs of two commonly prescribed antipsychotic drugs (risperidone and haloperidol) and placebo. RESULTS The trial faced significant problems in recruitment. The intent was to recruit 120 patients over 2 years in three centres and to use a validated aggression scale (Modified Overt Aggression Scale) score as the primary outcome. Despite doubling the period of recruitment, only 86 patients were ultimately recruited. CONCLUSIONS Variation in beliefs over the efficacy of drug treatment, difficulties within multidisciplinary teams and perceived ethical concerns over medication trials in this population all contributed to poor recruitment. Where appropriate to the research question cluster randomised trials represent an ethically and logistically feasible alternative to individually randomised trials.

Brief report: Aggressive challenging behaviour in adults with intellectual disability following community resettlement

BACKGROUND Aggressive challenging behaviour is common in adults with intellectual disability (ID) in long-term care facilities. The governments commitment to the closure of all facilities in England has led to concerns over how to manage this behaviour in the community. The aim of this study was to assess changes in aggressive challenging behaviour and psychotropic drug use in adults with ID following resettlement using a person-centred approach. METHOD The Modified Overt Aggression Scale was administered to carers of 49 adults with ID prior to discharge from a long-stay hospital and 6 months and 1 year after community resettlement. RESULTS All areas of aggressive challenging behaviour reduced significantly between baseline and 6 months following resettlement (P < 0.001). This reduction remained (but did not decrease further) at 1-year follow-up. CONCLUSIONS Further work is needed to evaluate the role of environmental setting on aggressive challenging behaviour in adults with ID.