Has teaching about intellectual disability healthcare in Australian medical schools improved? A 20-year comparison of curricula audits.

BACKGROUND: People with intellectual disability (ID) have multiple and complex health needs, more frequent healthcare episodes, and experience poorer health outcomes. Research conducted two decades ago showed that medical professionals were lacking in the knowledge and skills required to address the complex needs of this patient group. The aim of the current study was to determine whether Australian undergraduate medical schools that offer ID health education content had changed the amount and nature of such teaching over this period. METHODS: Identical or equivalent questionnaire items were compared across eight Australian medical schools that participated in curricula audits conducted in 1995 (referred to as T1) and 2013/14 (T2). The audits were of the nature of the ID content, methods used to teach it, and who taught it. RESULTS: There was no significant difference in the number of hours of compulsory ID content offered to medical students at T2 (total = 158.3 h; median = 2.8 h per ID unit) compared with T1 (total = 171 h; median = 2.5 h). At T2 compared with T1, units with ID content taught in the area of general practice had increased (2 units; 3.6% to 7 units; 16.3%), while decreases were seen in paediatrics (22 units; 40.0% to 10 units; 23.3%) and psychiatry (10 units; 18.2% to 4 units; 9.3%). The number of schools using problem- and/or enquiry-based learning rose to six at T2 from one at T1. Inclusive teaching practices (people with ID develop or deliver content) in compulsory/elective units had increased at T2 (10 units; 23.3%) compared with T1 (6 units; 10.9%), but direct clinical contact with people with ID had decreased (29 units; 52.7% to 11 units; 25.6%). CONCLUSIONS: Overall, little progress has been made to address the gaps in ID education for medical students identified from an audit conducted in 1995. Renewal of ID content in medical curricula is indicated as a key element in efforts to improve workforce capacity in this area and reduce barriers to care, with the aim of reversing the poor health outcomes currently seen for this group.

Intellectual disability content within tertiary medical curriculum: how is it taught and by whom?

BACKGROUND: Individuals with intellectual disability experience higher rates of physical and mental health conditions compared with the general population, yet have inequitable access to health care services. Improving the workplace capacity of medical professionals to meet the needs of this population is one way to reduce barriers to care and improve health outcomes. Using diverse pedagogy appropriate to learning outcomes to teach medical students about intellectual disability is a necessary step in improving future workplace capacity. However, there is a lack of research into how, and by whom, medical students are taught about intellectual disability. The aim of this study was to investigate this through an audit of Australian medical school curricula. METHODS: The Deans of Australian universities that provide accredited medical degrees (n = 20) were invited by email to participate in a two-phase audit of intellectual disability content in the curricula. Phase 1 (n = 14 schools) involved the Dean's delegate completing a telephone interview or questionnaire regarding medical course structure. If intellectual disability content was identified, a unit coordinator was invited to complete a survey regarding how this content was taught and by whom (Phase 2; n = 12 schools). RESULTS: There was considerable variability across Australian medical schools regarding methods used to teach content about intellectual disability. Didactic teaching methods were most frequently used (62% of units included some form of lecture), but workshops and tutorials were reasonably well represented (34% of units contained one or both). Thirty-six percent of units included two or more teaching methods. Almost all schools (83%) used some problem- and/or enquiry-based learning. Educator backgrounds included medicine, nursing, and allied health. A majority of schools (n = 9, 75%) involved people with intellectual disability designing and teaching content, but the extent to which this occurred was inconsistent. CONCLUSIONS: Renewing curricula around intellectual disability across all medical schools by introducing varied teaching methods and the inclusion of people with intellectual disability would assist students to develop knowledge, skills, attitudes, and confidence in intellectual disability health. Such renewal offers the potential to reduce barriers to service this population regularly face, thereby improving their health outcomes.

What effect does regular exercise have on oxidative stress in people with Down syndrome? A systematic review with meta-analyses.

OBJECTIVE: What effect does regular exercise have on oxidative stress in people with Down syndrome? DESIGN: Systematic review with meta-analyses. METHODS: A systematic review with meta-analyses was conducted. Six databases were searched from inception until August 2017. Studies where included if participants with Down syndrome (any age) had completed an exercise program of at least 6 weeks duration and at least one biomarker measured the generation or removal of reactive oxidative species. Data were extracted using a customised form. Risk of bias was assessed using the Cochrane Collaboration's Risk of Bias assessment tool. Effect sizes were calculated and meta-analyses completed for clinically homogeneous data using a random effects model. RESULTS: Seven studies (11 articles) involving 144 inactive participants investigated the effect of moderate intensity aerobic exercise. No pattern emerged for how most biomarkers responded with non-significant pooled effect sizes and high levels of heterogeneity observed. The exception was catalase which increased significantly after exercise (standardised mean difference 0.39, 95%CI 0.04-0.75; I2 15%). Available studies were at high risk of bias. Two of five studies that measured more than one biomarker reported a decrease in oxidative stress with increased antioxidant activity after exercise but the other three (including one small randomised controlled trial) reported increased oxidative stress with variable change in antioxidant activity. CONCLUSIONS: There remains uncertainty about the effect of exercise on oxidative stress in people with Down syndrome. REVIEW REGISTRATION: PROSPERO CRD42016048492.

Family caring of older adults with intellectual disability and coping according to loci of responsibility.

BACKGROUND: A complex interplay of factors is evident in the response of family caring for older adults with intellectual disability (ID). The aim of this study was to explore the interaction of these factors. METHODS: Quantitative data on health and wellbeing, and coping strategies were obtained for carers and their adult children with ID. Qualitative data were from three focus groups conducted with 19 main family carers. RESULTS: Carers varied in their health and wellbeing. Four overarching themes emerged from an initial interpretative phenomenological analysis of the qualitative data: loci of responsibility, impacts of caring and responses to it on health and wellbeing, transitioning care responsibilities, and interrelationships around the caring role. Further interrogation of data according to carers' coping strategies revealed three loci of responsibility, providing a point of convergence that related to carer experiences, plans for transition, and relationships within families. These loci of responsibility were having sole responsibility because there was no-one else, having sole responsibility because no-one could do it better, and sharing responsibility. CONCLUSION: The loci of responsibility provide a means to understand carers' appraisal of their role and the degree of control they have over it, and may account for varied coping strategies adopted.

Intellectual disability health content within medical curriculum: an audit of what our future doctors are taught.

BACKGROUND: There is a high burden of unmet health needs for people with intellectual disability. Despite experiencing significantly higher rates of morbidity and mortality compared with the general population, this group faces greater barriers to accessing healthcare. While increasing workplace capacity is one way to reduce this inequitable access, previous research indicates a scarcity of undergraduate teaching in intellectual disability. The aim of the study was to determine the extent and nature of intellectual disability content currently offered within medical degree curricula. METHODS: All Australian universities (n = 20) providing accredited medical training were invited to participate in a two-phase audit via an email invitation to the Dean of each medical school. The Dean's delegate from 14 medical schools completed Phase 1, which involved a questionnaire or telephone interview about the overall medical course structure. Unit coordinators and/or teaching staff from 12 medical schools completed Phase 2, which involved an online survey about intellectual disability content within the curriculum. RESULTS: In Australia, medical school curricula contain a median of 2.55 h of compulsory intellectual disability content. The majority of universities only offer a small amount of compulsory content. Of compulsory units, intellectual disability teaching is minimal in sexual health and emergency medicine (only one unit offered in one school for each). Topics of key relevance in intellectual disability health such as human rights issues, interdisciplinary team work and preventative health are poorly represented in intellectual disability teaching. Elective content varies markedly across universities (1 to 122 h), but emergency medicine, women's health, men's health and many other specialist medicine areas are not represented. Inclusive practice is inconsistent in degree and nature, but a majority of universities (nine) involve people with intellectual disability in the development or delivery of content. CONCLUSIONS: There is a mismatch between the considerable unmet health needs of people with intellectual disability and the inconsistent teaching within medical schools. Future doctors will be better equipped to support the health and wellbeing of people with intellectual disability if curricula are enhanced in this area.

Central nervous system medication use in older adults with intellectual disability: Results from the successful ageing in intellectual disability study.

OBJECTIVE: Information on the rates and predictors of polypharmacy of central nervous system medication in older people with intellectual disability is limited, despite the increased life expectancy of this group. This study examined central nervous system medication use in an older sample of people with intellectual disability. METHODS: Data regarding demographics, psychiatric diagnoses and current medications were collected as part of a larger survey completed by carers of people with intellectual disability over the age of 40 years. Recruitment occurred predominantly via disability services across different urban and rural locations in New South Wales and Victoria. Medications were coded according to the Monthly Index of Medical Specialties central nervous system medication categories, including sedatives/hypnotics, anti-anxiety agents, antipsychotics, antidepressants, central nervous system stimulants, movement disorder medications and anticonvulsants. The Developmental Behaviour Checklist for Adults was used to assess behaviour. RESULTS: Data were available for 114 people with intellectual disability. In all, 62.3% of the sample was prescribed a central nervous system medication, with 47.4% taking more than one. Of those who were medicated, 46.5% had a neurological diagnosis (a seizure disorder or Parkinson's disease) and 45.1% had a psychiatric diagnosis (an affective or psychotic disorder). Linear regression revealed that polypharmacy was predicted by the presence of neurological and psychiatric diagnosis, higher Developmental Behaviour Checklist for Adults scores and male gender. CONCLUSION: This study is the first to focus on central nervous system medication in an older sample with intellectual disability. The findings are in line with the wider literature in younger people, showing a high degree of prescription and polypharmacy. Within the sample, there seems to be adequate rationale for central nervous system medication prescription. Although these data do not indicate non-adherence to guidelines for prescribing in intellectual disability, the high rate of polypharmacy and its relationship to Developmental Behaviour Checklist for Adults scores reiterate the importance of continued medication review in older people with intellectual disability.

Training on intellectual disability in health sciences: the European perspective.

BACKGROUND: Intellectual disability (ID) has consequences at all stages of life, requires high service provision and leads to high health and societal costs. However, ID is largely disregarded as a health issue by national and international organisations, as are training in ID and in the health aspects of ID at every level of the education system. SPECIFIC AIM: This paper aims to (1) update the current information about availability of training and education in ID and related health issues in Europe with a particular focus in mental health; and (2) to identify opportunities arising from the initial process of educational harmonization in Europe to include ID contents in health sciences curricula and professional training. METHOD: We carried out a systematic search of scientific databases and websites, as well as policy and research reports from the European Commission, European Council and WHO. Furthermore, we contacted key international organisations related to health education and/or ID in Europe, as well as other regional institutions. RESULTS: ID modules and contents are minimal in the revised health sciences curricula and publications on ID training in Europe are equally scarce. European countries report few undergraduate and graduate training modules in ID, even in key specialties such as paediatrics. Within the health sector, ID programmes focus mainly on psychiatry and psychology. CONCLUSION: The poor availability of ID training in health sciences is a matter of concern. However, the current European policy on training provides an opportunity to promote ID in the curricula of programmes at all levels. This strategy should address all professionals working in ID and it should increase the focus on ID relative to other developmental disorders at all stages of life.

Maintenance electroconvulsive therapy for depression with catatonia in a young woman with Down syndrome.

OBJECTIVES: To describe and discuss the use of maintenance electroconvulsive therapy (ECT) in a young woman with Down syndrome and depression with catatonia. METHODS: Clinical case report. RESULTS: A 23-year-old woman with Down syndrome (mosaic type) and a 4-year history of depressed mood triggered by adverse life events presented with mutism, psychomotor retardation, and compromised oral intake. Multiple trials of antidepressant medications were either ineffective or complicated by adverse reactions. She improved rapidly with a course of bilateral ECT but required maintenance ECT to sustain recovery. A series of premorbid, morbid, and post-treatment drawings by the young woman highlight the efficacy of treatment. CONCLUSION: Electroconvulsive therapy was found to be a safe and effective treatment for life-threatening mental illness in a young woman with Down syndrome who had failed multiple trials of antidepressant medications. This case highlights the importance of considering catatonia as a diagnosis in persons with Down syndrome and the effectiveness of electroconvulsive treatment.

Experiences of supporting people with Down syndrome and Alzheimer's disease in aged care and family environments.

BACKGROUND: Research addressing the experiences of families of adults with Down syndrome and Alzheimer's disease in seeking diagnosis and gaining support is limited. The aim of this study was to gain a greater understanding of these processes by exploring the experiences of families and carers in supporting people with Down syndrome and Alzheimer's disease who had lived most or all of their lives with family. METHOD: Three detailed case studies were created from multiple data sources, and then analysed thematically. RESULTS: Families of adults with Down syndrome experienced stress and confusion as they negotiated a service system poorly equipped to meet their needs and professionals more focused on longstanding disability than the recent diagnosis of Alzheimer's disease. Such overshadowing led to mismanagement by services. CONCLUSIONS: This research advances understandings of the support needs of people with Down syndrome and Alzheimer's disease and their families. It exposes gaps in the service system.

Relationships amongst age, language and related skills in adults with Down syndrome.

Studies into the effects of ageing on language in adults with Down syndrome (DS) have tended to rely on measures that lack sensitivity to change because they fail to explore across linguistic domains or rely on proxy reports. The study aim was to use measures of receptive and expressive language from studies of younger individuals with DS in exploring relationships across linguistic and associated skills, and age in young to older adults. Fifty-five adults (aged 19-58 years), 10 with a diagnosis of or signs of early stage Alzheimer's Disease (AD), provided data on measures of functioning associated with AD, non-verbal cognition, receptive language (which provided a measure of mental age), receptive and expressive language, and short term auditory and visual memory. The first order correlation between the measure of AD and CA was significant; but not when the 10 participants with AD were removed from the analysis. Significant negative correlations were obtained between CA and all other measures; small to large significant positive correlations were found amongst the other measures. Partial correlations were conducted to remove the potential effects of AD and IQ (the latter measured by a test of non-verbal cognition). Remaining significant correlations were between auditory short term memory and all other included measures, expressive language and all other included measures, and CA and auditory short term memory and expressive language. The results indicate that deterioration with age in this cross-sectional study was accounted for largely by the presence of AD. The exceptions were for auditory short term memory and expressive language. The findings may reflect an underlying deficit in auditory short term memory for adults with DS, as has been found in previous research of children and adolescents. The implications are discussed in terms of the importance of including comprehensive measures of receptive and expressive language and the need to account for the presence of AD in studies of cognitive decline associated with ageing in DS.

International guide to prescribing psychotropic medication for the management of problem behaviours in adults with intellectual disabilities.

Psychotropic medications are used regularly to manage problem behaviours among people with intellectual disabilities. This causes concern because often these medications are used out of their licensed indications in this context. The WPA Section on Psychiatry of Intellectual Disability has recently developed an evidence and consensus-based international guide for practitioners for the use of psychotropic medications for problem behaviours among adults with intellectual disabilities. This guide advises on assessment of behaviours, producing a formulation, initiation of treatment, assessment of out-come and adverse effects, follow-up arrangements, and possibility of discontinuation of treatment.

Psychiatric care of adults with intellectual disabilities: changing perceptions over a decade.

OBJECTIVE: In light of developments in training and service provision, the aim of the present study was to compare two state-wide surveys, undertaken in 1994 and in 2004, of psychiatrists about their perceptions of their training and psychiatric treatment of adults with intellectual disabilities who also have mental health needs. METHODS: A 50-item self-administered questionnaire was developed for the 2004 survey, based on the 1994 study. This was sent to all 624 Fellows of the Royal Australian and New Zealand College of Psychiatry registered in Victoria at the time. A series of questions was asked based on workload, training, the role of psychiatry in intellectual disabilities, opinions on assessment and management, improving services, and the demographics of participant psychiatrists. Results of the 2004 survey are compared with the 1994 study. RESULTS: There has been some change in psychiatrists' opinions about acute admission wards, believing strongly that they do not meet the needs of the adults with severe intellectual disabilities, leaving them vulnerable to exploitation. There has been some improvement in their ability to adequately manage adults with intellectual disabilities who have mental health needs and/or problem behaviours. CONCLUSIONS: Mainstream mental health services fail to meet the needs of adults with intellectual disabilities. Improved specialist clinical services and more clinical training opportunities are required.

Ageing and mental health problems in people with intellectual disability.

PURPOSE OF REVIEW: Increasing numbers of people with intellectual disability are now living well into old age. This paper will review the recent literature pertaining to the mental health of older people with intellectual disability. RECENT FINDINGS: Overall, the prevalence of mental health problems is high in adults of all ages with intellectual disability. A major epidemiological study did not report sufficient detail to examine the effect of ageing on specific disorders or the differential effects of ageing and early mortality in people with Down's syndrome. At least a third of people with Down's syndrome can expect to develop Alzheimer's disease in middle age whilst for other people with intellectual disability, Alzheimer's disease is probably no more common than in the general population. Diagnosis and management of dementia is complicated by the high rates of comorbid physical and mental health problems. SUMMARY: Overall, mental health problems in older people with intellectual disability are similar to younger people with intellectual disability, however there are more cases of dementia and physical health problems. Further research is needed to improve our understanding of the effects of ageing on the mental health and care needs of older people with intellectual disability.