intellectual impairment Flashcards
learning disability
- “A learning disability is a reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life.”
- MENCAP
intellectual impairment
Intellectual disability involves problems with general mental abilities that affect functioning in two areas:
- Intellectual functioning (such as learning, problem solving, judgement, IQ – mild, moderate or severe)
- Adaptive functioning (activities of daily life such as communication and independent living)
intellectual disability prevalance
Intellectual disability affects about one percent of the population, and of those about 85% have mild intellectual disability.
- Males are more likely than females to be diagnosed with intellectual disability.
terms that can be used
Person with an intellectual impairment
People with a learning difficulty e.g. dyslexia
People with a learning disability
Developmental delay
terms which should not be used
Mentally retarded
Mentally handicapped
Intellectually disabled
Special needs
and learning disabled people - borderline
key way to refer to someone with intellectual impairment
PERSON…………with an intellectual impairment/disability
global terms in health and social care
- Person with additional care needs
- Person with additional support needs
- Person who requires special care – very broad – intellectual impairment, cancer, age
eugenics
A philosophical and social movement which sought to improve the human race
Stems from Darwin’s publication “The origin of species” and Mendel’s Laws
Developed by Francis Galton and Charles Davenport
Eugenic = Well Born
- 2 Types
- Positive encouraging those with “desirable traits” to reproduce more
- Negative - discouraging those with “undesirable traits” to reproduce less
Eugenics is USA
- Forced sterilization
- 50 States with > 60,000 disabled people sterilised
Eugenics in Nazi germany
July 1933
- “Law for the Prevention of Progeny with Hereditary Diseases. “
- Included: congenital feeble-mindedness (learning disability), schizophrenia (mental illness), manic depression (now bipolar), hereditary epilepsy, Huntington’s chorea, hereditary blindness, hereditary deafness, serious physical deformities.
1939-1941
- Aktion T4 Program
- 700,000 deaths Including those who had congenital defects and learning disability
lennox castle hospital
Opened in 1936
Considered “ahead of its time”
- Purpose built villas
1913 Mental Deficiency Act
- Allowed “special hospitals” to be built to prevent dilution of the gene pool
Cases
- People with learning disability – admitted and locked away as they were ‘corrected’
- Abusive behaviour evidence
- Deaths – mass graves possible
was lennox castle hospital a new concept
not a new concept
- Lunacy Act 1857 (Scotland)
- Asylums
- For ‘mad’ admissions
- Special Schools
- Take people with learning disabilities out of their family units
lennox castle hospital closure
Closed in 2002
- People with Learning Disability or Mental Incapacity were “locked up” hidden from the community
- Punishments were often given
- No choice in decisions made
- Chores
- Segregation of male / female
- Use of Paraldehyde – sedatives, clinical trial type work
2 sides – some positive experience – well supported and care
But, importantly positive change now
social and policy changes
relatively recent
The concept of normalisation, reinforced by legislation (Department of Health, 1990), led to closures of long-stay institutions
- Transfer of residents to smaller homes in the community with a change in emphasis and responsibility for care and support from health to social services.
60% of adults with a learning disability now live with their families.
- Also living longer – new challenge
vulnerable people
some people with intellectual impairment are not able to be cared for sufficiently in a family environment
- Need a specialised caring environment
- Need to ensure they are not abused – Winterbourne view case
ICIDH 1980
impairment Vs Disability
In the context of health experience an impairment is any loss or abnormality of psychological, physiological or anatomical structure or function. Impairment is considered to occur at the level of organ or system function.
Disability is concerned with functional performance or activity, affecting the whole person.
Disability: In the context of health experience a disability is any restriction or lack (resulting from an impairment) of ability to perform an activity in the manner or within the range considered normal for a human being
WHO
disability Vs impairment
Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions.
Impairment is a problem in body function or structure
WHO
activity limitation
is a difficulty encountered by an individual in executing a task or action
WHO
participation restriction
- problem experienced by an individual in involvement in life situations.
Social model of disability
- Disability is caused by the way society is organised, rather than by a person’s impairment or difference.
medical model of disability
- The medical model of disability says people are disabled by their impairments or differences.
- Under the medical model, these impairments or differences should be ‘fixed’ or changed by medical and other treatments,
social model for causing disablity limitations
society willing to overcome disability so no longer viewed as
- Social organization (for example, work practices, buildings or products) that takes little or no account of people who have impairments and / or
- social organization that creates segregated and second-rate provision (for example, segregated welfare provision, transport, employment, education and leisure facilities).
barriers to positive social model changes for disabiled
- Segregated social provision
- Inflexible organisational procedures and practices
- Inaccessible information
- Inaccessible buildings
- Inaccessible transport
- Negative cultural representations
- Very true historically – positive changes but still steps
4 times for causes of learning disability
- preconception
- pre-natal
- perinatal
- postnatal
preconception causes of learning disability
heredity - perinatal genotype
environmental - maternal health
pre-natal causes of learning disability
heredity - chromosomal, genetic
environmental - infection, maternal health, nutrition, toxic agents
perinatal causes of learning disability
environmental - prematurity, injury
postnatal causes of learning disability
hereditary - untreated genetic disorders (PKU)
environmental - infection, trauma, toxic agents, nutrition, sensory social deprivation
6 syndromes associated with learning disability
- Autistic Spectrum Disorders
- Down’s Syndrome
- Cerebral Palsy
- Fragile X Syndrome
- Prader Willi
- PKU
Not everyone with these syndromes will have a learning disability – 2 separate things
Down’s syndrome
A neurodevelopmental disorder of genetic origin affecting chromosome 21.
Causes
- Most commonly DS is due to a full trisomy of chromosome 21 (95%)
- Small number of cases is due to mosaicism (2-4%)
- Inherited chromosomal rearrangement involving chromosome 21 (2–4 %)
head and neck clinical features of Down’s syndrome
- Broad flat face
- Slanting eyes
- Short nose
- Epicanthic eye fold
- Flat back of head
- Atlantoaxial instability of neck – imp in position pts – need to support neck
DS causes (3)
- Most commonly DS is due to a full trisomy of chromosome 21 (95%)
- Small number of cases is due to mosaicism (2-4%)
- Inherited chromosomal rearrangement involving chromosome 21 (2–4 %)
DS prevalence
Occurs in every 1 in 700 births
- DS has been estimated to affect 41 725 people in England and Wales in the year 2011 (Wu and Morris, 2013).
People with DS are living for longer, reflected in the age distribution peaking at 40 years of age.
Antenatal screening and subsequent termination have resulted in the total number of live DS births decreasing
greatest risk factor for DS
The single greatest risk factor for DS is advanced maternal age
- Women over the age of 35 are more likely to have a child with DS with the risk continuing to increase with advancing age.
Despite this, the majority of children with DS are born to younger mothers as the total number of births in this group is greater (Olsen et al., 1996).
medical features of DS (9)
- Congenital Heart Defects
- Alzheimer’s Dementia
- Epilepsy
- Leukaemia
- Hearing impairment
- Coeliac Disease oral impact
- Diabetes Mellitus oral impact
- Thyroid Disease
- Intellectual Impairment
- Especially when they are young (epilepsy, leukaemia)*
- Evens out with age*
relationship between Down’s syndrom and periodontal disease (6 possible)
Oral hygiene – reduced possibly
Oral function – oral clearance after chewing maybe reduced
Impaired migration of gingival fibroblasts
Saliva – different composition
Periodontal pathogens
Immune system related factors – main argument
- Impaired neutrophil chemotaxis
- Upregulated production of inflammatory mediators (MMPs more)
Prader Willi syndrome
Chromosome 15
1 in 15,000 affected
- Constant desire to eat food
- Restricted Growth, leading to short stature
- Reduced Muscle Tone (hypotonia)
- Learning difficulties (but may have normal IQ)
- Lack of sexual development
- Behavioural problems, such as temper tantrums or stubbornness
cerebral palsy
1 in 400 affected
Neurological conditions that affect movement and co-ordination
- Muscle stiffness or floppiness (hypotonia)
- Muscle weakness
- Random and uncontrolled body movements
- Balance and co-ordination problems
Sub-types defined by movement, limbs affected or severity
DOES NOT NECESSARILY MEAN YOU HAVE A LEARNING DISABILITY
health and welfare of people with intellectual impairment
Move towards community care
- Multiple people involved Learning Disability Team
- games, musical therapy, acting, community feel
There are an estimated 210,000 people with severe and profound learning disabilities:
- Only 20% of adults with a learning disability are known to learning disability services
- 80% may not be getting the support they need and are entitled to – can be choice but can also be lack of access
learning disability team members
Medical doctor, psychiatry (mental illness higher), social work (finding housing etc), specialist nurse, occupational therapy, nutrition/dietician, SLT
sensory room in community centres for people with learning disabilty
can help stimulate severely disabled individuals that aren’t able to communicate
dental services should be provided in a way
- Recognises everyone as an individual
- Recognises that everyone has a right to participate in decisions that affect their lives
- Provides the amount of support necessary to enable everyday living, including adequate health care
(Clark and Vanek, 1984)
Links between the services – primary, secondary and tertiary care
4 types of barreri to oral healthcare
- User / Carer
- Professional Service Providers
- Physical Barriers
- Cultural Issues
access - primary care
- Benefits of primary care access
- Learning disability is more common in families of a lower socioeconomic status
- Finance is an issue – transport can be issue to higher levels care
- Diet, culture impacts on oral health
- Proximity
- financial, work, transport for person +/- carer
- Relationships may already be established
- Good for person with learning disability to have continuous care from one professional
- Family members may attend practice
- See a family as a whole – more welcoming environment
- Longitudinal care - Prevention and Follow up
- Equal opportunity to services
special care dentistry
specialist services
- Blend of services necessary
- Primary – community clinics
- Secondary and tertiary – units in hospitals
- Risk of neglect of care if mainstreaming
- Referral
- Complex cases = SCD
- Mild and moderate – primary care
Advice – always an open door policy
idea of shared care of pt
- Most complex seen in specialist services
- Downstream to primary care - mild and moderate complexity of cases
Model made for dentistry (specifically special care dentistry)
tips for getting person with learning disability into the surgery
Can be overwhelming for pt and HCP at first appointment so preparation is key
- Preparation
- Information gathering
- Social stories (Autism)
- Pictorial – prepares the person before appointment
- Hospital / Health Passport
- Pre-visit (Scout the place out)
- Multiple visits with slow progress
- Liaise with Community Disability Nurse / Team for help
when pt with learning disability arrives
- Timing of appointment for you and the patient
- Start of a session – not running late
- Give yourself time – allow extra for appointments for explanation etc
- Best time of the day for the patient (missing activity / routine / best mood / medications)
- Take patient straight into the surgery
- Limit time spent in the waiting room
communication principles for someone with learning disability
- Respect and Equality
- Never make assumptions
- Can the person communicate verbally?
- Sometimes speech can be difficult to hear / understand
- Don’t be afraid to say “sorry didn’t understand that can you repeat it for me, it’s me it’s my hearing I couldn’t quite tune into you”
- Can the person communicate verbally?
- If non-verbal communication Ask if and How they communicate
verbal communication points for soemeone with learning disability
6
- Speak naturally and clearly
- Ask to repeat the information if you don’t understand.
- Ask questions that can be answered “yes” or “no” if possible.
- Repeat them as may get different answers – understand their level of the understanding
- Don’t lead patient responses
- Allow enough time to communicate with your patient as they may speak more slowly.
- Don’t interrupt or finish your patient’s sentences – wait for them to finish.
- Repeat the question if they don’t understand
6 possible adjuncts to communication
- Makaton – translators
- Picture Boards
- Letter Boards
- Talking Mats – not for consent
- Draw
- Write
how you can aid create the right response from someone with learning disability
6
- Non-threatening environment
- Friendly
- Acclimatise – multiple visits
- Consider augementive techniques
- relaxation, music
- Can be fun
- Singing, laughing
- But don’t lose control
first visit thoughts for pt with learning disaibilty
- What can you find out before the visit?
- Keep it simple
- Don’t expect too much – dentist and pt
- Building trust and relationships
- For the most severely disabled if you manage to see inside the mouth you are doing very well!
examination aids for pt with learning disability
Access to the mouth
- Bedi shield – prop mouth open, can fracture (like thimble)
- Open wide Mouth rests – place in horizontal plane and rotate into vertical plane – open wider and rest
Toothbrush
Mirror
Good light
Head support – ask consent
medical history points for someone with a learning disability
diagnosis? The unknown, no firm diagnosis often
Medical conditions:
- Epilepsy and its control
- Psychiatric Conditions
- Congenital defects in other systems – Down’s Syndrome and Congenital Heart Defects
Liaise with colleagues
- May need hospital level support
social history points for someone with intellectual impairment
- Living arrangements
- Support
- Transport
- Likes/dislikes
capacity considerations
- Assess
- Principles
- What can they understand and comprehend
- What about retention
- Each decision is specific
- POA, WG (more likely), NR
treatment planning considerations for someone with intellectual impairment
- Individual
- Co-operation
- Holistic
- Oral health – risk factors
The complexity of treatment provided may be influenced by the severity of the learning disability
- Realistic
risk factors for OH in individuals with intellectural impairment
- Poor motor control
- Imbrication of teeth – crowding, cross over – food trap
- Lack of cleansing
- Pouching (food sit in buccal sulcus for long times – substrate for bacteria) and limited food clearance
- Cervical caries risk
- Mouth breathing -> reduced saliva
- Xerostomia -> Caries, periodontal
- Medications
- Rewarding – less common
prevention for individuals with intellectutal impairment
Essential
What prevention can I use?
- Toothpastes – taste / foaming / swallowing / eating
- Flavourless, dysphasia issue with foam, risks of level of F
- Toothbrushes
- Electronic Vs manual
- What works for their individual circumstance?
- Do they need assistance?
- We are there to support and empower not to take over
- Electronic Vs manual
tooth brushing advice for individuals with intellectual impairment and their carers
- Explain first
- Good time of day / night– pattern
- Wear gloves
- Stand behind the person, slightly to one side.
- May vary according to what is comfortable for the client and carer
- Adapted toothbrush? – modify for easier grip, colours for areas ASD
- Keep brushing systematic
- Encourage the person to do as much as possible
self injurious behaviour
- Self-biting of hands, arms, lips, and tongue.
self-injurious behaviour can be linked to (6)
- Cerebral Palsy
- Autism
- Tourettes
- Lesch-Nyan Syndrome – tempted to self-harm
- Profound neuro-disability
- Exaggerated or abnormal oral reflex, habit, pain and/or frustration.
8 treatment strategies for self-injurious behaviour
- Symptomatic relief – pain analgesia
- Reassurance for patients, parents and carers with monitoring of the situation
- Distraction when self-injurious behaviour is observed – when it occurs it is self-reinforcing, needs challenged
- Pharmacological treatment e.g. Haloperidol, Diazepam and Carbamazepine not first line – changes the person
- Behavioural psychology such as positive reinforcement
- Construction of oral appliances – less common
- Extraction of specific anterior teeth, although this may transfer the self-injurious behaviour to another area of the mouth rather than resolve the behaviour e.g. remove canine as using to bite arm, sometimes work
- Orthognathic (jaw) surgery to create an open bite and prevent self-injurious biting extreme
drooling in individuals with intellectual impairment
rare to have increased formation, more impaired swallow and head position
Abnormalities in swallowing - rather than to absence of swallowing
Difficulties moving saliva to the back of the throat
- Poor mouth closure
- Jaw instability
- Tongue thrusting
- Head tilt forward
- Poor musculature control
5 possible causes of drooling
- Poor mouth closure
- Jaw instability
- Tongue thrusting
- Head tilt forward
- Poor musculature control
treatment planning for drooling management
- Techniques designed to improve posture should be implemented
- Treatment should be started with nonpharmacological and non-surgical methods
- There should be careful monitoring for oral complications if surgical or pharmacological treatment is carried out
bruxism/NCTSL treatment
- Construction of splints may be helpful, but their success is dependent on pt compliance
- An opinion should be sought from an appropriate dental specialist if required
causes of NCTSL (4)
- grinding
- reflux
- medications
- drinks
starts as change in behaviour e.g. if they are in pain - grind, pressure reassuring (ASD)
erosion advice
- Fluoride mouthwashes unless there are swallowing difficulties
- Toothpaste which is low in abrasion, low acidity, high-Fluoride and anti-hypersensitivity
- Brushing should be delayed for at least one hour after consuming acidic food or drink
- Professional application of fluoride varnish is advised
- Dentine bonding agents may be of value
- Referral to an appropriate dental specialist may be advised
- Reduce or eliminate intake of carbonated and acidic drinks and acidic fruits, or include as part of regular meal times
- Chew sugar-free gum, suck a sugar-free lozenge or eat cheese after an acidic meal
find out cause and try to deal with that
dry mouth advice
- Saliva replacements may be helpful
- The use of sugar-free chewing gum and sugar-free fluids is advised ( if possible?)
- The mouth should be examined regularly
- Fluoride rinses ( if possible?) or high fluoride containing toothpastes are advised
Referral to an appropriate dental specialist may be required
feeding problems advice
Individual assessment should be carried out
A multi professional approach is advised
- Good oral hygiene should be promoted
- More likely to aspirate – pneumonia risk – if mouth healthy then less likely to get a pneumonia
- An intensive regime should be followed to prevent oral disease
- A low foaming toothpaste is recommended (SLS free)
- more likely to aspirate, sensory issue
- The use of a suction toothbrush can be of benefit
- Therapy should be carried out to try and reduce oral defensiveness
diet alteraion in individuals with intellectual impairment
thickeners and tasters
Dysphagia – impaired swallow
- SLT will assess and prescribe
Thickening of food – prevent aspiration, easier to swallow
Nil by Mouth
- can still get tasters – honey, jam
- Still need to brush even if nil by mouth
treatment of individuals with intellectual impairment
LA considerations (4)
- Ability to co-operate
- Volume of treatment – regards level cooperation
- Type of treatment – is it realistic
- Behavioural techniques and patient management
aims of sedation
include reducing fear and anxiety, augmenting pain control, minimising movement and increasing safety
conscious sedation requires
Experienced practitioner, equipment and facilities:
- More flexible than GA
- Available in Primary Care / PDS
- Need for IV access
- Oral/ intranasal or IV route all need to get IV access
- Need to maintain airway – keep breathing
- Level of understanding necessary – consent
- Medical status
- ASA III needs to be seen in hospital for conscious sedation
benefits of concious sedation over GA
GA risk so do not want them to have to return in 5-8 years
- Sedation less risk - more likely to be able to give higher number of teeth chance that would’ve been extracted in GA
concious sedation can be done in primary care/PDS
indication for GA
A clear inability to co-operate with the provision of dental care, using other patient management techniques including sedation (or contraindications to the use of sedation).
2 requirements prior to GA
- Systematic assessment - Full History and Consent
- Ideally seen by the dentist who will perform GA
- Anaesthetist assessment prior to treatment session (pre-op)
admissions protocol for GA
- Day case – come in early in morning and are home by evening
what tx can be done under GA
Exam, X-rays, scale and polish, restorations, extractions
- Endodontic rare – unable to guarantee success so GA is risk
- No prosthodontics/Crown and bridges – will require repeated GA to fit it
post op GA
- medical issues in/out patient
- need to be seen in hospital unit with critical care unit as high risk?
- someone to look after them – next 24hours key
4 pros GA
- Comprehensive Care
- Potentially more controllable environment if medical diseases
- Opportunity for joint working
- even non HCP e.g. haircut
- Aftercare and monitoring – inpatient
8 cons GA
- Risk – death, brain damage
- Need support for 24hours post-op
- Organisation of procedure
- Complex restorative dental treatment not possible
- Teeth of dubious prognosis removed – reduce risk of future GA
- No improvement in coping mechanisms – GA pattern/dependent
- Difficult working environment
safeguarding and adult protection
spectrum of measures with the purposes of (2)
- Preventing harm and promoting welfare
- Protecting individuals from harm
role of dental practitioner in safeguarding
3 Rs
- Recognise – Being able to identify an adult at risk
- Respond – Manage the acute situation and inform other services as required
- Record – Document and report in detail the information obtained, and the actions taken
concers arise/disclosure made to practitioner what are the initial steps in management
- Remain calm and reassure the individual
- Seek further information – obtaining who, what, when, where and why?
- Record the information given
- Inform person of your next actions.
