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Development of a clinic for adults with Down syndrome

Authors:

Abstract

In an effort to better support the adults with Down syndrome that it serves, parents from the National Association for Down Syndrome, a parent organization, worked with staff members from The Family Study and Service Program of the University Affiliated Program for Developmental Disabilities of the University of Illinois and the Department of Family Practice of Lutheran General Hospital to develop a clinic for adults with Down syndrome. The clinic was developed to provide comprehensive health care with an emphasis on preventative services. The multidisciplinary approach of the clinic has proved to be effective in the management of a variety of patient care needs. The most common health problems found were discussed.
Mental Retardation Vol.32, No. 2, 100-106 April 1994
Development of a Clinic for Adults
With Down Syndrome
Brian Chicoine, Dennis McGuire, Sheila Hebein, and Donna Gilly
Abstract: In an effort to better support the adults with Down syndrome that it
serves, parents from the National Association for Down Syndrome, a parent
organization, worked with staff members from The Family Study and Service
program of the University Affiliated Program for Developmental Disabilities of
the University of Illinois and the Department of Family Practice of Lutheran
General Hospital to develop a clinic for adults with Down syndrome. The clinic
was developed to provide comprehensive health care with an emphasis on pre-
ventative services. The multidisciplinary approach of the clinic has proved to
be effective in the management of a variety of patient care needs. The most
common health problems found were discussed.
In January of 1992, the Lutheran General Adult Down Syndrome Clinic opened
and served its first patient. The opening came after several years of effort to improve the
delivery of health care and supportive psychological and social (psychosocial) services
for adults with Down syndrome. The development of the clinic came primarily at the
urging of parents representing the National Association for Down syndrome (NADS). In
the present article we have discussed the development and operation of the clinic and
described the services provided. This information can serve as a model for others who are
seeking to provide care for adults with Down syndrome. We hope that it will also
encourage those who want to expand the services they provide to this patient population.
The NADS is a parent-driven advocacy organization that has been providing
support services to individuals with Down syndrome and their families in the Chicago
metropolitan area for over 30 years. Although the parents who belong to this association
have been able to effectively help parents of children with Down syndrome, they have
been frustrated by the limited availability of resources for adults with this syndrome.
Until the 1960s, adults with Down syndrome primarily lived in large institutions
(Cooley & Graham, 1991; Merker & Wernsing, 1984). Consequently, health care and
sup-portive services were viewed as a matter for institutions. However, during the past 20
to 30 years, more children with Down Syndrome have been raised by their parents, and
now the majority of adults with Down syndrome live in the community, either with their
families or in residential programs (Thomas, 1986). Many parents of sons and daughters
with Down syndrome living in the community called on NADS to help them locate
comprehensive health care and supportive services for their children. The organization
responded by identifying individual resources within the medical community to whom
they could refer adults with Down syndrome.
In addition, NADS surveyed its members regarding the needs of adolescents and
adults with Down syndrome and their families regarding psychosocial issues (National
Association,1989) and health care (National Association,1990). The survey was included
in an issue of the Association's newsletter, which is distributed to members and sent to
1,200 addresses; approximately 400 of these members are parents of adults with Down
syndrome. Sixty-five responses were returned, all from the Chicago metropolitan area
and, presumably, all from parents of a person with Down syndrome.
Regarding health care, parents expressed a number of needs, including health care
availability and health screening. They were interested in obtaining regular physical
exams and other health screening tests for their sons and daughters with Down syndrome
to warn them of problems at an early stage or reassure them that certain findings are
normal and/or did not need treatment.
Respondents also expressed the need for a physician knowledgeable in the
treatment of adults with Down syndrome who would, therefore, be aware of problems
(e.g., hypothyroidism) that occur more frequently in this population (Pueschel &Pezzullo,
1985) and less frequently (e.g., hypertension) (Pueschel & Pueschel, 1992). They were
also concerned about the transition from pediatric to adult medicine. Although it may
have been reassuring that their son or daughter had been cared for by the same physician
for years, a physician who was knowledgeable about developmental disabilities, parents
still expressed some concerns. The adults with Down syndrome and their parents were
not comfortable seeing a physician whose office was clearly for children. The parents felt
that many pediatricians were unfamiliar with questions addressing the unique needs of
adults with Down syndrome.
Financial issues were another concern for both parents and physicians. Parents
found it difficult to find a physician who would accept Medicare or Medicaid patients.
Some pediatricians were unfamiliar with Medicare regulations as few of their patients
require such funding.
Second, surveys of the psychosocial issues and concerns of NADS members
showed that families were very concerned about the absence of viable social and job
opportunities once their sons and daughters transitioned out of the school system into
adult life. Some families reported that loneliness, withdrawal, depression, and weight
management problems were frequent responses to this transition. They also reported
verbal and nonverbal expressions of frustration and even despair among their adult sons
and daughters, particularly when comparing their limited range of opportunities to
siblings and others without developmental disabilities. Further, some families reported
enormous difficulty locating mental health professionals with either the interest or
experience to help ameliorate the painful or debilitating symptoms of this transition.
Three years prior to the opening of the Lutheran General clinic, the NADS Board
responded to these issues and concerns by funding a fellowship that would provide
clinical and consultation services for families with adults who had Down syndrome. The
services were provided by the Family Study and Service Program (hereafter called the
Family Program), a clinical program of the Illinois University Affiliated Program in
Developmental Disabilities at the University of Illinois at Chicago to serve the needs of
individual families, to define and document areas of general concern, and to assist in the
development of and advocacy for more responsive social programs. Combining the
support and advocacy network of NADS with the resources and experiences of the Family
Program staff in both the clinical and developmental disabilities fields allowed a unique
partnership that successfully increased the service options available to families of adult
members. Since its inception, hundreds of families have been served directly by Family
Program staff or through a network of service providers who were trained or identified by
NADS and Family Program staff as knowledgeable and sensitive to the unique needs and
concerns of adults with Down syndrome.
A review of the problems seen by personnel of the Family Program suggested that
medical illnesses could be related to at least some of the psychosocial problems
encountered. That possibility and a review of the survey information made it clear to
NADS staff that a comprehensive clinic for adults with Down syndrome was needed, and
they asked Lutheran General Hospital to develop such a clinic. In 1990, the hospital's
Department of Family Practice accepted that challenge.
The availability of training for physicians in the care of adults with Down
syndrome is limited. Therefore, the medical directorship was assigned to a member of the
faculty of the Department of Family Practice (the first author) who had interest in and
experience in caring for adults with developmental disabilities. Extensive review of the
literature and regular conference attendance has increased the director's understanding of
the care of adults with Down syndrome.
The next step in the development of this comprehensive health care clinic was for
the medical director to review the aforementioned concerns of NADS members and the
findings of the staff of the Family Program and then meet with their representatives to
discuss a means for creating the clinic. The medical director was then asked to join the
Adult Issues Committee of NADS, which included the Family Program fellow. This
provided a forum for open discussion and eventual implementation of the Lutheran
General Adult Down Syndrome Clinic.
One of the most important aspects of the clinic development, both to date and in
the future, is the association with NADS. Input from NADS on patient questionnaire
forms, research efforts, feedback from families, and many other operational and
philosophical issues has helped keep the program focused on the needs of the patients and
families and how to implement them. The input into this article by the third author, the
executive director of NADS, reflects the regular input into the functioning of the clinic.
In addition, the efforts of NADS members to inform the community abut the clinic are
important. Forty-seven percent of the first 115 patients were NADS referrals. Table 1
lists the sources of all referrals.
Table 1
Referral Source of the first 115 patients Seen at
the Lutheran General Adult Syndrome Clinic Source
NADS 54
Clinic activities/publicity 24
Community agencies 18
University Affiliated Program 7
Physician 5
Other 7
National Association for Down Syndrome. Includes
lectures at local meetings attended by community
agencies and parents, advertising, and articles in hos-
pital publications. Referrals came from the second
author.
Cooperation with the patient primary care physician is also important. Although
referral from physicians has not been a source of a large number of patients to date (see
Table 1), follow-up with the primary physician on certain problems is important. This is
especially true for patients who travel a great distance.
The key, again, to implementation of the recommendations was listening to the
perceived needs as described by NADS and focusing on provision of those services,
which helped (a) prevent duplication of services available to patients in their local areas
and (b) keep down costs. In addition, it required discussions with multiple departments
inside and outside of the hospital system describing the needs and development of a
system to provide for them. For example, rather than trying to hold the clinic in the
limited space near the hearing booth in audiology, the Audiology Department agreed to
send an audiologist to the Family Practice Center with a portable hearing machine for
hearing screening.
A major hurdle was cleared through the joint efforts of Family Program and
NADS, which has continued to fund the fellowship at the Family Program (the position
held by the second author). As a social worker with both clinical skills in counseling and
knowledge of the available social support networks, he is an important element of the
clinic services.
Recruitment of members of the audiology and nutrition departments who had
experience working with children and adults with a variety of developmental and/or
chronic health problems was also important. Nursing personnel were sought who had a
strong outpatient clinical background and a desire to serve the needs of patients, families,
and other care providers. Extensive experience with adults who have Down syndrome,
although desirable, was not mandatory. Good candidates were found for all the positions
within the hospital system. In choosing candidates', the clinic director focused on the
candidates' desire to serve the patients and their willingness to continue to learn and
develop new ways to provide services.
The Lutheran General Adult Down Syndrome Clinic which opened in January
1992, incorporates the principles of a multidisciplinary approach to comprehensive
medical care with an emphasis on preventive medicine and psychosocial adaptation. The
clinic was designed to compliment the existing services provided by primarily care
physicians and other service providers in the community.
The initial contact with the clinic is through a phone call taken by a certified
medical assistant in the Family Practice Department. The needs of the adult with Down
syndrome are discussed with the family member or the care provider and appropriate
appointments are scheduled. An information packet is then mailed that includes a detailed
clinic description, a medical and social questionnaire, and a release of records form to
obtain previous medical data. After the returned information is reviewed by the clinic
director, an effort is made to help the patient and his or her family or caregiver decide
whether other consultations, lab tests, or x -rays will be necessary on the day of the clinic
visit so appropriate appointments can be made. Further discussion and decisions
regarding additional tests and consultations are made on the day the of the clinic visit.
The medical director evaluates each patient by reviewing the complete medical
history and completing a physical examination. This information is recorded on forms
tailored for adults with Down syndrome. Comprehensive care is provided, including
pelvic exam and PAP smear, immunization update, and other minor procedures as
necessary.
Each patient is then evaluated by the Family Program social worker, who assesses
relevant psychosocial issues and concerns. Information is gathered directly from the
patients and from accompanying family members or agency staff. This information
includes the personal resources, skills, and attributes of the adult with Down syndrome;
the availability of economic, educational, and recreational resources in the community;
and the network of family, peers, and community supports. Assessment instruments
include the Checklist for Psycho-social Concerns, which is administered in a structured
interview with a family member or caregiver and the patient. This interview is an
adaptation of the diagnostic criteria for depression and other potential problem areas
taken from the Diagnostic and Statistical Manual of Mental Disorders--DSM-III-R
(American Psychiatric Association, 1987) by the second author. It is suited to the unique
needs and expressive limitations of adults with Down syndrome. A standardized
instrument, the Developmental Diagnostic Profile, is also used to assess adaptive and
living skills (Brown et al., 1986). When administered during yearly clinic visits, this
Profile is useful in assessing strengths in independent living skills. Changes in these
living skills would indicate the need to evaluate for the possibility of early onset aging or
dementia processes, both of which have been hypothesized to occur in this population,
and to evaluate for reversible causes of the decline in skills.
An audiologist performs an audiogram for each patient and a nutritionist makes
dietary recommendations. A modified version of the Down Syndrome Checklist
(Ohio/Western, 1992) is used. Therefore, each patient has as a minimum the following
labs: complete blood count, chemistry profile, thyroid uptake, and thyroxine
and thyroid stimulatory hormone levels. Cervical spine x-rays are obtained if they have
never been done or if the history or physical exam indicates a need for this procedure.
Consultants in a variety of specialties are available.
The patient sees each health care provider on the same day at the clinic, and a
brief verbal summary of the findings is provided to the patient and parents or caregiver. A
written report documenting the findings and the recommendations for care, further
consultation, additional testing, and follow-up is also provided. This includes a summary
of the psychosocial evaluation detailing strengths, resources, problem areas, gaps in
programs or services, and recommendations. This report is sent to the parent or caregiver,
the primary physician, and other pertinent care providers. Follow-up clinic visits are
available for further consultation with the clinic staff as needed.
At the end of the first 18 months, 115 patients had been served in the clinic. Many
patients have been seen for routine physical exams with an emphasis on prevention and
early detection of health problems. The most common problems encountered are outlined
in Table 2.
Table 2
Most Common Health problems of first patients
of the Lutheran General Adults Down Syndrome
Center (N=115)
Health problem n
Xeroderma 112
Cerumen 79
Tinea pedis 72
Impaired vision 68
Obesity 65
Onychomycoses 59
Impaired hearing 58
Follicultis 48
Hypothyroidism 40
Strabismus 36
Hypercholoesterolemia 37
Depression 34
Seborrhea 20
Note: January 1992-July 1993.
The clinic has also been used as a referral source, particularly by NADS,
community service agencies, and local residential facilities, for problems that have been
difficult to diagnose or treat. These organizations have been the source of a number of
referrals of adults with Down syndrome whose intellectual and functional capabilities
seemed to have diminished. The effectiveness of the multidisiplinary approach of the
clinic is well-demonstrated with this type of problem or concern. The patients presented
with decreased self-care, loss of skills in activities of daily living, loss of verbal skills,
loss of job skills, withdrawal, slow down in activity level, paranoid features, increase in
talking to themselves, aggressive behavior, self-abuse, change in sleep patterns, weight
change, and/or persistent forgetfulness. The diagnoses of 48 patients presenting with
decreased level of function are shown in table 3. In addition, because Alzheimer's disease
is felt to occur more frequently and at a younger age in some individuals with Down
syndrome (Dalton & Crapper-McLachlan, 1986; Wisniewski, Rabe, & Wisniewski, 1987;
Zigman, Schupf, Lubin, & Silverman, 1987), often the family or caregiver expressed
concern that this was the cause of the diminishing skills. Although the population seen at
the clinic to date has been fairly young (average age of 34 years), the etiology for the
lower functioning has been found to be a diagnosis other than Alzheimer disease in
almost all cases to date.
In addition, numerous patients have been seen who are healthy, well-adjusted, and
living productive lives. The multidisiplinary approach of the clinic has provided a great
deal of insight into these individuals as well. Some patients expressed a need to discuss
the stress of daily life or assistance in finding suitable programs.
Table 3
Diagnoses of Patients (N=48) Presenting With
Diminished Skills
Diagnosis n
Depression 34
Adjustment reaction 13
Hypothyroidism 12
Dementia 2
Anxiety 2
Other__________________________________
Note: Some patients had more than one problem contributing
to the decline, and, therefore, the sum of the diagnoses is greater
than 48.
Includes one each of alcoholism, seizure disorder, hyperthyroidism,
severe vision impairment, recurrent lung infections, menopause, severe
nonsurgically corrected congenital heart disease, possible sexual
abuse, and sinus infection.
In response to psychosocial needs, services have been provided and coordinated
between NADS, the Family program, and Lutheran General Hospital. Support groups led
by a social worker focus on social, employment, and educational issues and provide an
opportunity for adults with Down syndrome and other developmental disabilities to share
concerns and to understand and appreciate normal and healthy aspects of their
personalities. In addition, groups have addressed weight awareness issues. An exercise
videotape has been produced featuring a physician and a nurse leading four young adults
with Down syndrome in an exercise program, and an exercise class is currently being
developed.
When problems arise, a variety of approaches are used. A growing network of
contacts with community service organizations is being developed to assist in provision
of employment training and placement, home medical care, and respite care. Employment
issues are frequently a part of psychosocial problems. In addition, extensive discussions
with families or residential facility care providers, home visits by the medical director and
social worker, and assessments and appropriate referral to family therapists is provided.
Support groups for families are also available, as is an extensive support network through
NADS. Involvement with and evaluation of the home situation, whether it be the family
or residential care facility, has been important in understanding potential areas of conflict
and resources within the home setting that can be useful in problem resolution. Assistance
with residential placement has been provided when appropriate and desired by directing
individuals to appropriate community agencies and providing assistance in negotiating
the system. When placement is appropriate and desired, further evaluation of the home
setting and referral for additional assistance is sought to optimize the setting until
placement is available.
The clinic is held twice a week, and up to 4 patients are seen in each session. Each
patient spends between 3 and 4 hours at the clinic. Although the cost varies depending on
the needs of the patient, the basic care as outlined is billed as approximately $350 to $450
and has been covered by Medicare, Medicaid, and the private insurance.
The costs of the clinic include several areas. Salaries and benefits for the physician
and staff and office space are primarily provided by the Department of Family Practice.
Physician services are billed in the standard fashion as are lab and X-ray. Audiology and
nutrition services are also directly billed services. The social work services are generally
not reimbursed and, therefore, are provided free-of-charge with the assistance of funds
provided by NADS. Although only about 50% of the expenses are covered with gross
revenues, further expenses are covered through the assistance of NADS, the Lutheran
General Foundation, and as charitable services provided by the Lutheran General Health
System.
A patient satisfaction survey is sent to each family or care provider after the clinic
visit. Approximately one-half have been returned. The responses to date have been
predominately appreciative of having medical services tailored to the needs of adults with
Down syndrome. Recommendations have been made and acted on regarding improving
some areas of the clinic process. Another area of change based on the survey responses
has been expanding availability of follow-up at the clinic. The original NADS survey
suggested that people were looking for a clinic primarily to get an annual exam and not
for ongoing care. Their intent was to continue ongoing care with their own physician.
However, the patient satisfaction survey and discussions with families and care providers
revealed that many were interested in on-going services. The needs were particularly
centered on follow-up with the social worker and /or the physician. Therefore, the clinic
was expanded to include these services. In addition, both the medical director and the
social worker continue to serve on the Adult Issues committee of NADS and regularly
seek input from the committee.
Research is an important part of the clinic services. Defining optimal care of adults
with Down syndrome and evaluating its effectiveness has not been as thoroughly studied
as it has with children who have Down syndrome (Thomas, 1986). A database of the
associated health problems and the medical and psychosocial history is being compiled.
An ongoing evaluation is also being conducted on the services of the clinic, the health
care needs of adults with Down syndrome, and the effectiveness of the care provided.
The clinic also includes community education for adults with Down syndrome,
their families, and other caregivers. Several talks have been provided by clinic staff for
local organizations and residential facilities. In addition, the clinic serves an educational
function for physicians, clinicians, and other providers in the community and for residents
and medical students in the medical center. This is provided both by lecture and direct
involvement by residents and students in the clinic.
A young woman with Down syndrome was recently hired to perform data entry and
secretarial services for the clinic. She not only directly provides an important service to
the clinic but also indirectly contributes to the educational component by demonstrating
to the local community and others some of the range of skills that adults with Down
syndrome can achieve.
After a direct request from and working closely with NADS, the Lutheran General
Adult Down Syndrome Clinic was developed to better serve adults with Down syndrome.
This population has the same basic health needs as the general population as well as some
special ones; the clinic is a model to meet all of these. In addition, research in these areas
is limited and, therefore, investigations will be undertaken through the clinic to evaluate
health care and psychosocial needs. The clinic will also serve as a source of information
for adults with Down syndrome and their families. practicing physicians-in-training, and
others in the health care fields. The clinic is more than a model for providing good health
care for adults with Down syndrome and for meeting these other goals. We hope that this
information on the clinic will also provide a catalyst for further discussion on how to
optimize the health care of adults with Down syndrome.
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Received 4/ 30/ 93; accepted 11/9/93.
Editor-in -Charge: Naomi Karp
Authors: BRIAN CHICOINE, MD, Medical
Director; DONNA GILLY, CMA, Lutheran General
Adult Down Syndrome Center, Department of Family
Practice, Lutheran General Hospital, 1775 Ballard Rd.,
Park Ridge, IL 60068. DENNIS McGUIRE, PhD,
Coordinator of Family Support Services, Family
Studies and Services Unit, University Affiliated
Program in Developmental Disabilities, University of
Illinois, 1640 W. Roosevelt Rd., Chicago, IL 60608.
SHEILA HEBEIN, BS, Executive Director, National
Association for Down Syndrome, P.O. Box 4542, Oak
Brook, IL 60522.
... 38,39 As adults with DS can also present cerumen plugs, otoscopy should be part of the clinical assessment of these patients. 40,41 Visual deficits and ocular anomalies are also frequent in adults and older adults with DS. Visual loss tends to occur earlier and to have a more rapid onset in adults with DS than in those without the syndrome. ...
... Although the prevalence of severe visual deficit is estimated at around 45% in adults with DS aged 50-59 years, a little over half of these cases are diagnosed and only 50% of individuals with DS have corrected eyesight. 39,40,41 When detected, the most common ocular problems among adults with DS include refraction, strabismus, cataracts and keratoconus. The prevalence of cataracts increases with age in people with DS, being comparable or greater than that found in the general population. ...
Article
Full-text available
The estimated average survival of people with Down syndrome (DS) is currently over 50 years of age. This demographic finding warrants attention of health professionals who will care for an increasing number of adults with DS. Clinical evaluation of adults with DS should correlate characteristics inherent to the age group, especially the peculiarities produced by the syndrome. The present article proposes the development of preventive and vaccination programs — according to gender and age — and screening of diseases and conditions associated with the syndrome: 1) endocrine diseases; 2) cardiac diseases; 3) mental health; 4) dental care; 5) sensory organs; 6) osteoarticular abnormalities; 7) skin and appendages; 8) gastrointestinal diseases; and 9) cancer. However, there is scant information on the impact of comorbidities on life expectancy and quality of life or on the social and hospital costs of adults with DS.
... However, whilst frequent screening of children is commonplace, less vigilance may be paid in adulthood, and the transition from paediatric care to adult services may not be straightforward (Hallum 1995;Pueschel 1996;Olsen & Swigonski 2004;Schrander-Stumpel et al. 2007). Specialist multidisciplinary services for adults with DS may be beneficial, but few exist (Chicoine et al. 1994;Schrander-Stumpel et al. 2007). ...
Thesis
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Access the full repository record here: https://era.ed.ac.uk/handle/1842/22917 Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is characterised by repeated cycles of upper airway obstruction during sleep, leading to diurnal symptoms. Individuals with Down syndrome (DS) are predisposed to this as the DS phenotype overlaps with OSAHS risk factors. Around 2-4% of the general adult population and 55% of children with DS have OSAHS but, to date, no large-scale study has assessed OSAHS prevalence or efficacy of treatment in DS adults. This study aimed to: 1) Systematically assess subjective and objective OSAHS prevalence; 2) Assess the effectiveness of continuous positive airway pressure (CPAP) in an adult DS population. Standard questionnaires including pictorial Epworth Sleepiness Scale (pESS) and Developmental Behaviour Checklist for Adults (DBC-A) were sent to UK adults aged ≥16yr with DS and their caregivers. All questionnaire responders were invited to undergo home polygraphy. Symptomatic adults with DS with ≥10 apnoeas/hypopnoeas per hour in bed (AH) on home polygraphy were invited to participate in a prospective randomised controlled trial (RCT) of CPAP v. lifestyle advice, with review at 1, 3, 6 and 12m. Participants in the lifestyle arm were offered CPAP at 1m. Standard measurements of sleepiness, behaviour, cognitive function and general health were undertaken. Standard statistical analyses were conducted, with significance set at p<0.001 to control for multiple testing. Of 5270 questionnaires sent, 1105 responses were valid (21%). Responders (55% males) were overweight/obese young adults: mean BMI 29.0±6.8kg/m2; mean age 28±9 years. Women had a higher BMI (p<0.0001), but collar size was greater in men (p<0.0001). Mean pESS scores were broadly within the normal range (7±5/24). No significant gender differences in OSAHS symptoms were noted. Individuals with probable OSAHS had higher pESS and DBC-A scores, and significantly more symptoms of OSAHS. Subjective OSAHS prevalence was estimated at 35%. Of the 790 individuals invited, 149 underwent polygraphy, with 134 valid studies obtained: mean AH 21.8(10.9-42.7); mean oximetry desaturation index (ODI) 6.6(2.3-20.0). No significant gender differences were observed. Forty-two percent of participants met standard clinical diagnostic criteria for OSAHS. Twenty-eight eligible adults with DS (19 male) were randomised: age 28±9yr; BMI 31.5±7.9kg/m2; AH 28.6(14.8-47.9); ODI 7.3(1.8-21.9); pESS 11±6/24. Groups did not differ significantly at baseline. By 12m, 4 participants had withdrawn (all remaining participants on CPAP). The pESS (p=0.001), DBC-A Disruptive (p<0.0001) and Kaufmann Brief Intelligence Test verbal subscale (p=0.001) scores improved significantly. This first large study of OSAHS prevalence in the adult DS population estimates a prevalence of 35-42% - around 10 times higher than in the general adult population. Sustained, significant improvements in sleepiness, cognitive function and behavioural/emotional outcomes with CPAP use over a 12m period were demonstrated during this first RCT of CPAP in adults with DS. A larger trial of CPAP in this population is warranted.
... There is, however, a growing literature published in peer-reviewed medical journals addressing screening and/or evaluation for co-occurring medical conditions seen in adults with DS. Many of the reports that highlight co-occurring medical conditions in adults with DS are largely informed by clinical experience and supported by existing literature when available (Chicoine, McGuire, Hebein, & Gilly, 1994;Galley, 2005;Jensen & Bulova, 2014;Malt et al., 2013;Martin, 1997;Pueschel, 1990;Smith, 2001;Steingass, Chicoine, McGuire, & Roizen, 2011;Wilson, Jones, Weedon, & Bilder, 2015). Clinical convenience samples ascertained through specialty clinics focused on DS or intellectual and developmental disabilities (IDD) have also been used to estimate the prevalence and variety of medical conditions in adulthood (Henderson, Lynch, Wilkinson, & Hunter, 2007;Jensen, Taylor, & Davis, 2013;Jones, 2009;Real de Asua, Quero, Moldenhauer, & Suarez, 2015;van Allen et al., 1999;Van Buggenhout et al., 1999). ...
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Adults with Down syndrome (DS) represent a unique population who are in need of clinical guidelines to address their medical care. The United States Preventive Service Task Force (USPSTF) has developed criteria for prioritizing conditions of public health importance with the potential for providing screening recommendations to improve clinical care. The quality of existing evidence needed to inform clinical guidelines has not been previously reviewed. Using the National Library of Medicine (NLM) database PubMed, we first identified 18 peer reviewed articles that addressed co-occurring medical conditions in adults with DS. Those conditions discussed in over half of the articles were prioritized for further review. Second, we performed detailed literature searches on these specific conditions. To inform the search strategy and review process a series of key questions were formulated a priori. The quality of available evidence was then graded and knowledge gaps were identified. The number of participating adults and the design of clinical studies varied by condition and were often inadequate for answering all of our key questions. We provide data on thyroid disease, cervical spine disease, hearing impairment, overweight-obesity, sleep apnea, congenital heart disease, and osteopenia-osteoporosis. Minimal evidence demonstrates massive gaps in our clinical knowledge that compromises clinical decision-making and management of these medically complex individuals. The development of evidence-based clinical guidance will require an expanded clinical knowledge-base in order to move forward.
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Down syndrome continues to be the most common chromosomal condition,¹,2 with rising prevalence and increased survival. An estimated 1 in 700 infants are born with Down syndrome in the US each year; the median life span is 57 years, with reported survival up to age 82 years.²,3 Improved childhood survival is credited to advances in surgery for congenital heart disease, management of respiratory illness, and decreased institutionalization. Mortality after age 20 years is associated with disorders of the cardiovascular and respiratory systems, with severity of the level of intellectual disability, dementia, and mobility restrictions as important risk factors.³,4
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Difficulties of diagnosing and managing dementia in people with Down syndrome - Volume 213 Issue 5 - David Smith, Brian Chicoine
Chapter
Dementia assessment in adults with intellectual disabilities (ID) is a challenging task, but past work by clinicians and researchers has improved diagnostic accuracy. Diagnostic criteria were outlined [1] and found to be feasible and useful [2–4]. Gradations from mild to major neurocognitive disorders were identified and found to affect dementia prevalence figures [5–7]. A battery of tests was proposed to identify significant declines [8, 9]. Ongoing investigations examined the sensitivity and specificity of tests from the proposed battery and additional alternative batteries [2, 3, 6, 10–25]. The purpose of this chapter is to outline and discuss general issues and factors that can affect dementia assessment either directly or indirectly [3, 11, 26]. Such issues are important to consider when evaluating tests for clinical and research purposes. As indicated in Table 2.1, a discussion of general theoretical issues will be followed by a more specific discussion of methodological issues.
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Individuals with Down syndrome (DS) commonly possess unique neurocognitive and neurobehavioral profiles that emerge within specific developmental periods. These profiles are distinct relative to others with similar intellectual disability (ID) and reflect underlying neuroanatomic findings, providing support for a distinctive phenotypic profile. This review updates what is known about the cognitive and behavioral phenotypes associated with DS across the lifespan. In early childhood, mild deviations from neurotypically developing trajectories emerge. By school-age, delays become pronounced. Nonverbal skills remain on trajectory for mental age, whereas verbal deficits emerge and persist. Nonverbal learning and memory are strengths relative to verbal skills. Expressive language is delayed relative to comprehension. Aspects of language skills continue to develop throughout adolescence, although language skills remain compromised in adulthood. Deficits in attention/executive functions are present in childhood and become more pronounced with age. Characteristic features associated with DS (cheerful, social nature) are personality assets. Children are at a lower risk for psychopathology compared to other children with ID; families report lower levels of stress and a more positive outlook. In youth, externalizing behaviors may be problematic, whereas a shift toward internalizing behaviors emerges with maturity. Changes in emotional/behavioral functioning in adulthood are typically associated with neurodegeneration and individuals with DS are higher risk for dementia of the Alzheimer's type. Individuals with DS possess many unique strengths and weaknesses that should be appreciated as they develop across the lifespan. Awareness of this profile by professionals and caregivers can promote early detection and support cognitive and behavioral development. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.
Article
With longer life expectancy, the population of persons with Down syndrome (DS) is in need of closer surveillance, monitoring, and treatment of medical problems in order to care for and improve their quality of life. This national survey investigated the health services utilization of persons with DS in residential and community care in Israel. A total of 614 persons with DS were found and their medical records reviewed. Heart disease was most common, followed by endocrine and visual problems. This population utilized both emergency room, hospitalization, family, and residential care physician to a larger extent than the general population. As other studies, this survey also showed the large utilization of health care for persons with DS with a life long need for health monitoring and treatment.
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Reviews the state of knowledge about Down syndrome (DS) and presents physicians with a framework in which to provide care and information. The history, genetics, and incidence of DS are discussed. Diagnostic issues include clinical suspicions leading to diagnosis, interviews in which the parents are informed, and prenatal screening/diagnosis. Specific healthcare concerns for children with DS include evaluation of newborn and young infants with DS and general health maintenance. Neurologic, cognitive, and language concerns are noted. Physicians are also alerted to controversial therapies for DS, including vitamin therapy and plastic surgery to "normalize" facial features. Parents of a newborn with DS should be reminded that prospects for their child's future are generally good. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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A study of 658 consecutive psychiatric outpatients receiving careful medical and biochemical evaluation, defined an incidence of medical disorders productive of psychiatric symptoms in 9.1% of cases. The most frequent presentations were of depression, confusion, anxiety, and speech or memory disorders. The presence of visual hallucinations was believed to indicate medical etiology until proved otherwise. Major illnesses presenting with psychiatric symptoms in order of frequency were infectious, pulmonary, thyroid, diabetic, hematopoietic, hepatic and CNS diseases. Forty-six percent of these patients suffered from medical illnesses previously unknown to either them or their physician. A plea is made for careful medical evaluation of psychiatric patients.
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Adaptive skills of 2,144 individuals with Down syndrome were compared to a similar group of 4,172 developmentally disabled people without Down syndrome. Activities of daily living and cognitive skills were examined across etiology, age group, and level of mental retardation. For individuals with Down syndrome at all levels of retardation, adaptive competence declined with increasing age to a greater extent than for retarded control subjects. Clear age-related deficits associated with Down syndrome were observed only in people older than 50 years of age. Findings support previous evidence of an increased risk for the clinical signs of Alzheimer's disease among people with Down syndrome; however, signs of dementia appeared later in life than would be predicted from available neuropathological data.
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• We investigated the thyroid function of 151 patients with Down syndrome. Compared with a control group of 89 siblings nearest in age to their brother or sister with Down syndrome, the mean thyroid-stimulating hormone (TSH) value was significantly higher in patients with Down syndrome than in subjects without Down syndrome. However, the mean thyroxine (T4) levels in both groups were nearly the same. In the Down syndrome group there was a trend for TSH values to increase and for T4 values to decrease with advancing age. Of the 151 patients with Down syndrome, ten had both significantly elevated TSH levels (≥9.5 μU/mL) and significantly decreased T4 levels (≤5.5 μg/dL), 21 had only abnormally high TSH values, seven had only markedly Increased T4 levels (≥12.0 μg/dL), and three had only significantly decreased T4 levels. The intellectual function of patients with both abnormal TSH and T4 levels was significantly lower (mean IQ, 41.7) than that of Down syndrome patients with only increased TSH values (mean IQ, 53.8) and that of Down syndrome patients with normal thyroid function (mean IQ, 55.3). This study provides further evidence that there is an increased prevalence of thyroid dysfunction In patients with Down syndrome. (AJDC 1985;139:636-639)
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