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Medical Concerns in Adults with Developmental Disabilities

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Down Syndrome. Spina Bifida. MEDICAL CONDITIONS IN CEREBRAL PALSY. Spasticity or Hypotonia ... MEDICAL CONDITIONS IN DOWN SYNDROME. In addition to the typical ... – PowerPoint PPT presentation

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Title: Medical Concerns in Adults with Developmental Disabilities


1
Medical Concerns in Adults with Developmental
Disabilities
  • Sharon Witemeyer, MD
  • Continuum of Care Project
  • UNM-HSC

2
Medical Concerns in Adults with Developmental
Disabilities Objectives
  • Define Developmental Disabilities
  • Become familiar with common co-morbidities
  • medical conditions
  • polypharmacy
  • communication issues
  • Become familiar with common medical concerns for
    women with developmental disabilities
  • Know some ways to enhance the DD patients visit
    to the office

3
Developmental Disability Definition
  • Injury to the developing brain before age 22
    years that impacts function in
  • - mobility
  • - communication
  • - self help
  • - independence
  • - learning

4
Individuals with Developmental Disabilities NM
Population
  • 1-2 of the total population
  • 20,000 with all types
  • 1,000-1,500 severe
  • All reside in the community
  • Life expectancy in the 1930s was 18.5 yrs
  • Life expectancy today is 66.2 yrs

5
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6
COMMON CO-MORBIDITIES
  • Medical Conditions
  • Polypharmacy
  • Communication Issues

7
MEDICAL CONDITIONS
  • Some medical conditions commonly seen among
    individuals with developmental disabilities are
    intimately associated with the disability itself.

8
Some Diagnoses Associated with Specific Medical
Conditions Include
  • Cerebral Palsy
  • Down Syndrome
  • Spina Bifida

9
MEDICAL CONDITIONS IN CEREBRAL PALSY
  • Spasticity or Hypotonia
  • Movement Disorder
  • Contractures
  • Limb and chest wall deformity
  • Kyphoscoliosis
  • Seizure disorder

10
MEDICAL CONDITIONS IN DOWN SYNDROME
  • In addition to the typical physical features,
    Down Syndrome may be associated with
  • Congenital Heart Defects (40) AV communis,
    VSD, PDA, ASD, and aberrant subclavian artery
  • GI Defects esophageal atresia, duodenal atresia
  • GI problems GERD, increased triglycerides,
    decreased HDL cholesterol, apolipoprotein A1,
    HDLTG ratio, Hirschprungs, Celiac disease,
    obesity,constipation, neonatal jaundice

11
MEDICAL CONDITIONS IN DOWN SYNDROME
  • Developmental brain abnormalities delayed
    myelination, fewer neruons, decreased synaptic
    density, decreased acetycholine neurotransmitter
    receptors, mental retardation
  • ADHD
  • Hypotonia
  • Seizures (5-10)
  • Autism
  • Sleep Apnea

12
MEDICAL CONDITIONS IN DOWN SYNDROME
  • Thyroid problems neonatal hypothyroidism (27 X
    normal), hypothyroidism, hyperthyroidism
  • Atlanto-axial instability
  • Abnormalities of immune function
  • Vision and hearing impairments
  • Dementia

13
Things to consider before making the diagnosis of
Alzheimers
  • Electrolyte imbalance Stroke
  • Hydrocephalus Other Dementias
  • Thyroid disease Other Psychiatric Problems
  • Vitamin deficiency
  • Infection
  • Drug toxicity
  • Depression
  • Subdural hematoma
  • Brain tumor

14
MEDICAL CONDITIONS IN SPINA BIFIDA
  • Hydrocephalus
  • VP/AP shunt malfunction
  • Sleep Apnea
  • Tethered cord
  • Chronic urinary tract infections
  • Skin breakdown
  • Obesity

15
MEDICAL CONDITIONS
  • Some medical conditions are found more frequently
    among individuals with any developmental
    disability than in the general population.

16
MEDICAL CONDITION COMMON AMONG INDIVIDUALS WITH
DD REGARDLESS OF ETIOLOGY
  • Endocrine especially thyroid problems
  • GERD
  • Osteoporosis
  • Weight concerns
  • Constipation

17
MEDICAL CONDITIONS
  • Among the medically fragile and developmentally
    disabled common concerns include
  • Aspiration risk
  • Marginal nutritional status
  • GT/JT placement risks including bowel
    obstruction or perforation and diaphragmatic
    hernia
  • Tracheotomy
  • Pulmonary insufficiency due to scoliosis
  • Marked osteoporosis, silent fractures

18
MEDICAL CONDITIONS
  • Of course specific syndromes are associated with
    a myriad of other abnormalities such as
  • Congenital anomalies
  • Renal/Metabolic disease
  • Cardiac disease
  • Vision/Hearing impairments

19
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20
MEDICAL CONDITIONS
  • Individuals with DD are frequently brought to the
    doctor because of behaviors that can vary from
    mild to extremely severe. Before assuming it is
    just behavior or prescribing a psychotropic
    medication, consider some of the common medical
    conditions that may be manifested in this way.

21
MEDICAL CONDITION OR BEHAVIOR PROBLEM?
  • PAIN from
  • Otitis
  • Sinusitis
  • Dental problem
  • GERD
  • Glaucoma
  • Undiagnosed fracture
  • Hidden abscesses
  • Foreign bodies
  • UTI
  • Renal or gallstones
  • Headache
  • Constipation

22
MEDICAL CONDITION OR BEHAVIOR PROBLEM?
  • Thyroid disease
  • Sleep apnea
  • Spinal cord problems
  • Increased ICP
  • Vitamin deficiencies (especially the B vitamins)
  • Drug side effects

23
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24
Review of 150 patients with DD and MI seen in DD
Clinic
  • Number of Medications
    Number of Individuals
  • 0 8
  • 1 10
  • 2 22
  • 3 20
  • 4 24
  • 5 27
  • 6 16
  • 7 11
  • 8 7
  • 9 2
  • 10 2
  • 12 1
  • 13
    1

25
Review of 150 patients with DD and MI seen in DD
Clinic
  • Number of medications per patient 1-13
  • Mean number of medications per patient 4.45

26
POLYPHARMACY
  • Side Effects
  • Neurologic paresthesias, seizures, psychiatric,
    movement disorders,headaches, delirium
  • GI dry mouth, heartburn, pain, constipation,
    anorexia, bleeding
  • Cardiac arrhythmias
  • GU retention, incontinence
  • Bone - osteoporosis

27
POLYPHARMACY
  • Drug-Drug Interactions
  • SSRI
  • Anticonvulsants
  • Neuroleptics
  • GI drugs acid blockers, proton pump inhibitors
  • Antibiotics
  • Birth control pills

28
POLYPHARMACY
  • Idiosyncratic and Allergic Reactions
  • Benadryl
  • Phenobarbital
  • Benzodiazepines
  • Neurontin

29
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30
COMMUNICATION
  • Non-verbal
  • Limited expressive language skills
  • Limited receptive language skills
  • Usually history must be obtained from a third
    party parent, guardian, or direct care provider

31
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32
REPRODUCTIVE HEALTH CARE FOR WOMEN WITH DD
  • Most women with developmental disabilities have
  • normal female anatomy
  • normal endocrine function
  • normal breast development

33
REPRODUCTIVE HEALTH CARE FOR WOMEN WITH DD
  • Some women with developmental disabilities do not
    have normal reproductive systems.
  • Pituitary dysfunction may be seen in women with
    central nervous system malformations as the
    result of genetic, congenital, traumatic or post
    operative abnormalities.
  • Thyroid dysfunction is more common in
    individuals with developmental disabilities

34
REPRODUCTIVE HEALTH CARE FOR WOMEN WITH DD
  • Women with spina bifida frequently enter puberty
    early
  • Reproductive endocrine disorders occur more
    frequently among men and women with epilepsy
  • Anticonvulsant medications used in this
    population are associated with ovarian
    dysfunction (Polycystic Ovary Syndrome)

35
REPRODUCTIVE HEALTH CARE FOR WOMEN WITH DD
  • Most women with developmental disabilities have
  • normal female anatomy
  • normal endocrine function
  • normal breast development

36
REPRODUCTIVE HEALTH CARE FOR WOMEN WITH DD
  • Many families and physicians are reluctant to
    provide routine gynecologic health maintenance to
    women with developmental disabilities because
    they think it is
  • too traumatic
  • takes too much time
  • simply a waste of time

37
REPRODUCTIVE HEALTH CARE FOR WOMEN WITH DD
  • Women with developmental disabilities need and
    deserve the highest standard of medical care
    available and this includes reproductive health
    surveillance

38
REPRODUCTIVE HEALTH CARE RECOMMENDATIONS
  • Breast Examinations
  • First breast examination at age 18 years
  • Annual examination thereafter
  • Many women with developmental disabilities are
    unable to perform breast self examination

39
REPRODUCTIVE HEALTH RECOMMENDATIONS
  • Mammograms
  • First mammogram at age 50 years
  • Annually thereafter
  • If there is a family history of breast cancer in
    mother, sister, daughter or two close female
    relatives or known genetic risk (BRCA1 or BRCA2
    genes) then first mammogram should be at age 35
    years. Annual mammograms thereafter

40
REPRODUCTIVE HEALTH RECOMMENDATIONS
  • Pelvic Examinations and Pap Smears
  • First pelvic examination and Pap smear when
    patient becomes sexually active or age 18 years
  • Annual pelvic examination and Pap smear for 3
    years. If normal exams and 3 negative Pap smears
    the Pap smears can be done every 2-3 years

41
REPRODUCTIVE HEALTH RECOMMENDATIONS
  • Pelvic Examinations and Pap Smears
  • Annual pelvic examinations
  • Annual pelvic examinations and Pap smear after
    age 40 years
  • The problem with increasing the interval between
    Pap smears is that many women will not return for
    a routine annual pelvic examination and ovarian
    cancer may be missed.

42
REPRODUCTIVE HEALTH CARE FOR WOMEN WITH DD
  • Pelvic Examination
  • Position may be limited by patient anxiety or
    physical deformities (flexion contractures,
    paralysis, spasticity)
  • Visualization
  • Bimanual
  • Speculum Use a narrow speculum such as a
    Pederson for virginal patients
  • Pap Smear may use a Q tip blindly to sample os

43
Common Problems
  • Dysmenorrhea and PMS
  • Withdrawn behavior, rocking motions,
    vocalizations of a distressed nature, aggression
    toward caretakers or self-abuse use
    Prostaglandin inhibitors
  • PMS violent, physically abusive to staff or
    selves use Prostaglandin inhibitors, OCPs or
    long-acting progestin

44
REPRODUCTIVE HEALTH CARE FOR WOMEN WITH DD
  • Women with developmental disabilities are more
    likely to have been sexually abused than women in
    the general population

45
PREVENTATIVE HEALTH CARE
  • Immunizations
  • Obesity nutrition, exercise
  • Tobacco
  • Alcohol and Substance Abuse
  • Responsible/Safe Sex
  • Check our website (http//star.nm.org/coc) for
    syndrome specific health-watch recommendations

46
COMMON PROBLEMS OSTEOPOROSIS
  • Osteoporosis is usually defined as a reduction of
    bone mineral density per unit volume of bone. It
    is caused by reduced bone matrix.
  • Osteomalacia is caused by reduced mineral
    deposition secondary to Vitamin D deficiency
  • Osteopenia refers to an early form of osteoporosis

47
COMMON PROBLEMS OSTEOPOROSIS
  • Osteoporosis and the risk of fractures is a
    significant problem in people with developmental
    disabilities.
  • There is little medical literature that
    addresses the problem. Those studies that do
    exist report increased prevalence of osteoporosis
    among female and male, young and old with
    developmental disabilities.

48
COMMON PROBLEMS OSTEOPOROSIS
  • Fracture rate for individuals with developmental
    disabilities is
  • 1.7-3.5 times greater than the rate for the
    general population.

49
COMMON PROBLEMS OSTEOPOROSIS
  • Factors associated with osteoporosis in
    individuals with developmental disabilities
  • 1. Immobility
  • 2. Gonadal/Endocrine Dysfunction
  • 3. Medications (i.e.ACM)
  • 4. Small Body Size (i.e. Down Syndrome)

50
COMMON PROBLEMS OSTEOPOROSIS
  • Diagnosis
  • DEXA determination of bone mineral
    density (BMD) is the gold standard but is not
    always possible in individuals with developmental
    disabilities because of deformity or inability to
    cooperate.
  • Urinary peptides may provide an alternative in
    the future.

51
COMMON PROBLEMS OSTEOPOROSIS
  • Prevention
  • 1.Calcium (1000-1500mg/day)
  • 2.Vitamin D (400 units/day)
  • 3.Weight bearing exercise
  • 4.Avoid smoking and excess alcohol consumption

52
COMMON PROBLEMS OSTEOPOROSIS
  • Treatment
  • 1. Fosamax
  • 2. Didronel
  • 3. Calcitonin
  • 4. Estrogen in women
  • 5. Androgen in men
  • 6. Parathyroid hormone (Forteo) ?

53
THE DD PATIENT IN THE OFFICE
  • Preparation of the Patient
  • Explain ahead of time
  • Role play
  • Define desired behavior
  • Rewards and reinforcers
  • A tour visit
  • A familiar person to accompany the patient

54
THE DD PATIENT IN THE OFFICE
  • Preparation of the office staff
  • Schedule on days that are not crowded
  • Plan for a short waiting time
  • Schedule a series of appointments
  • Provide staff for continuity
  • Explain procedure calmly and in a soft voice
  • Know that the procedure may take longer
  • Consider specifics of the disability
  • Avoid restraints, be flexible
  • Safety is a priority

55
THE DD PATIENT IN THE OFFICE
  • PATIENCE
  • SENSITIVITY
  • FLEXIBILITY
  • CREATIVITY
  • DIGNITY
  • RESPECT

56
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