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Learning disabilities

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Learning disabilities VTS 19.10.2010 Aims of session 1. Learning disability entry in e-portfolio Aim 2 2. Genetics entry in e-portfolio Additional aims 3. – PowerPoint PPT presentation

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Title: Learning disabilities


1
Learning disabilities
  • VTS 19.10.2010

2
Aims of session
  • 1. Learning disability entry in e-portfolio

3
Aim 2
  • 2. Genetics entry in e-portfolio

4
Additional aims
  • 3. Learn about Cardiff health checks
  • 4. Case study to illustrate communication skills.

5
Scale of the problem
  • 210,000 with severe learning difficulties in
    England
  • 1.2 million mild or moderate

6
Major problems
  • Insufficient support for carers
  • Little choice or control over aspects of life
  • Unmet, substantial health care needs
  • Limited housing choice
  • Day services not tailored to individual needs
  • Limited employment opportunities

7
Definition
  • Learning disability includes the presence of
  • A significantly reduced ability to understand
    new or complex information, to learn new skills
    (impaired intelligence), with
  • A reduced ability to cope independently
    (impaired social functioning)
  • which started before adulthood, with a lasting
    effect on development.
  • Many also have physical and/or sensory impairments

8
Underlying conditions
  • Downs syndrome
  • Fragile X
  • Retts syndrome
  • Williams syndrome
  • Angleman syndrome
  • Kabuki syndrome
  • Noonan syndrome

9
Cerebral palsyAutistic spectrum
disorderMiscellaneous
  • Underlying conditions

10
Impact on GP services
  • Patients with learning disabilities have 2.5
    times as many associated medical problems as
    non-learning disabled control patients
  • The number of repeat prescription drugs
    prescribed by primary care are about three times
    those for non-learning disabled control patients
  • Learning disability is a major economic burden on
    the NHS, the local authority social services and
    on the social security system.

11
Co-morbidity
  • Increased incidence of psychiatric illness and
    behavioural disorders
  • 30 have epilepsy
  • 30 have visual problems and 30 hearing problems
  • Hypothyroidism and dementia can complicate Downs
    syndrome
  • Continence and ambulation problems

12
  • Increased morbidity and mortality
  • Decreased life expectancy
  • Development of register (QoF/DES) allows regular
    structured health reviews with implementation of
    the resulting health action plan.

13
Mencap study
  • Avoid making assumptions about quality of life
  • Be clear on law about the capacity to consent
  • Explore the best way to communicate
  • Listen to parents and carers
  • Be suspicious about potentially important symptoms

14
Health Inequalities Formal Investigation
  • Preventable deaths for people with learning
    disabilities are 4 times higher than for rest of
    population
  • People with schizophrenia live 9years less on
    average
  • lt20 of women with LD attend cervical screening
    compared with 81 of women overall
  • People with LD are 58 times more likely to die
    lt50 than the general population
  • Diabetes 4-5 times more common in people with MH
    problems

15
Negative experiences
  • Loss of trust (medical staff and patients)
  • Inappropriate services provided
  • Patient not believed
  • Mis-diagnosis or non-diagnosis
  • Preconceptions/stereotyping
  • Patronising conversations (treated like children)
  • Not just what said, but how said (tone of voice)
  • Not treated as a person
  • Assumption that disabled trouble
  • Overfocus on impairment rather than health
    condition
  • Repetition of repeat prescriptions, no clinical
    review etc

16
Treating the same
  • Examinations for new patients
  • Flexibility
  • Health checks
  • Medication reviews
  • Ask all patients for their access requirements
  • Treat the whole person (holistic)
  • Focus on treating health condition
  • Engagement with patients
  • Informing about medical results
  • Respect
  • Trust
  • Openness
  • Routine health checks
  • Routine screening

17
Treating Differently
  • Flexibility over timings for routine screening
  • Ask how best to help access (they are the expert)
  • Continuous support
  • Time to listen
  • Routine follow-up appointments
  • Consider any impairment (or medication-related)
    issues
  • Crisis or planning prevention meetings
  • Importance of getting to know well
  • emergency telephone appointments
  • Prevention screening flexibility, when well
  • Avoiding stereotyping
  • Help filling in forms

18
Learning Outcomes (RCGP)
  • Awareness of significant minority in a practice
    who may need no special services but who have
    reading, writing, comprehension difficulties
  • A few will have moderate severe and profound
    difficulties and will need to be identified,
    monitored and reviewed
  • Awareness of likely associated conditions and
    where to obtain specialist help and advice

19
Person-centred care
  • Importance of person-centred care including when
    involving carers
  • Respect autonomy, be aware of how communicating
    via carers may skew relationship
  • Awareness of residential settings/day centre
  • Optimise communication with consultation skills
    communication aids
  • Importance of continuity
  • Be aware of capacity and consent and how to asses

20
Specific skills
  • Atypical presentations of psychiatric and
    physical illness
  • Use of additional enquiry, tests and careful
    examination if unable to verbalise
  • Be aware of concept of diagnostic overshadowing

21
Diagnostic overshadowing
  • Diagnostic overshadowing is when a persons
    presenting symptoms are put down to their
    learning disability, rather than the doctor
    seeking another, potentially treatable cause.

22
Cardiff Health check
  • Other health checks are available.
  • 1 hour duration appointment
  • PN to check weight, height, urinalysis and
    completes checklist
  • GP for physical examination

23
Practice Nurse check
  • Patient details/carer circumstances
  • Consent
  • Communication
  • Weight, height, B.P., urinalysis
  • Immunisations and screening
  • Chronic illness and systems enquiry
  • Sexual health
  • Epilepsy

24
GP check
  • Hand over
  • General appearance
  • Cardiovascular, respiratory, abdominal
  • Dermatology, CNS, vision, hearing
  • Communication, mobility
  • Other investigations?
  • Summary
  • Action plan

25
Always focus on
  • Assessment of feeding, bowel and bladder function
  • Assessment of behavioural disturbance
  • Assessment of vision and hearing
  • Consider syndrome specific needs and checks

26
Mental Capacity
  • CURB
  • BADLIP
  • (Chadwick and Hoghton 2010 bioethics memory aid
    for patients gt18 in an emergency situation)

27
CURB
  • C Communicate Can the person communicate their
    decision?
  • U Understand Can they understand the
    information you are giving them?
  • R Retain Can they retain the information given?
  • B Balance Can they balance or use the
    information?

28
If no capacity
  • Consider BADLIP to ascertain if a decision can
    be made after reviewing their best interests

29
BADLIP
  • B Best interest. If no capacity can you make a
    best interest decision?
  • AD Advanced Decision is there an advanced
    decision to refuse treatment?
  • L Lasting Power of Attorney appointed?
  • I Independent Mental Capacity Advocate. If no-one
    to consult about best interest appoint IMCA in an
    emergency
  • P Proxy. If unresolved conflicts consider local
    ethics committee or Court of Protection appointed
    deputy.

30
Case Study
  • Consider the barriers to communication and the
    potential solutions in a young man with LD who
    has hypertension and obesity.

31
References and further reading
  • InnovAiT Vol 2 Issue 11 article on childhood
    learning disabilities
  • A Step by Step Guide for GP Practices (annual
    health checks, RCGP, Hoghton) should be a copy
    in each GP practice
  • DRC (2006) Equal Treatment Closing the Gap
    includes DVD on equal treatment
  • Assessing patient capacity Hoghton Chadwick
    BMJ 2010 340c2767

32
Resources
  • www.e-lfh.org.uk free learning modules on
    learning disability including annual health
    checks
  • www.easyhealth.org.uk downloadable information
    leaflets and books on LD
  • www.valuingpeople.gov.uk DoH publications and
    support
  • www.mencap.org.uk
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