Primary Care for the Developmentally Disabled Adult


	You may not be able to get a clear enough history from the patient to determine the extent of their upper GI disease or the therapeutic efficacy of your treatments. X-rays such as UGIs require a degree of cooperation that may not be attainable in some patients. Studies may be returned with suboptimal results. Endoscopy should be considered in those situations. When modified barium swallows are being performed, it is important to simulate a meal as much as possible including assessing oral motor performance at the end of a meal when fatigue may be resulting in aspiration risk. You may also want to request that pill swallowing be specifically studied.
	Treatment of dysmotility and GERD may include acid inhibition (usually with proton pump inhibitors) and the use of pro-motility agents. Metoclopramide (Reglan) can cause tardive dyskinesia and, if used, the patient should be monitored with DISCUS evaluations. For certain cases, surgical fundoplication may be indicated. Finally, if dysphagia has resulted in significant adverse effects despite interventions such as dietary modification, positioning, and mastication exercises, the switch to non-oral feedings may need to be considered. If reflux has been problematic and non-responsive to treatment, a jejunostomy tube, perhaps with fundoplication, may be recommended. If either a jejunostomy or gastrostomy tube appears adequate, such things as ease of medication administration, length of feedings required, skill necessary to care for the tube should be considered in making the decision.