Community Health Care for Adults and Elders with Developmental Disabilities Research and Training A Project of the University Center for Excellence in Developmental Disabilities (UCEDD) funded by the Washington State Developmental Disabilities Council (DDC)
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Developmental Disabilities in the Elderly

Why is this a relevant issue to address?

Why Should We Take on This challenge of Aging Patients with Developmental Disabilities?

• Because they are human beings just as we are who have health care needs
• This allows us to more fully participate in the true meaning of being physicians
• Fulfillment of seeing those with significant disabilities have improved quality of life related to our care

Common Misconceptions

• All persons with developmental disabilities have severe physical, cognitive, and behavioral impairments.
       - Truth is that many individuals have very mild disabilities.
       - Some who have severe physical deficits are cognitively intact.
• Primary care providers have little or no capacity to care for the developmentally disabled.
       - Truth is most primary care physicians have developmentally disabled patients in their practice.
       - Most care needs of elders with developmental disabilities are the same as other elders.

Definition of Developmental Disability

• Occurs before age of 22 and persists indefinitely
• Chronic mental or physical impairment that results in delay or failure to achieve normal developmental milestones.
• Causes significant functional impairment in areas such as independent living, self care, receptive and expressive language, learning, and economic self sufficiency

Developmental Disability(cont)

• Includes cerebral palsy, mental retardation, learning disorders, autism, and epilepsy
• Heterogeneous causes of disability may introduce medical complexity (eg Down syndrome)
• Dual diagnosis: developmental disability plus psychiatric disorder

Demographics of DD

• Caseload  in Washington State of about 32,000
• Number of elderly with DD identified by the Division of Developmental Disabilities is about 1000
• Many cases likely go underreported indicating a significant underestimation

Demographics of DD(cont)

• Overall estimates are of 2-3% in the general population.
• Average life expectancy as of 1993 estimated at 66 years and is increasing at a rate similar to the general population
• Most older persons surviving to old age are higher functioning individuals with milder deficits, but with improved medical care and technological advancement, those with more limiting disabilities will live to older ages

Review of Aging Process

• Orthostatic hypotension and underperfusion of CNSAltered thermoregulation
• Diminished thirst driveDecreased muscle mass and strength
• Increased body fat
• Decreased bone density

Review of Aging Process(cont)

• Gait and balance decline
• Decreased renal function and mass(25%)
• Hearing loss
• Compromised light adaptation, glare sensitivity, and decreased contrast sensitivity
• Lessened capacity to maximally utilize O2 at high exercise level

Review of Aging Process(cont)

• Diminished smell acuity
• Lessened pulmonary defense mechanisms to fight off infection
• Decreased liver mass(10%), blood flow, and synthetic rate

Pharmacology in Aging/Appropriate Prescribing

• Decreased lean body mass
• Increased percentage of body fat
• Increased volume of distribution of lipophilic drugs
• Decreased volume of distribution of hydrophilic drugs
• Decreased renal mass and blood flow
• Decreased tubular secretion
• Decreased glomerular filtration rate
• Renal impairment common despite normal measured creatinine levels

Adverse Drug Reactions  

• Risk Factors include
  • Age
  • Number of medications taken 
  • Number and severity of chronic diseases
  • Intercurrent illnesses

Pharmacology Interactions: Drug-Disease

• Benign prostatic hypertrophy
• Cardiac conduction abnormalities
• Chronic obstructive pulmonary disease
• Anticholinergics, decongestants due to urinary retention
• Verapimil, Tricyclic anti-depressants, b-blockers
• b-blockers, narcotics  

Pharmacology Interactions: Drug-Disease

• Congestive heart failure
• Dementia
• b-blockers, Verapimil (increase chf); 
• Lidocaine, digoxin, prazosin, quinidine, and theophylline (decreased clearance)
• Multiple medications with increased confusion and deliriumPharmacology Interactions: Drug-Disease
• Htn
• Orthostatic hypotension
• Non-steroidal anti-inflammatory agents
• Diuretics, tricyclic anti-depressants, levodopa, vasodilators

Pharmacology Interactions: Drug-Food

• Nutritional deficits
• Adverse oral and GI effects of medications
• Decreased absorption of certain drugs due to foods
• Effects of Vitamins C and E on Warfarin therapy

Pharmacology Interactions: Drug-Drug

Pharmacology Interactions: Drug-Drug

• Competition for renal tubular secretory function
• Changes in protein bindings with displacement
• Digoxin clearance decreased by quinidine, amiodarone, and Verapimil
• Sulfonamides displace Warfarin therapy from albumin

Pharmacology Interactions: Drug-Drug

• Drug-homeostatic impairment including sympathetic activity:  clonidine
• vasomotor responsiveness:  hydralazine
• cardiac function:  propranolol
• volume regulation:  furosemide
• metabolic balance:  diuretics, nsaids
• glucose intolerance:  steroids, thiazides

Principles of Appropriate Prescribing

• Thorough medication history: prescription, non-prescription and alternative/supplement
• Establish list of true allergies vs sensitivities
• Establish definite diagnosis if able before prescribing
• Review comprehensive medication list each visit
• Bring all medications for first visit
• Discontinue all unnecessary medications
• Start low and go slow
• Assess and encourage compliance
• Consider complexity of dosing schedule, expense, and potential adverse side effects
• Communicate clearly and give legible written instructions
• Know all physicians prescribing for patient

Common Concerns in Elderly and Developmentally Disabled

• Increased sensitivity of the central nervous system
• Polypharmacy common
• Unreliable or no history provided
• Medical records can be very difficult to obtain
• Non-verbal communication: Symbolic: sign, assistive tech; Nonsymbolic: agitation and irritability
• Auditory and visual difficulties very common
• Seizures and dysphagia common problems

Where Developmental Disabilities and Aging Concerns Meet

• Sensitivity to meds
• Cognitive difficulties
• Fragile sensorium at young age
• Affect of disease on sensorium in later age
• Genetic, hereditary, or traumatic cerebral abnormalities
• Development of dementia with aging
• Communication difficulties        
• Mobility, musculoskeletal, rehabilitative issues
• Associated with hearing and visual abnormalities
• Impaired cognitive and physical function with aphasias and dysarthrias
• Deformities, spasticity, contractures

Psychiatric Issues

• Abnormal behavior may be affected or caused by medical problems
• Observe closely for occult difficulties with skin abnormalities, sinus problems, abdominal or pelvic disease, constipation, or urinary retention
• Assess for psychosocial and environmental concerns
• Determination of true psychiatric disorders
• Treatment based upon   
• Behavior which adversely affects patient of others   
• Takes into account frequency versus severity of behavior  
• Attempts to simplify medication regimen in case meds causing behavior  
• Monitors for response closely to optimize benefit and limit side effects

Challenges for the Primary Care Physician

• Difficulty obtaining an accurate history
• Communication difficulties
• Potential disruptions in office waiting area
• Patients sense of apprehension related to office environment
• Potential resistance to examination
• Increased utilization of office staffs time
• Difficulties obtaining informed consent
• Limited financial resources and reimbursement

Ways to Counteract These Challenges

• Always request to have knowledgable family or care providers present
• Bring all medications to appointments both present and past
• Schedule extra time for visits with more complicated situations
• Consider premedication in office prior to extensive exam or procedures contemplated or scheduled

Medical Issues Deserving Close Attention

• Concept of premature aging in those with developmental disabilities and accelerated rate of functional decline
• Earlier development of eye and ear abnormalities
• Monitoring for the usual chronic health conditions such as arthritis, hypertension, heart disease, high cholesterol, and diabetes
• Higher incidence of seizures in elderly developmentally disabled patient
• Higher incidence of affective disorders, depression, and bipolar disorders associated with aging and mental retardation
• Unique issues of increased incidence of thyroid disease and Alzheimer’s disease in patients with Down syndrome
• Monitor for signs of abuse to patient but also to caregiver

Updated 02/7/05

AEDD at University of Washington
Box 357920, Seattle, WA 98195-7920

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