Polypharmacy in the treatment of subjects with intellectual disability

Value of a web-based pediatric drug information system to prevent serious adverse drug reactions in child and adolescent psychiatry

Psychotropic drugs are frequently prescribed 'off-label' to children and adolescents and carry the risk of serious adverse drug reactions (sADR). We examined the frequency of sADRs of psychotropic drugs in pediatric inpatients and explored their potential preventability through following the recommendations of a web-based pediatric drug information system (PDIS). The potential socio-economic impacts of using this online system is also addressed. Routine clinical data from all inpatients treated in a child and adolescent psychiatry department between January 2017 and December 2018 were retrospectively examined for the occurrence of sADRs as defined by the European Medicines Agency. The preventability of the sADRs was assessed based on the information of the PDIS. Furthermore, the expected prolongation of the hospital stay due to sADRs was calculated as well as the associated treatment costs. The study was supported by the Innovation Fund of the Joint Federal Committee, grant number 01NVF16021. In total, 1036 patients were screened of whom 658 (63.5%) received psychopharmacological treatment. In 53 (8.1%) of these patients 54 sADRs were documented, of which 37 sADRs were identified as potentially preventable through PDIS. Mitigating sADR through PDIS would likely have prevented prolonged hospital stays and conferred considerable savings for health insurance companies. PDIS provides systematic and evidence-based information about pediatric psychopharmacotherapy and helps to prevent prescribing errors. Therefore, PDIS is a useful tool to increase drug therapy safety in child and adolescent psychiatry. Further prospective studies are needed to confirm the results.

Special Considerations for Management of Diabetes in Adult Patients with Intellectual and Developmental Disabilities

Diabetes mellitus (DM) is a chronic health condition that is very prevalent worldwide. It has been demonstrated that individuals with intellectual and developmental disabilities (IDDs) are at a disproportionately high risk for developing diabetes. Persons with IDDs are estimated to be 2-3 times more likely to develop DM compared to the general population. The elevated risk of developing diabetes within the population of adults with IDDs is multifactorial and includes contributions from genetics, lifestyle, medication use and misuse, boundaries to appropriate medical care, a higher incidence of comorbid mental health disorders, and others. Further, inadequate screening for and management of diabetes for these patients results in heightened risk for adverse cardiovascular events and inferior health care outcomes. To improve patient outcomes for this unique patient population, health care providers need to be well trained in the optimal modalities of screening, diagnosis, and management of diabetes in adults with IDDs. This requires the development of effective diabetes intervention and health promotion programs aimed at patients with IDDs, utilizing a patient-centered approach to screening and management, and conducting further research to assess the impact of these interventions.

Pharmacotherapy of Disruptive Behaviors in Children with Intellectual Disabilities

Disruptive behaviors are a class of predominantly externalizing behaviors that include physical aggression, property destruction, temper outbursts, verbal aggression, and some forms of self-injurious behaviors. Externalizing behaviors are also major components of disruptive, impulse-control and conduct disorders, disruptive mood dysregulation disorder, trauma-related and stressor-related disorders, intermittent explosive disorder, personality disorders, and other neuropsychiatric and neurodevelopmental disorders. Disruptive behaviors and associated disorders are among the most frequent reasons for child behavioral health referrals and are the most common reason for referrals among children with intellectual disabilities. The focus of this paper is on the adjunctive role of integrated psychopharmacological treatment in the management of children with disruptive behaviors and co-occurring intellectual disabilities. The decision-making process for adding pharmacotherapy to a comprehensive treatment plan incorporates not only a working knowledge of basic behavioral neurobiology of disruptive behaviors but also an understanding of the strengths and weaknesses of various pharmacotherapies. Importantly, there is little evidence to support the use of psychopharmacologic agents in managing difficult behaviors in children with intellectual disabilities, but with that said, risperidone has the strongest evidence base for its use.

Community-Based Support and Social Services and Their Association with Frailty Factors in Older People with Intellectual Disability and Affective and Anxiety Disorders: A Swedish National Population-Based Register Study

Affective and anxiety diagnoses are common in older people with intellectual disability (ID). The aim was to describe support and social services for older people with ID and affective and/or anxiety diagnoses, also to investigate in this study group the association between support and social services and frailty factors in terms of specialist healthcare utilisation, multimorbidity, polypharmacy, level of ID and behavioural impairment. Data was selected from four population-based Swedish national registries, on 871 identified persons with affective and/or anxiety diagnoses and ID. Multivariate regression analysis was used to investigate associations between frailty factors during 2002-2012 and social services in 2012. People with multimorbidity who frequently utilised specialist healthcare were less likely to utilise residential arrangements. Those with polypharmacy were more likely utilise residential arrangements, and receive personal contact. People with moderate, severe/profound levels of ID were more likely to utilise residential arrangements and to pursue daily activities.

TOP-ID: a Delphi technique-guided development of a prescription and deprescription tool for adults with intellectual disabilities

OBJECTIVES

Adults with an intellectual disability (AWID) are often polymedicated because of somatic and psychiatric health problems. Besides, they may display challenging behaviours, leading to off-label prescription of psychotropic drugs, without efficacy and with numerous adverse effects. In this context, a prescription/deprescription tool (Tool for Optimising Prescription in Intellectual Disability/TOP-ID) was developed to improve the care of AWID. This paper describes how TOP-ID was designed.

DESIGN

Four-step consensus-based process involving a review of the literature, eight semistructured interviews and a two-round Delphi process.

SETTING

Seventeen general practices and university and general hospitals from Belgium, France and Switzerland.

PARTICIPANTS

Eighteen French-speaking physicians from different domains of expertise participated in the Delphi process.

PRIMARY AND SECONDARY OUTCOME MEASURES

For the Delphi iteration process, consensus was defined as at least a 65% agreement between the experts.

RESULTS

Two rounds were needed for the Delphi process. Eighty-one items of the tool were submitted to 18 out of 35 recruited French-speaking experts during the first round. Sixty-nine per cent of the items reached a rate of agreement of 65% or more in that round. Thirteen questions were reformulated and resubmitted for the second Delphi iteration round. All of the statements reached a rate of agreement of 65% or more in the second round.

CONCLUSION

TOP-ID is the first prescription-deprescription tool developed specifically for AWIDs in French. It is intended to help prescribers document patient care in order to reduce prescription errors and to improve safety. The next steps of the project include the development of an electronic version of TOP-ID and a utility study.

Psychotropic medications use and side effects of individuals with intellectual and developmental disabilities

BACKGROUND

Many people with intellectual and developmental disabilities (IDD) are treated with psychotropic medications, and polypharmacy is common. Although few studies address psychotropic side effects in the population, people with IDD have been found more likely to experience side effects than others who do not have IDD. Because many individuals with IDD may not report side effects reliably, there is risk that side effects may be missed.

METHODS

Psychotropic use and side effects of 71 adults with IDD admitted for a 30-day crisis stay to a Systemic, Therapeutic, Assessment, Resources, and Treatment (START) Resource Center were reviewed. START is a specialised behavioural health outreach, training and crisis programme for individuals with IDD. During crisis stays, centre nurses administer the Matson Evaluation of Drug Side Effects screen, a psychometrically established psychotropic medication side effects screen developed for use with people with IDD. Data reviewed were de-identified data used to inform day-to-day practices and assess outcomes for individuals START served.

RESULTS

The average age was 28 years, and 56% of the sample was male. All individuals were taking at least one psychotropic, while 79% were taking three or more. The average number of psychotropics used was 3.94. Antipsychotics were the most commonly prescribed medications taken by 85% of the sample; 49% of whom were not reported to have psychosis. Although the overall number of psychotropics did not correlate with Matson Evaluation of Drug Side Effects scores, the average scale scores for all participants was high in contrast to prior studies of people with IDD not taking psychotropics, with central nervous system side effects being the most commonly reported.

CONCLUSION

In the present study, data for individuals experiencing a crisis were reviewed and indicated high rates of psychotropic polypharmacy and side effects rates higher than previously reported for people with IDD not taking psychotropics. Prospective study in larger samples is needed to determine if missed or under-appreciated psychotropic side effects may play a role in behavioural health challenges of some people with IDD.

Effectiveness of medication reviews in identifying and reducing medication-related problems among people with intellectual disabilities: A systematic review

Background

Polypharmacy is common in people with intellectual disabilities. Using multiple medication may lead to unintended medication‐related problems (MRPs). Medication review may serve as a tool to reduce MRPs. This systematic review assessed the scientific evidence for the effectiveness of medication reviews in identifying and reducing MRPs in people with intellectual disabilities.

Method

Literature databases were searched up to August 2017. Studies were selected that included the effect of medication reviews on identifying and/or reducing MRPs in people with intellectual disabilities with no restriction of type of medication, age and level of intellectual disabilities.

Results

The eight studies that fulfilled the inclusion criteria report that systematic medication reviews appear to assist in the identification and reduction of MRPs.

Conclusion

There is a lack of studies about the effect of medication reviews on identification and reduction of MRPs, especially health outcomes for people with intellectual disabilities. Further studies with long‐term follow‐up are needed.

Psychotropic medication and psychotherapeutic treatment of adults with intellectual disabilities (PROMPT-ID): a cross-sectional, epidemiological study in Saxony, Germany

INTRODUCTION

The psychotropic medication and psychotherapeutic treatment of adults with intellectual disabilities study is a cross-sectional, epidemiological study carried out in Saxony, Germany. The main aim of the study is, among others, to assess the prevalence and quality of psychotropic medication in adults with ID.

METHODS

Inclusion criteria are mild to profound forms of ID and an age of 18 years or older. A representative sample is realised by a two-stage sampling procedure. Study participants will be recruited from sheltered workshops (SW) and sheltered housings (SH). The stratified cluster sampling is realised by a random selection of service providing institutions followed by a random selection of adults with ID. An estimated total number of n=200 study participants via SW and n=400 via SH will be contacted to obtain data of approximately n=131 study participants recruited through SW and n=232 participants through SH. Thus, based on a psychotropic medication prevalence of 30%, an estimated number of n=109 in-depth interviews about psychotropic prescription practice will be carried out. Data collection is realised through interviews with key carers in the living environment. If psychotropics are prescribed currently, basic information (eg, dosage, treatment duration) are obtained, and a newly developed interview targeting the quality of the psychotropic medication treatment is conducted both with the carers and with the prescribing physicians. In addition to the prevalence and quality of psychotropic treatment, other parameters (eg, mental healthcare utilisation, psychiatric symptomatology, problem behaviour, institutional factors and parameters of the provision area) are assessed using well-established instruments.

ETHICS AND DISSEMINATION

Approval of the responsible ethics committee was obtained. Findings will be disseminated to participating institutions, published in journals and conferences and fill the lack of representative data that is urgently needed in this often criticised health service area. They shall help to improve mental health services in adults with ID prospectively.

TRIAL REGISTRATION NUMBER

NCT03558815; Pre-results.

Anticholinergic burden in adult and elderly people with intellectual disabilities: Results from an Italian multicenter cross-sectional study

BACKGROUND

Adults and older people with intellectual disabilities (ID) frequently receive anti-cholinergic drugs in chronic use, but no studies in Italy to date have investigated cumulative anticholinergic exposure and factors associated with high anticholinergic burden in this frail population.

AIM

To probe the cumulative exposure to anticholinergics and the demographic, social and clinical factors associated with high exposure.

METHODS

The 2012 updated version of the Anticholinergic Burden Score (ACB) was calculated for a multicentre sample of 276 adult and older people over 40 years with ID and associations with factors assessed.

RESULTS

Overall, antipsychotics, antiepileptics, anxiolytics, and antidepressants were the most frequent classes contributing to the total ACB score. People living in residential care were more likely exposed to high anticholinergic burden (an ACB score of 3+): both community housing (odds ratio [OR] 4.63, 95%CI 1.08-19.95) and nursing home facility ([OR] 9.99, 95%CI 2.32-43.04). There was also a significant association between an ACB score of 3+ and reporting mental health conditions ([OR] 25.56, 95% CI 8.08-80.89) or a neurological disease ([OR] 4.14, 95%CI 1.32-12.94). Neither demographic characteristics (age and gender) nor other clinical conditions (somatic comorbidity, levels and typology of ID) were associated with higher anticholinergic load. A high burden of anticholinergic was significantly more frequent in laxative users (22.6% ACB3+ vs. 5.1% ACB 0) (p = 0.003).

CONCLUSIONS

Psychotropics drugs were the highest contributors to the anticholinergic burden in adult and old age ID, especially in those people living in institutional settings with mental health and/or neurological conditions. High anticholinergic load has shown to be associated with the use of laxatives.

Non-pharmacological interventions for adults with intellectual disabilities and depression: a systematic review

BACKGROUND

Although high rates of depression symptoms are reported in adults with intellectual disabilities (IDs), there is a lack of knowledge about non-pharmacological treatment options for depression in this population. The first research question of this paper is: Which non-pharmacological interventions have been studied in adults with ID and depression? The second research question is: What were the results of these non-pharmacological interventions?

METHOD

Systematic review of the literature with an electronic search in six databases has been completed with hand searches. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines have been followed. Selected studies met predefined inclusion criteria.

RESULTS

Literature search resulted in 4267 papers of which 15 met the inclusion criteria. Five different types of non-pharmacological interventions have been studied: cognitive behavioural therapy, behavioural therapy, exercise intervention, social problem-solving skills programme and bright light therapy.

CONCLUSION

There are only a few studies of good quality evaluating non-pharmacological interventions for adults with ID and depression. Some of these studies, especially studies on cognitive behavioural therapy, show good results in decreasing depressive symptoms. High-quality randomised controlled trials evaluating non-pharmacological interventions with follow-up are needed.

Characterization, treatment patterns, and patient-related outcomes of patients with Fragile X syndrome in Germany: final results of the observational EXPLAIN-FXS study

BACKGROUND

As data on the phenotype, characteristics and management of patients with Fragile X Syndrome (FXS) are limited, we aimed to collect such data in Germany in experienced centres involved in the treatment of such patients.

METHODS

EXPLAIN-FXS is a prospective observational (non-interventional) study (registry) performed between April 2013 and January 2016 at 18 sites in Germany. Requirements for patient participation included confirmed diagnosis of FXS by genetic testing (>200 CGG repeats) and written informed consent. Patients were followed for up to 2 years.

RESULTS

Seventy-five patients (84.0 % males, mean age 16.7 ± 14.5 years, ranging from 2 - 82 years) were analysed. The mean 6-item score, determined according to Giangreco (J Pediatr 129:611-614, 1996), was 6.9 ± 2.5 points. At least one neurological finding each was noted in 53 patients (69.7 %). Specifically, ataxia was noted in 5 patients (6.6 %), lack of fine motor skills in 40 patients, (52.6 %), muscle tonus disorder in 4 patients (5.3 %), and other neurological disorders in 39 patients (51.3 %). Spasticity was not noted in any patient. Seizures were reported in 6 patients (8.1 %), anxiety disorders in 22 patients (30.1 %), depression in 7 patients (9.6 %), ADHD/ADD in 36 patients (49.3 %), impairment of social behavior in 39 patients (53.4 %), and other comorbidities in 23 patients (31.5 %). The mean Aberrant Behaviour Checklist Community Edition (ABC-C) score on behavioral symptoms, obtained in 71 patients at first documentation, was 48.4 ± 27.8 (median 45.0, range 5-115). The mean visual analogue scale (VAS) score, obtained in 59 patients at first documentation, was 84.9 ± 14.6 points (median 90; range 50 - 100).

CONCLUSIONS

This report describes the largest cohort of patients with FXS in Europe. The reported observations indicate a substantial burden of disease for patients and their caregivers. Based on these observations, an early expert psychiatric diagnosis is recommended for suspected FXS patients. Further recommendations include multimodal and multi-professional management that is tailored to the individual patient's needs.

TRIAL REGISTRATION

The ClinTrials.gov identifier is NCT01711606 . Registered on 18 October 2012.

Assessing the Impact of Psychotropic Medication Changes on Challenging Behavior of Individuals with Intellectual Disabilities

OBJECTIVE

The use of psychotropic medication to address challenging behavior in individuals diagnosed with intellectual disabilities is common practice; however, very few studies have examined how multiple medication use (or combination treatment) impacts the behaviors these medications are prescribed to treat.

METHOD

The current study followed eight individuals over a two-year period as they experienced changes in their psychotropic medication regimens. During that time, data from functional analyses and indirect assessments of challenging behavior were collected.

RESULTS

The results suggest that changes in psychotropic medication regimens can produce changes in functional assessment outcomes, suggesting a need for continued behavioral assessment to better inform medication practices and behavioral treatment. Of the eight participants in the study, five participants' behaviors varied in rate of responding in FAs across all medication changes. Additionally, three participants' FAs produced changes in outcomes; however, those changes were not consistent across all medication changes, that is, not every medication change yielded different outcomes from previous assessments.

CONCLUSION

This study demonstrates how the outcome of an FA can be used to monitor the effects of psychotropic medication changes, specifically when medications are combined, on challenging behavior in individuals with intellectual and developmental disabilities.

Central nervous system medication use in older adults with intellectual disability: Results from the successful ageing in intellectual disability study

OBJECTIVE

Information on the rates and predictors of polypharmacy of central nervous system medication in older people with intellectual disability is limited, despite the increased life expectancy of this group. This study examined central nervous system medication use in an older sample of people with intellectual disability.

METHODS

Data regarding demographics, psychiatric diagnoses and current medications were collected as part of a larger survey completed by carers of people with intellectual disability over the age of 40 years. Recruitment occurred predominantly via disability services across different urban and rural locations in New South Wales and Victoria. Medications were coded according to the Monthly Index of Medical Specialties central nervous system medication categories, including sedatives/hypnotics, anti-anxiety agents, antipsychotics, antidepressants, central nervous system stimulants, movement disorder medications and anticonvulsants. The Developmental Behaviour Checklist for Adults was used to assess behaviour.

RESULTS

Data were available for 114 people with intellectual disability. In all, 62.3% of the sample was prescribed a central nervous system medication, with 47.4% taking more than one. Of those who were medicated, 46.5% had a neurological diagnosis (a seizure disorder or Parkinson's disease) and 45.1% had a psychiatric diagnosis (an affective or psychotic disorder). Linear regression revealed that polypharmacy was predicted by the presence of neurological and psychiatric diagnosis, higher Developmental Behaviour Checklist for Adults scores and male gender.

CONCLUSION

This study is the first to focus on central nervous system medication in an older sample with intellectual disability. The findings are in line with the wider literature in younger people, showing a high degree of prescription and polypharmacy. Within the sample, there seems to be adequate rationale for central nervous system medication prescription. Although these data do not indicate non-adherence to guidelines for prescribing in intellectual disability, the high rate of polypharmacy and its relationship to Developmental Behaviour Checklist for Adults scores reiterate the importance of continued medication review in older people with intellectual disability.

Pharmacotherapy for mental health problems in people with intellectual disability

PURPOSE OF REVIEW

Psychotropic medications are commonly prescribed to people with intellectual disability. We reviewed current evidence-based pharmacotherapy options and recent updates to guide clinicians in their medication management plans.

RECENT FINDINGS

Antipsychotics, particularly risperidone, appear to be effective in reducing problem behaviors in children with intellectual disability. Evidence in adults is inconclusive. Methylphenidate appears to be effective, and α-agonists appear promising in reducing attention-deficit hyperactivity disorder symptoms. Lithium might be effective in reducing aggression. Evidence is limited to support the use of antiepileptic drugs, anxiolytics, and naltrexone for management of problem behaviors. Antidepressants may be poorly tolerated and might not be effective in reducing repetitive/stereotypic behaviors.In recent trials, glutamatergic and GABAergic agents for fragile X syndrome, and acetylcholinesterase inhibitors for Down's syndrome, failed to show efficacy. Growth hormone treatment might improve cognition and behavior in Prader-Willi syndrome population. Results from oxytocin trials on social behaviors are inconclusive albeit promising. Melatonin appears to improve sleep. Most trials of dietary supplements did not show benefits.

SUMMARY

Evidence-based pharmacotherapy options in people with intellectual disability are limited, and many agents can cause substantial adverse events. For this reason, clinicians should consider pharmacotherapy as only a part of comprehensive treatment, and regularly assess drug effects, adverse events, and the feasibility of decreasing dose or withdrawing medications.

Structured Medication Review to Improve Pharmacotherapy in People with Intellectual Disability and Behavioural Problems

BACKGROUND

Polypharmacy and chronic drug use are common in people with intellectual disability and behavioural problems, although evidence of effectiveness and safety in this population is lacking. This study examined the effects of a structured medication review and aimed to improve pharmacotherapy in inpatients with intellectual disability.

METHODS

In a treatment facility for people with mild to borderline intellectual disability and severe behavioural problems, a structured medication review was performed. Prevalence and type of drug-related problems (DRPs) and of the recommended and executed actions were calculated.

RESULTS

In a total of 55 patients with intellectual disability and behavioural problems, 284 medications were prescribed, in which a DRP was seen in 106 (34%). No indication/unclear indication was the most prevalent DRP (70). Almost 60% of the recommended actions were also executed.

CONCLUSIONS

This high prevalence of DRPs is worrying. The structured medication review is a valuable instrument to optimize pharmacotherapy and to support psychiatrists in adequate prescribing of both psychotropic and somatic drugs.