Aging and Developmental Disability

Interventions to reduce falls in community-dwelling adults with intellectual disability: a systematic review

BACKGROUND

People with intellectual disability have a high risk of falls and falls-related injuries. Although people with intellectual disability are at increased risk of falls, there is a need to better understand the efficacy of interventions that can help reduce falls and address risk factors in this population. This systematic review aimed to evaluate the type, nature and effectiveness of interventions undertaken to reduce falls with community-dwelling adults with intellectual disability and the quality of this evidence.

METHOD

Four electronic databases were searched: Ovid MEDLINE, PsycINFO, CINAHL Plus and the Cochrane Library. Studies were included if they involved people aged 18 years or over, at least 50% of study participants had intellectual disability, participants were community-dwelling, and the study evaluated any interventions aiming to reduce falls. Study quality was assessed using the National Institutes of Health study quality assessment tools. Reporting of the review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Seven studies were eligible for review, with a total of 286 participants and mean age of 50.4 years. As only one randomised trial was identified, a narrative synthesis of results was undertaken. Five studies evaluated exercise interventions, one evaluated a falls clinic programme, and one evaluated stretch fabric splinting garments. Methodological quality varied (two studies rated as good, four as fair, and one as poor). Exercise interventions varied in terms of exercise type and dosage, frequency and intensity, and most did not align with recommendations for successful falls prevention exercise interventions reported for older people. While the majority of studies reported reduced falls, they differed in methods of reporting falls, and most did not utilise statistical analyses to evaluate outcomes.

CONCLUSION

This review identified a small number of falls prevention intervention studies for people with intellectual disability. Although several studies reported improvements in fall outcomes, ability to draw conclusions about intervention effectiveness is limited by small sample sizes and few studies. Further large-scale research is required to implement and evaluate falls prevention interventions specifically for adults with intellectual disability.

Factors associated with the progression of deficit accumulation frailty among adults with an intellectual disability: a systematic review revealing research gaps

Background: People with an intellectual disability are more likely to experience frailty earlier in life and with greater severity compared to the general population. There is growing consideration of determinants of frailty and identifying factors which may influence the change in frailty status over time. The objective of this review was to investigate factors associated with the progression of frailty over time among adults with an intellectual disability. Methods: A systematic review of literature was conducted using PRISMA guidelines to identify studies reporting factors associated with transitions and trajectories in deficit accumulation frailty among adults with an intellectual disability. The following eligibility criteria was used: defined frailty as deficit accumulation; longitudinal design; reported at least one individual characteristic associated with change in frailty status; sample was people with an intellectual disability aged ≥18 years; English language. No limitation on publication date was applied. Studies which did not measure frailty according to deficit accumulation, did not report the frailty measure used, or had a cross-sectional design were excluded. Selected studies were assessed for quality using the Critical Appraisal Skills Programme (CASP) framework. Results: In total, two studies qualified for inclusion in this review. Findings revealed that frailty defined as deficit accumulation is a dynamic process and improvements are possible. Changes in the direction of frailty states over time among adults with an intellectual disability may be influenced by several factors including baseline frailty status, age, the presence of Down syndrome, functional ability, cognitive ability, living in a group home, and the use of nursing services and therapies. Conclusions: There is a relative paucity of research on frailty among adults with an intellectual disability and the evidence base must be grown. Exploration of the social domain of frailty in this group should be a priority of future research. PROSPERO registration: 179803 (05/07/2020)

Musculoskeletal diagnoses, comorbidities, and physical and occupational therapy use among older adults with and without cerebral palsy

BACKGROUND

Musculoskeletal (MSK) disorder in adults with cerebral palsy (CP) is higher than in the general population. Evidence lacks about physical therapy (PT) and occupational therapy (OT) service utilization among older adults (65> years) living with CP.

OBJECTIVE

We compared the presence of comorbidities and patterns of PT and OT use among older adults with and without CP seeking care for MSK disorders.

METHODS

A 20% national sample of Medicare claims data (2011-2014) identified community-living older adults with (n = 8796) and without CP (n = 5,613,384) with one or more ambulatory claims for MSK diagnoses. The sample matched one CP case to two non-CP cases per year on MSK diagnoses, age, sex, race, dual eligibility, and census region. Exposure variable was the presence/absence of a CP diagnosis. Outcomes were use of PT and OT services identified via CPT and revenue center codes, and the presence/absence of Elixhauser comorbidities.

RESULTS

In older adults with MSK diagnoses, less than a third regularly utilized PT and/or OT services, and adults with CP utilized significantly less PT than adults without CP, and for some MSK diagnoses had fewer visits than their matched peers. Older adults with CP were at greater risk for secondary conditions that influence morbidity, mortality, and quality of life compared to their age-matched peers without CP.

CONCLUSIONS

Older adults with CP and MSK diagnoses had a greater prevalence of numerous comorbidities and lower use of PT services relative to their non-CP peers.

A Photovoice Study: The life experiences of middle-aged adults with intellectual disabilities in Korea

BACKGROUND

As adults with intellectual disabilities approach older adulthood, they face unique physical and psychosocial challenges. This study explored the lived experiences of middle-aged adults with intellectual disabilities living in their community.

METHOD

Six sessions of Photovoice were conducted with a purposeful sample of six middle-aged adults with intellectual disabilities in South Korea. Participants were involved with the theme selection, taking photographs related to the themes, group discussion of photo stories and sharing Photovoice outcomes.

RESULTS

Thematic analysis yielded 11 subthemes under the five major themes selected by the participants: health, free time, time in the centre, family and my future in old age.

CONCLUSIONS

The study findings showed complex issues middle-aged adults with intellectual disabilities may face in later life, including bereavement and healthy lifestyle concerns. It is important to create a space for meaningful social support and social interactions without stigma.

A Life Course Perspective on Growing Older With Cerebral Palsy

Despite most children with cerebral palsy (CP) now living within typical life spans, little is known about how the effects of CP unfold across the life course and impact participation in everyday life during adulthood. In this study, we explored the experiences of 38 adults growing older with CP. Data were gathered using semi-structured interviews focused on participants' engagement in activities in their community and analyzed using a life course perspective to deepen our understanding of the experiences of our participants. We found that individual agency, family and social contexts, as well as larger sociocultural contexts all shaped participants' experiences as they grew older. The findings highlight the usefulness of the life course perspective for understanding how the effects of a diagnosis of CP unfold over time. Further use of this perspective can better inform health care services to meet the needs of adults with CP aging with a lifelong disability.

Does the Person-Centered Care Model Support the Needs of Long-Term Care Residents With Serious Mental Illness and Intellectual and Developmental Disabilities?

Person-centered care approaches continue to evolve in long-term care (LTC). At the same time, these settings have faced increased challenges due to a more diverse and complex population, including persons with intellectual and developmental disabilities (IDD) and serious mental illness (SMI). This study examined the mental, social, and physical wellbeing of residents with different diagnoses, within a person-centered care model. It was hypothesized that individual wellbeing would be comparable among all residents, regardless of primary diagnosis. The study cohort was drawn from all admissions to long-term care facilities in the USA from 2011 to 2013. Data are based on admission, 3 and 6 month follow-up Minimum Data Set (MDS) 3.0 assessments. The groups examined included: schizophrenia, other psychotic disorders, IDD, dementia, and all others (i.e., none of the above diagnoses). The wellbeing outcomes were depression (mental), pain (physical), and behaviors (social). All residents experienced improvements in pain and depression, though the group without the examined diagnoses experienced the greatest gains. Behaviors were most prevalent among those with psychotic disorders; though marked improvements were noted over time. Improvement also was noted among persons with dementia. Behavior worsened over time for the three other groups. In particular, those with IDD experienced the highest level of worsening at 3-month follow-up, and continued to worsen. The results suggest person-centered care in US nursing homes provides the necessary foundation to promote mental and physical wellbeing in persons with complex needs, but less so for social wellbeing.

Examination of Community Participation of Adults With Disabilities: Comparing Age and Disability Onset

Objective: Explore community participation between adults with disabilities ⩽50 and >50 years and between early-(⩽40) and late-(>40) onset disability. Method: A survey examining participation was conducted with a national convenience sample of 692 community-dwelling adults with disabilities. Results: Participants ⩽50 reported presence of more (p < .05) environmental supports for work/volunteer/education and use of transportation. Participants >50 had higher (p < .01) visits to pharmacies; higher (p < .05) evaluative quality of participation (EQOP) at gas stations, exercise facilities, beauty salons/barbers, and use of transportation (p < .01); and more difficulty participating without assistance at grocery stores (p < .05) and gas stations (p < .01). The early-onset group reported higher (p < .05) EQOP at work/volunteer/education and homes of family/friends. The late-onset group reported higher (p < .01) EQOP at exercise facilities; more (p < .05) environmental supports at pharmacies, restaurants, grocery stores (p < .01), doctors' offices (p ⩽ .01), and beauty salons/barbers (p < .01); greater (p < .01) influence of pain/fatigue; and more difficulty without assistance at grocery stores (p < .05) and gas stations (p < .01). Discussion: Understanding these differences can improve interventions to support community participation of individuals aging with disabilities.

Improving Prediction of Risk of Admission to Long-Term Care or Mortality Among Home Care Users With IDD

Background

Frailty is an established predictor of admission into long-term care (LTC) and mortality in the elderly population. Assessment of frailty among adults with intellectual and developmental disabilities (IDD) using a generic frailty marker may not be as predictive, as some lifelong disabilities associated with IDD may be interpreted as a sign of frailty. This study set out to determine if adding the Home Care-Intellectual and Developmental Disabilities Frailty Index (HC-IDD Frailty Index), developed for use in home care users with IDD, to a basic list of predictors (age, sex, rural status, and the Johns Hopkins Frailty Marker) increases the ability to predict admission to long-term care or death within one year.

Methods

A retrospective cohort study was conducted using Residential Assessment Instrument for Home Care (RAI-HC) data for adult home care users with IDD who had a home care assessment between January 1, 2010 and December 31, 2013 (N = 6,169).

Results

The HC-IDD Frailty Index was found to significantly improve prediction of transitions into LTC or death by explaining an additional 5.95% of the variance in such transitions among home care users with IDD (p value < .0001).

Conclusions

We recommend the use of the HC-IDD Frailty Index in care planning and in further research related to the effectiveness of interventions to reduce or delay adverse age-related outcomes among adults with IDD.

What do stakeholders understand by self-determination? Consensus for its evaluation

BACKGROUND

Advances in international studies on self-determination point out the need for continuous efforts to deepen its understanding and implications. The aim of this study is to obtain a comprehensive pool of items to operationalize the self-determination construct that serves as a starting point towards a valid instrument based on the reports of others.

METHOD

We conducted a Delphi study of three rounds involving three panels of experts: ten professionals, five people with intellectual disability and six relatives of people with intellectual disability. Data analysis required both qualitative and quantitative methods.

RESULTS

The initial pool of 131 items was refined through the different rounds to a final set composed of 115-some were removed and new ones were added. Content-based evidence is provided. In this study, the present authors generated a potential valid pool of items to develop a new measurement tool based on the latest advances on the self-determination theoretical framework.

CONCLUSIONS

The implications for future research focus on strengthening the knowledge of self-determination.

Accelerated functional losses in ageing congenital Minamata disease patients

Severe methylmercury poisoning occurred in Minamata and neighboring communities in Japan during the 1950s and 1960s. A considerable number of children were born with conditions resembling cerebral palsy, later known as congenital Minamata disease. Although surviving patients are now in their 50s or 60s, few assessments of functional capacities in daily living have been performed. We assessed the changes in Activities of Daily Living (ADL) status of 11 patients over a 10-year period. For assessment of ADL, we applied the Barthel Index (BI) and the Functional Independence Measure (FIM). We obtained the patients' current and previous status information by interview of their caregivers or from medical records and then compared them using the Wilcoxon signed-rank test. Both ADL measures, including the status related with cognition, had significantly declined during the 10 years. The same was true for the overall BI score (p = 0.01). Similarly, all functions of the FIM scores declined (i.e., self-care, sphincter control, mobility, locomotion, communication, and social cognition), and for FIM physical and cognition subscores as well as FIM total score, the declines were statistically significant. The present study indicates that the ADL status of congenital Minamata disease patients, now in their 50s or 60s, has substantially declined during the last 10 years; a decline that was much steeper in comparison with expectation in subjects of similar ages, but in agreement with accelerated ageing also reported in subjects with cerebral palsy, past polio infection, or epilepsy. While already incapacitated due to the prenatal methylmercury poisoning, their accelerated ageing may suggest that patients with developmental neurotoxicity have less reserve capacity to compensate for normal ageing. These patients will need continuous and increasing medical and welfare support in the community.

Health status, health behaviors, and the ability to perform everyday activities in Poles aged ≥65 years staying in their home environment

Background

The incidence of chronic diseases increases with age; about 73% of people who are aged ≥60 years suffer from at least 1 chronic disease, and among those older than 70 years, chronic diseases afflict more than >84% of the population. According to epidemiological data, at least 4 chronic disease types coexist in senior citizens, causing their disability. These are mainly cardiovascular diseases; motor system diseases; ophthalmological, auditory, neurological, and mental diseases; and mental impairment. They worsen or limit self-dependence in everyday activities. The process begins with complex activities and advances with age. At first, functional performance deficits are discreet; then, they may gradually lead to complete dependence on other people or institutions.

Objective

This study aimed to assess the relationship between diseases and health behaviors, as well as the everyday functioning of people aged ≥65 years staying in their home environment.

Methods

The research involved 504 elderly people. The inclusion criteria were age (≥65 years) and staying in one's own home environment. The direct interview technique was applied, as well as use of proprietary interview questionnaire and standardized tools used in geriatrics: Barthel scale, measuring performance in everyday activities, and the Instrumental Activities of Daily Living scale, assessing complex everyday activities.

Results

The most frequent disease among the responders was arterial hypertension (77.58%), followed by degenerative joint disease (62.10%), and circulatory failure (43.23%). Lower functional performance was associated with circulatory failure, cerebral stroke, atherosclerosis, Alzheimer's disease, diabetes, Parkinson's disease, degenerative joint disease, and bronchial asthma. Performance worsening significantly influenced the frequency of hospitalizations, with a mean score of 4.31 per person. Medical rehabilitation was practiced by 18.65% of the responders.

Conclusion

Circulatory failure, cerebral stroke, atherosclerosis, bronchial asthma, diabetes, degenerative joint disease, Parkinson's disease, and Alzheimer's disease negatively affect functional performance in elderly people. Hospitalization rates increase with lowering independence in everyday functioning. Future research is needed with regard to the relationship between the practiced rehabilitation and independence in everyday functioning of the elderly.

Once frail, always frail? Frailty transitions in home care users with intellectual and developmental disabilities

AIM

Frailty is understood as a dynamic non-linear process, and used to indicate age-related decline. Recent work has shown that adults with intellectual and developmental disabilities experience higher rates of frailty at much earlier ages than the general population. The present study describes transitions in frailty status (i.e. non-frail, pre-frail, frail) over 1 year, and explores the association between baseline frailty status and worsening/death over time.

METHODS

Results are based on secondary analysis of 2893 individuals with intellectual and developmental disabilities receiving community-based home care services in Ontario (Canada). Frailty status is based on a validated 42-item frailty index (FI); where FI ≤0.21 indicates non-frail, 0.21 < FI ≤ 0.3 indicates pre-frail and FI >0.30 indicates frail. Baseline characteristics of frailty groups at baseline were compared using the χ² -test/analysis of variance. Relative risk of worsening/dying was calculated using a modified Poisson regression model.

RESULTS

Initially, 67.0% of participants were non-frail, 16.2% were pre-frail and 16.8% were frail. Of those non-frail at baseline, 84.3% remained non-frail, 11.8% worsened and 3.9% died. Among those initially pre-frail, 37.0% remained stable, 35.3% improved, 18.2% worsened and 9.6% died. Although similar proportions of frail individuals improved (37.4%) or remained stable (36.8%), 25.9% had died. After controlling for other factors, being pre-frail at baseline was associated with an increase in the risk of worsening or death (RR 1.24, 95% CI 1.04-1.49).

CONCLUSIONS

While many experience worsening of frailty status, stability and improvement are viable goals of care. Future research should examine the rate at which non-frail, pre-frail and frail individuals accumulate deficits, as well as the impact of home care services on frailty. Geriatr Gerontol Int 2018; 18: 547-553.

Medication, rehabilitation and health care consumption in adults with cerebral palsy: a population based study

Objective:

To evaluate medication, rehabilitation and healthcare consumption in adults with CP as a function of Gross Motor Function Classification System (GMFCS) level.

Design:

Questionnaire-based cross-sectional study.

Setting:

Brittany, a French county.

Subjects:

Adults with cerebral palsy.

Interventions:

Questionnaires relating to drugs, orthotic devices, mobility aids, rehabilitation and medical input were sent to 435 members of a unique regional French network dedicated to adults with cerebral palsy. The questionnaire was completed by the participant or a helper if necessary.

Results:

Of the 282 responders, 7.8% had a GMFCS level of I, 14.2% II, 17.7% III, 29.1% IV and 31.2% V. Participants consumed a large amount of healthcare. Almost three-quarters took orally administered drugs, of which antispastic and antiepileptic drugs were among the most frequent. Nearly all patients had at least one type of rehabilitation, 87.2% had physiotherapy, 78% used at least one mobility aid and 69.5% used at least one orthotic device. The frequency of numerous inputs increased with GMFCS level. Specificities were found for each GMFCS level, e.g. participants with GMFCS level IV and V had a high level of medical input and a greater use of trunk-supporting devices, antireflux and laxative. Profiles could be established based on GMFCS levels.

Conclusions:

Adults with cerebral palsy use a large amount of drugs, mobility aids, orthotic devices, rehabilitation and medical input. Healthcare is targeted at cerebral palsy-related issues. GMFCS is a determinant of healthcare consumption and thus a useful tool for clinical practice to target care appropriately.

Frailty as a Predictor of Institutionalization Among Adults With Intellectual and Developmental Disabilities

Adults with intellectual and developmental disabilities (IDD) frequently become frail earlier than the general population, resulting in higher care needs. This population is at risk for institutionalization, or re-institutionalization, into long-term care (LTC). Using a retrospective cohort design to follow 3,034 individuals (18-99 years) living in Ontario, Canada, and assessed with the Resident Assessment Instrument-Home Care, individuals were characterized with a frailty index (FI) for persons with IDD. Survival analyses determined differences in rates of admission to LTC and survival in the community. Frail individuals had greater rates of admission than non-frail individuals, adjusted HR = 2.19, 95% CI [1.81, 2.64]. The FI predicts institutionalization.

The continuum of care for individuals with lifelong disabilities: role of the physical therapist

Many individuals with lifelong disabilities (LLDs) of childhood onset are living longer, participating in adult roles, and seeking comprehensive health care services, including physical therapy, with greater frequency than in the past. Individuals with LLDs have the same goals of health and wellness as those without disabilities. Aging with a chronic LLD is not yet well understood; however, impairments such as pain, fatigue, and osteoporosis often present earlier than in adults who are aging typically. People with LLDs, especially those living with developmental disabilities such as cerebral palsy, myelomeningocele, Down syndrome, and intellectual disabilities, frequently have complex and multiple body system impairments and functional limitations that can: (1) be the cause of numerous and varied secondary conditions, (2) limit overall earning power, (3) diminish insurance coverage, and (4) create unique challenges for accessing health care. Collaboration between adult and pediatric practitioners is encouraged to facilitate smooth transitions to health practitioners, including physical therapists. A collaborative client-centered emphasis to support the transition to adult-oriented facilities and promote strategies to increase accessibility should become standard parts of examination, goal setting, and intervention. This perspective article identifies barriers individuals with selected LLDs experience in accessing health care, including physical therapy. Strategies are suggested, including establishment of niche practices, physical accessibility improvement, and inclusion of more specific curriculum content in professional (entry-level) doctorate physical therapy schools.

Cerebral palsy

The syndrome of cerebral palsy encompasses a large group of childhood movement and posture disorders. Severity, patterns of motor involvement, and associated impairments such as those of communication, intellectual ability, and epilepsy vary widely. Overall prevalence has remained stable in the past 40 years at 2-3·5 cases per 1000 livebirths, despite changes in antenatal and perinatal care. The few studies available from developing countries suggest prevalence of comparable magnitude. Cerebral palsy is a lifelong disorder; approaches to intervention, whether at an individual or environmental level, should recognise that quality of life and social participation throughout life are what individuals with cerebral palsy seek, not improved physical function for its own sake. In the past few years, the cerebral palsy community has learned that the evidence of benefit for the numerous drugs, surgery, and therapies used over previous decades is weak. Improved understanding of the role of multiple gestation in pathogenesis, of gene environment interaction, and how to influence brain plasticity could yield significant advances in treatment of the disorder. Reduction in the prevalence of post-neonatal cerebral palsy, especially in developing countries, should be possible through improved nutrition, infection control, and accident prevention.

The potential for technology to enhance independence for those aging with a disability

Technologies of all kinds can sustain and accelerate improvements in health and quality of life for an aging population, and enhance the independence of persons with disabilities. Assistive technologies are widely used to promote independent functioning, but the aging of users and their devices produces unique challenges to individuals, their families, and the health care system. The emergence of new "smart" technologies that integrate information technology with assistive technologies has opened a portal to the development of increasingly powerful, individualized tools to assist individuals with disabilities to meet their needs. Yet, issues of access and usability remain to be solved for their usefulness to be fully realized. New cohorts aging with disabilities will have more resources and more experience with integrated technologies than current elders. Attention to technological solutions that help them adapt to the challenges of later life is needed to improve quality of life for those living long lives with disabilities.

The state of the science of health and wellness for adults with intellectual and developmental disabilities

Historically, people with intellectual and developmental disabilities (IDD) have experienced health disparities related to several factors including: a lack of access to high quality medical care, inadequate preparation of health care providers to meet their needs, the social determinants of health (e.g., poverty, race and gender), and the failure to include people with IDD in public health efforts and other prevention activities. Over the past decade, a greater effort has been made to both identify and begin to address myriad health disparities experienced by people with IDD through a variety of activities including programs that address health lifestyles and greater attention to the training of health care providers. Gaps in the literature include the lack of intervention trials, replications of successful approaches, and data that allow for better comparisons between people with IDD and without IDD living in the same communities. Implications for future research needed to reduce health disparities for people with IDD include: better monitoring and treatment for chronic conditions common in the general population that are also experienced by people with IDD, an enhanced understanding of how to promote health among those in the IDD population who are aging, addressing the health needs of people with IDD who are not part of the disability service system, developing a better understanding of how to include people with IDD in health and wellness programs, and improving methods for addressing the health care needs of members of this group in an efficient and cost-effective manner, either through better access to general medical care or specialized programs.

Ageing Challenges the Results of any Outcome Study: How to Address the Effects of Ageing on Activities of Daily Living

OBJECTIVES: Clinical study results might be substantially biased by the effects of ageing, resulting in considerable underestimation of treatment efficacy, especially when assessing activities of daily living (ADL) in elderly people. This study aimed to define age- and comorbidity-related normative values in ADL. METHODS: In cross-sectional sampling, 23 763 German-speaking Swiss individuals were contacted. Valid questionnaires from 16 191 (68%) eligible individuals ≥ 18 years of age were included in the study. Age-related ADL reference values were calculated using questionnaire data. RESULTS: The sample was representative of the German-speaking Swiss population as determined by 2003 census data. Age- and pain-related ADL reference values were plotted and confirmed that disability increased with increasing age. CONCLUSIONS: The use of ADL scales that provide age- and comorbidity-related reference values for outcome studies or studies focusing on the elderly is recommended in order to reduce the effect of bias.