Pain underreporting associated with profound intellectual disability in emergency departments

Heart rate monitoring to detect acute pain in non-verbal patients: a study protocol for a randomized controlled clinical trial

BACKGROUND

Autism entails reduced communicative abilities. Approximately 30% of individuals with autism have intellectual disability (ID). Some people with autism and ID are virtually non-communicative and unable to notify their caregivers when they are in pain. In a pilot study, we showed that heart rate (HR) monitoring may identify painful situations in this patient group, as HR increases in acutely painful situations.

OBJECTIVES

This study aims to generate knowledge to reduce the number of painful episodes in non-communicative patients' everyday lives. We will 1) assess the effectiveness of HR as a tool for identifying potentially painful care procedures, 2) test the effect of HR-informed changes in potentially painful care procedures on biomarkers of pain, and 3) assess how six weeks of communication through HR affects the quality of communication between patient and caregiver.

METHODS

We will recruit 38 non-communicative patients with autism and ID residing in care homes.

ASSESSMENTS

HR is measured continuously to identify acutely painful situations. HR variability and pain-related cytokines (MCP-1, IL-1RA, IL-8, TGFβ1, and IL-17) are collected as measures of long-term pain. Caregivers will be asked to what degree they observe pain in their patients and how well they believe they understand their patient's expressions of emotion and pain. Pre-intervention: HR is measured 8 h/day over 2 weeks to identify potentially painful situations across four settings: physiotherapy, cast use, lifting, and personal hygiene.

INTERVENTION

Changes in procedures for identified painful situations are in the form of changes in 1) physiotherapy techniques, 2) preparations for putting on casts, 3) lifting techniques or 4) personal hygiene procedures.

DESIGN

Nineteen patients will start intervention in week 3 while 19 patients will continue data collection for another 2 weeks before procedure changes are introduced. This is done to distinguish between specific effects of changes in procedures and non-specific effects, such as caregivers increased attention.

DISCUSSION

This study will advance the field of wearable physiological sensor use in patient care.

TRIAL REGISTRATION

Registered prospectively at ClinicalTrials.gov (NCT05738278).

Population-level use of gynecological health services by female youth with intellectual/developmental disabilities in British Columbia Canada

BACKGROUND

There is evidence that female youth with intellectual/developmental disabilities (IDD) experience poorer gynecological care compared to female youth without disabilities.

OBJECTIVE

The objective of this study was to obtain baseline data on visits to a health care provider for a gynecological issue for females with IDD and compare that information to the experiences of female youth without IDD.

METHODS

This study is a retrospective cohort study using population-level administrative health data from 2010 to 2019 for females aged 15-24 years, with and without IDD.

RESULTS

6452 female youth with IDD and 637,627 female youth without IDD were identified in the data. Over the ten-year period, 53.77% of youth with IDD and 53.68% of youth without IDD had a visit to a physician for a gynecological issue. However, as females with IDD aged, the number of people seeing a physician for a gynecological issue decreased. In the group aged 20-24 years, 15.25% of females with IDD and 24.47% of females without IDD (p < 0.0001) had a Pap test done at any time; 25.94% of females with IDD had a visit for contraception management and 28.38% of females (p < 0.0001) without IDD had a visit for contraception management. Gynecological care also varied by type of IDD.

CONCLUSIONS

Females with IDD had a similar number of visits for a gynecological issue as female youth without IDD. However, the reasons for visits and the age at which visits occurred differed between youth with and without IDD. As females with IDD transition into adulthood, gynecological care must be maintained and improved.

Pain research and children and adolescents with severe intellectual disability: ethical challenges and imperatives

Children with severe intellectual disabilities encounter inequities in pain-related care, yet little pain research involves this population. A considerable issue with pain research in this population is its ethical complexity. This Viewpoint delineates the ethical challenges of pain research involving children (aged 2-12 years) and adolescents (aged 13-21 years) with severe intellectual disabilities. There are two main issues. First, some of the standard methods for assessing pain and pain sensitivity are not suitable for individuals with severe intellectual disability, who are often non-verbal and unable to understand or follow instructions. Second, children and adolescents with severe intellectual disability cannot provide informed consent or assent to participate in pain research, and their dissent is not always recognised. The existing ethical guidelines for pain research by the International Association for the Study of Pain provide helpful, but general, guidance. This Viewpoint supplements these guidelines and uses a well established framework for assessing the ethics of clinical research to highlight points relevant to designing, doing, reviewing, and evaluating research involving children and adolescents with severe intellectual disability, focusing on issues that are unaddressed in existing guidance.

Intellectually disabled patients' intensive care admission characteristics, weaning from mechanical ventilation, and sedative drug use: a single-center retrospective case-control study

BACKGROUND

Intellectually disabled (ID) patients present unique therapeutic challenges. We aimed to describe the characteristics of ID patients admitted to a general intensive care unit (ICU).

RESULTS

We conducted a retrospective cohort study comparing critically ill adult ID patients to matched patients without ID (1:2 ratio) in a single ICU (2010-2020). The main outcome measure was mortality. Secondary outcomes included complications during admission and characteristics of weaning from mechanical ventilation. The study and control groups were randomly selected based on similar age and sex. ID patients nonetheless had an average APACHE score of 18.5 ± 8.7 vs. 13.4 ± 8.5 in controls (p < 0.001). ID patients had more hematological (p = 0.04), endocrinological (p < 0.001) and neurological (p = 0.004) comorbidities and used more psychiatric medication before admission. No difference was found in mortality rates. Differences were found as there were more secondary complications, such as pulmonary and sepsis (p < 0.03), frequent requirement of vasopressors (p = 0.001), significantly higher intubation rates with more weaning attempts, tracheostomies and longer ICU and hospital admissions (p < 0.019).

CONCLUSIONS

Critically ill adult ID may have more comorbidities and be sicker at the time of admission compared to their age- and sex-matched counterparts. They require more supportive treatment and their weaning from mechanical ventilation may be more challenging.

Emergency Medical Care of People with Intellectual Disabilities: A Scoping Review

Purpose

The paper intends to do a scoping review of people with intellectual disabilities in emergency care where this group seems to face access barriers and discrimination. It analyses the conceptual and methodological framework for studies examining the former.

Methods

A scoping review is conducted. The studies' quality is assessed via a checklist developed by the authors drawing on a compilation of common assessment tools for study quality.

Results

Fourteen quantitative studies fulfil the inclusion criteria for further analysis. Summary measures are extracted. Results are synthesized with Andersen's Behavioral Model of Health Service Use. Studies employ a combination of variables attributable to different aspects of population characteristics and health behavior.

Conclusion

Most studies seek to quantify or predict emergency care overuse by people with intellectual disabilities. Future studies should also take patients' poor health or treatment outcomes and their perspectives into account.

Clinical Efficacy Analysis of Fast Rehabilitation Nursing on Pain Mitigation after Lumbar Discectomy and Bone Graft Fusion and Internal Fixation

Objective

To investigate clinical efficacy analysis of fast rehabilitation nursing on pain mitigation after lumbar discectomy and bone graft fusion and internal fixation.

Methods

A total of 60 patients with lumbar disc herniation who underwent lumbar discectomy and bone graft fusion and internal fixation in our hospital from January 2021 to December 2021 were randomized either into routine group (n = 30) or rehabilitation group (n = 30) via the random number table method. The patients in the routine group were intervened with the routine postoperative nursing mode, and the patients in the rehabilitation group were intervened with the fast rehabilitation nursing mode on the basis of the nursing of the patients in the routine group. The rehabilitation effect, self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores, postoperative pain improvement, and nursing satisfaction were compared between the two groups.

Results

The postoperative rehabilitation effect of the rehabilitation group was significantly better than that of the routine group (P < 0.05). The fast rehabilitation nursing resulted in a notably lower postoperative SAS and SDS scores versus the routine nursing (P < 0.001). The postoperative pain was significantly mitigated in the rehabilitation group when compared with the routine group (P < 0.001). The fast rehabilitation nursing implemented in the rehabilitation group led to a remarkably higher nursing satisfaction of the patients (P < 0.001).

Conclusion

The fast rehabilitation nursing mode intervention for lumbar disc herniation patients undergoing lumbar discectomy and bone graft fusion and internal fixation is a promising approach to improve the postoperative rehabilitation, mitigate postoperative pain, and relieve anxiety, depression, and other negative emotions, with higher clinical nursing satisfaction.

Pain Behavior of People with Intellectual and Developmental Disabilities Coded with the New PAIC-15 and Validation of Its Arabic Translation

Pain management necessitates assessment of pain; the gold standard being self-report. Among individuals with intellectual and developmental disabilities (IDD), self-report may be limited and therefore indirect methods for pain assessment are required. A new, internationally agreed upon and user-friendly observational tool was recently published—the Pain Assessment in Impaired Cognition (PAIC-15). The current study’s aims were: to test the use of the PAIC-15 in assessing pain among people with IDD and to translate the PAIC-15 into Arabic for dissemination among Arabic-speaking professionals. Pain behavior following experimental pressure stimuli was analyzed among 30 individuals with IDD and 15 typically developing controls (TDCs). Translation of the PAIC followed the forward–backward approach; and reliability between the two versions and between raters was calculated. Observational scores with the PAIC-15 exhibited a stimulus–response relationship with pressure stimulation. Those of the IDD group were greater than those of the TDC group. The overall agreement between the English and Arabic versions was high (ICC = 0.89); single items exhibited moderate to high agreement levels. Inter-rater reliability was high (ICC = 0.92). Both versions of the PAIC-15 are feasible and reliable tools to record pain behavior in individuals with IDD. Future studies using these tools in clinical settings are warranted.

Mirror therapy for phantom limb pain in moderate intellectual disability. A case report

BACKGROUND

Phantom limb pain (PLP) is a common problem after limb amputation. There is mounting evidence supporting the use of mirror therapy (MT) in the treatment of individuals with PLP. However, there is no research studying the effects of MT on PLP in individuals with intellectual developmental disorders (IDD). The aim of this study was to increase our understanding of MT when used with adults with IDD and PLP through a case study approach.

METHODS

Here, we describe the use of MT with a 53-year-old female with moderate IDD and PLP, related to her left leg being amputated after ulcer complications. The study followed an A-B-A-B design (baseline-treatment-withdrawal of treatment-re-introduction of treatment), lasting 2 years, which included a long-term follow-up.

RESULTS

The data showed that the PLP sensation decreased after the MT treatment, with a raw change of 3.92 points and a 48% decrease in mean pain intensity ratings from pre- to post-treatment.

CONCLUSIONS

This is a unique case-report on the use of MT with an individual with IDD suffering from PLP. The findings show that MT helped to significantly reduce the intensity of the PLP in this patient.

SIGNIFICANCE

This is a case-report that illustrates how mirror therapy can be applied to people with intellectual developmental disorders and phantom limb pain. The results showed that phantom limb pain decreased after the mirror therapy, with a raw change of 3,92 points and a percent change of 48%.

Specific Behavioral Responses Rather Than Autonomic Responses Can Indicate and Quantify Acute Pain among Individuals with Intellectual and Developmental Disabilities

Individuals with intellectual and developmental disabilities (IDD) are at a high risk of experiencing pain. Pain management requires assessment, a challenging mission considering the impaired communication skills in IDD. We analyzed subjective and objective responses following calibrated experimental stimuli to determine whether they can differentiate between painful and non-painful states, and adequately quantify pain among individuals with IDD. Eighteen adults with IDD and 21 healthy controls (HC) received experimental pressure stimuli (innocuous, mildly noxious, and moderately noxious). Facial expressions (analyzed with the Facial Action Coding System (FACS)) and autonomic function (heart rate, heart rate variability (HRV), pulse, and galvanic skin response (GSR)) were continuously monitored, and self-reports using a pyramid and a numeric scale were obtained. Significant stimulus-response relationships were observed for the FACS and pyramid scores (but not for the numeric scores), and specific action units could differentiate between the noxious levels among the IDD group. FACS scores of the IDD group were higher and steeper than those of HC. HRV was overall lower among the IDD group, and GSR increased during noxious stimulation in both groups. In conclusion, the facial expressions and self-reports seem to reliably detect and quantify pain among individuals with mild-moderate IDD; their enhanced responses may indicate increased pain sensitivity that requires careful clinical consideration.

Prescription of pain medication among older cancer patients with and without an intellectual disability: a national register study

Background

The longevity for people with intellectual disability (ID) has significantly increased in developed countries during the past decades. Consequently, the incidence of cancer is expected to increase in this group. The aim of the present study was to investigate the prescription of pain medication in older cancer patients with intellectual disability (ID) compared to older patients in the general population, surviving or living with a cancer diagnosis.

Methods

This Swedish national registry-based study, included people with ID aged 55 years or older in 2012, and alive at the end of that year (ID cohort, n = 7936). For comparisons, we used a referent cohort, one-to-one matched with the general population by year of birth and sex (gPop cohort, n = 7936). People with at least one diagnosis of cancer during 2002–2012 were identified using the Swedish National Patient Register, resulting in 555 cancer patients with ID and 877 cancer patients from the general population. These two cohorts of cancer patients were compared with respect to prescription of pain medication for the period 2006–2012. Outcome data were aggregated so that each patient was categorized as either having or not having at least one prescription of each investigated drug group during the study period, and relative risks (RRs) for prescription were estimated for prescription in the ID cohort vs the gPop cohort.

Results

Cancer patients with ID were less likely than cancer patients in the gPop cohort to have at least one prescription of COX inhibitors (RR 0.61) and weak opioids (RR 0.63). They were, however, more likely to be prescribed paracetamol (RR 1.16), antidepressants (RR 2.09), anxiolytics (RR 2.84), and “other hypnotics, sedatives, and neuroleptics” (RR 1.39). No statistically significant differences between the two cohorts were found for strong opioids, antiepileptics, tricyclic antidepressants, or hypnotics and sedatives.

Conclusion

In the studied cohort of older people surviving or living with cancer, prescriptions for pain-treatment was less common in patients with ID compared to the general population. These results may suggest that pain is not sufficiently treated among cancer patients with ID, a situation that most likely would compromise the quality of life in this group.

Primary care for people with an intellectual disability - what is prescribed? An analysis of medication recommendations from the BEACH dataset

Background

People with intellectual disability (ID) experience a range of health disparities. Little is known about differential primary care prescribing patterns for people with and without ID.

Aim

To compare medications recommended by GPs at encounters where ID is recorded versus other encounters.

Design & setting

Analysis of national Australian GP medication data from the Bettering the Evaluation and Care of Health (BEACH) programme, January 2003–December 2012 inclusive.

Method

Medication recommendations made at encounters where an ID-defining problem was recorded as a reason for encounter (RFE) and/or as a problem managed, were allocated to the ‘ID group’ (n = 563). These encounters were compared with all other encounters (the ‘non-ID group’, n = 1 004 095) during the study period. Following age–sex standardisation of ID group encounters, significant differences were determined by non-overlapping 95% confidence intervals (CIs).

Results

Antipsychotics and anticonvulsants were recommended more frequently at ID group encounters than at non-ID group encounters. Antidepressant and anxiolytic recommendation rates did not differ between groups. Narcotic analgesic and antihypertensive recommendations were significantly lower at ID group encounters.

Conclusion

Higher rates of epilepsy and mental illness, and off-label use of some antipsychotics and anticonvulsants for behaviour management in people with ID, may have contributed to medication recommendations observed in this analysis. Lower narcotic analgesic recommendations at ID group encounters may relate to complex presentations and the nature of problems managed, while lower antihypertensive recommendations may indicate some potential omission of routine blood pressure measurement.

Pain and Pain Medication among Older People with Intellectual Disabilities in Comparison with the General Population

Little is known about pain and pain treatment among people with intellectual disabilities (IDs). We aimed to describe pain and pain medications among older people with ID compared to the general population. Data on diagnoses and prescriptions were collected from national registers for the period between 2006 and 2012 for 7936 people with an ID and a referent cohort from the general population. IDs were associated with a decreased risk of being diagnosed with headaches, musculoskeletal pain, and pain related to the circulatory and respiratory systems, but they were associated with increased risk of being diagnosed with pain related to the urinary system. Among men, IDs were associated with an increased risk of being diagnosed with visceral pain. People with IDs were more likely to be prescribed paracetamol and fentanyl regardless of the type of pain but were less likely to be prescribed COX(1+2) and COX2 inhibitors and weak opioids. Healthcare staff and caregivers must be made aware of signs of pain among people with IDs who may not be able to communicate it themselves. Further research is needed to investigate whether people with IDs are prescribed paracetamol rather than other pain drugs due to physicians trying to avoid polypharmacy or if there are other reasons not to prescribe a greater range of pain treatments.

Rate and characteristics of urgent hospitalisation in persons with profound intellectual disabilities compared with general population

BACKGROUND

Little is known about the hospitalisation rate of adults with severe/profound intellectual disability (PID) presenting at emergency services or about the appropriateness of hospital admissions in this population. Examining the possible differences in the patterns of hospitalisation between people with PID and those without intellectual disability (ID) may shed light on aspects of health and illness in these patients and may in turn make it possible to differentiate more clearly between mild-moderate ID and PID.

METHODS

After an evaluation of the emergency visits made by adults with PID and by people without ID, patients in both groups requiring one or more hospitalisations were subsequently followed up for 18 months. The appropriateness of the decision to hospitalise was assessed using the ambulatory care-sensitive conditions index.

RESULTS

There were no differences in the proportion of people with PID and controls admitted to hospital after their emergency visit. The median hospital stay was higher for PIDs: 7.5 vs. 4 days for controls. People with PID were admitted more than controls for respiratory reasons and somewhat less for other somatic causes unrelated to the nervous system. There were no admissions for psychiatric causes in the group with PID other than unspecified conduct disorders. There were no differences in other diagnostic groups. The rate of inappropriate admissions was similar in the two study groups.

CONCLUSIONS

In contrast to previous results reported for the group with ID as a whole, patients with PID consulting the emergency service were not admitted to hospital more frequently than the general population nor did they present a higher rate of inappropriate admissions. These results support the utility of maintaining two distinct groups of people with ID: mild-moderate and severe-profound.

Prescription of potentially inappropriate medications among older people with intellectual disability: a register study

BACKGROUND

Older people have a greater disease burden and are more likely than younger to be prescribed medications. They are also more sensitive to adverse effects. With this in mind, a range of medications have been suggested inappropriate in this population. People with intellectual disability (ID) have a higher disease burden than the general population, putting them at even greater risk of prescription of such medications. The aim of this study was to describe prescription of potentially inappropriate medications among older people with ID in relation to prescriptions among their age peers in the general population.

METHODS

We established an administrative cohort of people with ID (ID cohort; n = 7936), using a Swedish national register. A referent cohort from the general population (gPop) was matched one-to-one by sex and year of birth. Data regarding prescription of potentially inappropriate medications were collected from the Swedish prescribed drug register for the years 2006-2012.

RESULTS

People with ID were more likely than the general population to be prescribed medications with anticholinergic effects, intermediate- or long-acting benzodiazepines, and antipsychotics at least once during the study period, and also had more number of years with prescription. Except for benzodiazepines, those in the ID cohort with at least one prescription had larger amounts prescribed than those in the gPop cohort. People in the ID cohort were less likely than the general population to be prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Among those with at least one prescription of NSAIDs, those in the ID cohort had prescriptions during fewer years and in lower amounts than those in the gPop cohort.

CONCLUSIONS

Although prescription of potentially inappropriate medications overall is more common among people with ID than in the general population, the opposite pattern is found for medications for pain management. This may be a result of pain being under-recognized and under-treated in this population. Thus, there is a need for training as well as increased knowledge and awareness among care and health care professionals regarding signs of adverse effects and the need of continuous evaluation of treatment in this vulnerable group.