July 2011
Reviewer: Jeff C. Huffman, MD
Assessment and management of patients with intellectual disabilities by psychiatric consultants
Friedman ND, Shedlack KJ
Psychosomatics 2011; 52(3):210-217
Background: Patients with developmental delay and other intellectual disabilities can pose a management problem in medical settings. Such patients may have difficulty managing in medical settings that are unfamiliar, especially when they are not feeling physically well, and typically medical and psychiatric clinicians are not experienced in managing common issues that arise in this population.
Methods: The authors review the adaptation of the psychiatric interview for this population and five common consultation questions in this cohort.
Results/Discussion: With regard to the psychiatric interview, the authors emphasize the importance of understanding patients’ expressive and comprehension abilities (which may be vastly different in a given patient, such as those who have very limited expression/language but very good comprehension); using concrete/simple wording and frequently performing comprehension checks; ensuring that any correctable sensory deficits are addressed, such as glasses/hearing aids, given high rates of sensory deficits in this cohort; and, above all, getting much collateral information before making diagnostic or treatment recommendations.
Consultation question 1: questions about psychotropic medications. The authors emphasize that the sometimes-typical practice of discontinuing psychotropic medications during inpatient medical admissions when there is diagnostic uncertainty can have disastrous consequences. They point to potential for escalation of seizure activity, OCD, anxiety, and psychosis that can occur when long-standing and effective treatments are discontinued; such problems are exacerbated by the fact that such symptoms may not present in typical fashion and may not be easily recognized, instead resulting in a more general decompensation of mental status.
Consultation question 2: questions about management of agitated/aggressive behaviors. The authors discuss the importance of assessing for pain, sensory problems, other physical symptoms, and other “non-psychiatric” causes of such behavior in addition to standard assessments, and for again getting consultation from caregivers and treaters who know the patient well to help assess the degree to which such behavior is atypical and to help investigate the nature of the problem. Treatment of agitation/aggression with atypical antipsychotics, especially risperidone, has the most evidence; dosing of all agents may need to start at lower doses than in other patients given higher rates of side effects, though some patients do require high doses.
Consultation question 3: safety assessments. Again, the importance of understanding the intent of self-injurious behavior is highlighted, and information that comes directly from the patient and from collateral sources are both critical.
Consultation question 4: capacity assessments. Certain strategies, such as using simple language, breaking information down into separate components, and incorporating non-verbal communication, can help consultants assess capacity for any given decision. The non-universal nature of capacity is also emphasized: patients may have the capacity to make some decisions and not others. A careful and thoughtful assessment will help patients to exercise autonomy in their medical care when possible and appropriate.
Consultation question 5: discharge planning questions. The critical importance of planning very early for discharge in this population is stressed. Often such patients will need new services or changes in staffing at their place of living, and often group homes and other settings simply need time to plan for the patient’s return. Involving one or two persons from these care settings as liaisons from the start can greatly speed this process. Finally, consideration of tapering psychotropic agents that were added as acute treatment to manage behaviors in the acute medical setting should be considered if it appears that such agents may no longer be needed as the medical condition resolves and the patient is in a familiar setting.