We examined the medical problems and medication treatment of psychiatric inpatients with ID, many of whom were hospitalized because of aggression and other challenging behaviors. Most had multiple comorbid medical diagnoses, and 40% were identified as having a medical problem as a primary contributing factor to the decompensation resulting in the need for an inpatient stay. The present investigation was intended to be descriptive, and to contribute exploratory data in an area with minimal investigation (medical problems affecting psychiatric inpatients with ID). The results are limited by the use of retrospective data and a small sample. However, it is noteworthy that so many of the 198 psychiatric inpatients in the present study had medical problems that were potentially preventable, or may have been detected and treated prior to a referral for hospitalization (i.e. constipation, GERD, UTIs, otitis, dental problems and medication side effects such as EPS). The high rate of medical problems identified in the current investigation may have also been the result of the specialized nature of the unit, as patients routinely received medical and neurological assessments by clinicians with experience evaluating individuals with ID.
Substantial evidence now exists linking medical problems, pain or physical distress and problem behaviors in individuals with ID (Carr et al., 2003
; Kennedy et al., 2007
), yet it remains unclear how often patients with ID are sent for psychiatric hospital admissions when they actually have a treatable medical problem that could be provoking agitated behaviors. It has been speculated that health problems are often missed in patients with ID because they do not provide accurate or reliable self-reports when experiencing illness (Cooper et al., 2006
). Medical problems might also be missed because the first sign of physical distress in many patients with ID may be a behavioral decompensation which may lead caregivers to seek psychiatric help for the individual (Kwok & Cheung, 2007
). The specific relationship between the medical problems identified and the behaviors leading to admission in the present investigation could not be determined based on the available data. However, many of the more frequently reported problems are ones recognized to cause physical discomfort (constipation, GERD) (Bohmer et al., 2001
; Molloy & Manning-Courtney, 2001).
Constipation was diagnosed in 69% of the psychiatric inpatients in the present study. It has been previously reported that individuals with ID may be at increased risk of experiencing constipation. Veugelers et al. (2008) reviewed studies of individuals with ID and reported that rates varied from 39–62%, though they that most included small samples. They conducted a population based survey of children with severe to moderate ID who also had severe motor problems (Cerebral Palsy) and reported that 60.9% were treated for constipation while 31.45% continued to experience problems despite laxative treatment. Thus individuals with ID may have not only undetected medical problems, but also under-treated ones. Patja, Molsa and Livainen (2001)
reported on causes of death among individuals with ID, and noted that “diseases of the digestive system” were 2.5 times greater in people with ID as compared to non-ID controls. They found 25% of these deaths for people with ID were due to bowel obstructions, and another 13% to perforated ulcers.
GERD, the second most frequent medical comorbidity in our sample, occurred in 38% of inpatients. Bohmer and colleagues (2000)
reported a prevalence rate for GERD of 50% among institutionalized individuals with ID with FSIQs < 50. In their study, 70% of the subjects with GERD had endoscopically confirmed disorder. These authors emphasized the fact that many of the individuals they diagnosed had significant disease by the time it was detected and treatment was initiated. We did not find any studies of individuals with ID acutely hospitalized for psychiatric problems reporting the rates of either constipation or GERD.
Urinary tract infections were identified in 15% of the inpatients. We were unable to find usual rates for these among people with ID except for a report by Kozma and Mason (2003)
which examined only institutionalized individuals with severe ID. These authors noted that 18% of residents had recurrent UTIs. US population prevalence estimates suggest approximately 8% of adults develop UTIs, though only about 13% of self-reported UTIs are experienced by men (Griebling, 2007
). In the present study, 8 males experienced UTIs or almost one third of the UTIs detected. It is possible that males with ID/MH might be at greater risk for UTI than individuals without ID. UTIs are known to be associated with mental status changes in elderly patients, and may be associated with similar alterations in individuals with ID, who also frequently have associated neurological problems or a fragile neurological substrate. Delirium was noted in a small number of the inpatients (n=6), and can be more challenging to diagnose in people with existing neurocognitive abnormalities, while correct diagnosis is critical to a positive outcome (Thomas et. al, 2008).
We examined other factors that might contribute to the risk for medical problems including the presence of a diagnosis of ASD, DS, age group, sex and level of ID. Neither ASD diagnostic status, nor level of ID correlated with any of the variables we examined. Children with ASDs have more health problems than peers without a developmental disability, but may have similar rates to peers with ID, when matched for level of cognitive disabilities (Skjeldal et al., 1998
Having a diagnosis of DS affected the rates for specific medical diagnoses in the present study, though these were all ones expected to occur more frequently among individuals with this syndrome (osteoarthritis, hearing loss, cardiac problems, hyperthyroidism, sleep apnea) (van Allen, Fung, & Jurenka, 1999
). The number of inpatients with DS was quite low (n =13) limiting the statistical power on contrasts. There were minimal gender based differences in rates of specific medical problems. However, age did affect the rates of medical problems identified, as expected. Numerous studies have found that individuals with and without ID have more medical problems as they age (Cooper, 1998
). As suggested by Davidson and colleagues (2003)
, older individuals with ID may be at increased risk of having a missed medical problem cause an apparent psychiatric or behavioral decompensation.
In addition to the medical problems noted above, a number of the psychiatric inpatients in the present investigation were diagnosed with medication side effects. Many were treated with multi-drug regimens, averaging close to 3 psychoactive medications per person. Nearly one-fifth of the inpatients were prescribed two antipsychotic agents and one-fifth was taking five or more psychoactive medications at the time of admission. The number of psychoactive medications was correlated significantly with the number of medical diagnoses, and with length of stay. Concerns have been raised by some investigators that side effects, like other medical problems, may often be missed in patients with ID, and they may provoke apparent behavioral or psychiatric decompensations. Valdovinos and colleagues (2005)
found a high rate of suspected medication side effects in their sample of 30 individuals with developmental disabilities. They noted that there is “potential confusion regarding the presentation of a side effect or the worsening of a problem behavior” in patients with ID (p 169). It is unclear whether or not treatment with multiple psychoactive medications contributed to the occurrence of medical complications or worsening behavior in the psychiatric patients with ID in the present study. However, agitation related to a medication side effect was documented as a suspected cause of decompensation in a number of the discharge summaries reviewed.
Rates of treatment with psychoactive medications reported in the present investigation were similar to those reported in a general population study in the same region, in which Medicaid prescriptions were tallied and residents receiving developmental disabilities services were found to be taking an average of 2.75 psychoactive medications (CDDER, 2005
). A high rate of psychoactive medication treatment for inpatients with ID is not surprising. The inpatients in the present investigation were usually admitted because of severe challenging behaviors. Stolker et al. (2001) examined medication pharmacotherapy of 105 inpatients with mild or borderline ID served in a facility in the Netherlands, and found multi-drug regimens were most common for individuals with long lengths of stay (stays over one month), and who primarily presented with “socially disruptive behavior.” More recent investigations have also reported that psychoactive medications are more often used to treat diagnostically non-specific challenging behaviors in patients with ID (Deb et al, 2007
; Tsakanikos et al., 2007
). This is in contrast to psychiatric patients without ID for whom psychoactive medications are primarily prescribed to treat symptoms of a psychiatric disorder. Some experts have argued that an over-reliance on psychoactive medications in the management of behavioral difficulties in people with ID has developed, in the absence of more systematic use of behavioral or “multi-modal” treatment (Matson & Neal, 2009
; Kroese, Dewhurst, & Holmes, 2001
). Of concern is the well documented fact that treatment with multiple medications increases the risk of side effects and adverse drug reactions, while patients with ID are less likely to complain about symptoms that would alert clinicians to their occurrence (Hovstadius, Astrand, & Petersson, 2009