Letters to the Editor
The Need for More Community Nursing for Adults With Intellectual Disabilities and Mental Health Problems
Dear Editor:
We are concerned about the lack of community nursing in our geographical area for adults with intellectual disabilities and mental health problems (that is, a dual diagnosis) and the significant impact this has on our patients and their caregivers. To put this issue into context, individuals with intellectual disabilities are at greater risk than the general population for mental health problems and undiagnosed medical problems. Psychotropic medications can be highly effective when used to treat specific psychiatric disorders in this population, but they are frequently overused and undermonitored (1). Many individuals are unable to report unpleasant or potentially dangerous medication side effects and depend on caregivers to recognize problems. Caregivers in turn may lack training and skills in the area of medication administration and monitoring for side effects. Community nursing support has been identified as an appropriate and cost effective way to follow these individuals in the community and work with their caregivers, families, and family physicians (2).
Our specialized, interdisciplinary mental health team serves a region with a population of approximately 900 000 adults (3) of whom an estimated 7500 have a dual diagnosis (assuming a 2.25% prevalence rate of intellectual disabilities in the general population and a 38% prevalence rate of psychiatric problems in individuals with intellectual disabilities, 4). We know of 4 full-time nurses who work with this patient population. By comparison, a study in the UK reported a mean of 2.4 community nurses per 100 000 population who were specifically trained to work with adults with intellectual disabilities (5). If we use data from the UK as a reference point, an area our size would support 21.6 such nurses, rather than the present 4.
We contend that enhanced community nursing would ensure better continuity of care for our dual-diagnosis patients and allow increased on-site monitoring and opportunities to educate caregivers about psychiatric disorders and medication effects and side effects. Moreover, it would enable psychiatrists who specialize in dual diagnosis to consult more efficiently with family physicians.
We provide actual case examples to illustrate some of our points.
Case 1
After a patient with challenging behaviour was again referred, the team discovered that the consulting psychiatrist’s recommendation to decrease the patient’s neuroleptic medication, made 2 years earlier to the family physician and shared with the group home staff, had not been carried out. This medication’s side effects contributed to the behaviour that precipitated the second referral. Moreover, the patient’s current staff did not seem to be aware that these recommendations had ever been made.
Case 2
Over a period of several weeks, caregivers had been giving a patient twice the prescribed dosage of neuroleptic medication. The patient experienced severe facial tics and contortions that developed into a serious dystonic reaction. The team was called in because the patient’s behaviour was deemed to be out of control. The facial tics and contortions were not mentioned at the time of the call.
Case 3
Staff called the team because a patient was confused and drowsy, had slurred speech, and was unsteady on his feet. Upon visiting the group home, the team nurse learned that the patient, who was taking lithium, was recovering from a flu-like illness but that his vomiting continued. The nurse found him to be severely dehydrated; she advised staff to discontinue the lithium until the patient’s blood level had been checked and to take him to emergency immediately. Blood work revealed that the patient had lithium toxicity.
We would be interested to hear of the experience of others in regard to these issues.
References
1. Reiss S, Aman M, editors. Psychotropic medications and developmental disabilities: the international consensus handbook. Columbus (OH): Nisonger Center for Mental Retardation and Developmental Disabilities; 1998.
2. Faux S, Ford-Gilboe M, O’Brien K. Health care coordination for persons with developmental disabilities in the community: a demonstration project. Clinical Bulletinof the Developmental Disabilities Program 1993;4(4):3.
3. Statistics Canada. 2001 Census. Ottawa: Statistics Canada; 2002.
4. Yu D, Atkinson L. Developmental disability with and without psychiatric involvement: prevalence estimates for Ontario. J Devel Disabil 1993;2:92–9.
5. Bailey NM, Cooper SA. The current provision of specialist health services to people with learning disabilities in England and Wales. J Intellect Disabil Res 1997;41:452–9.
Jane Summers, PhD, CPsych; Judith Adamson, RN; Elspeth Bradley, MB, BS, PhD, FRCPsych, FRCPC; Kerry Boyd, MD, FRCPC; Stephen Collins, MB, ChB, FRCPC; Anthony Levinson, MD, FRCPC; Jane Morgan, MD, MHSc, FRCPC
Hamilton, Ontario
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