Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0112Old Age and Learning DisabilityOyepeju Raji and Sheila HollinsSt George’s Hospital Medical School, London, UKThe age structure of people with learning disabilities is changingand more are surviving into old age, indicating considerableachievements in health and social development.Historically, there was little provision for the needs of olderpersons with learning disability. The reason for this was that suchpersons had a short lifespan and many died before reaching oldage, for reasons such as inadequate medical treatment and the lifethreateningcomplications associated with their condition. Duringrecent years, the provision of formal care for adults with learningdisabilities has changed from a largely institutional service to anincreasingly community-based one. This has affected the collectionof health statistics. Hospital populations provided the mainsource of data in the past. Although registers of need are astatutory requirement for children in the UK, there is no similarrequirement for adults with disabilities. However, many localauthorities do maintain learning disabilities registers, and includea wider range of service users than those who would previouslyhave been long-stay hospital patients.SOCIAL BACKGROUNDIn the mid- to late 1800s, ‘‘mentally defectives’’ (including peoplewith learning disabilities and those with mental illness) were keptaway from society and were housed in asylums. One reason forthe institutionalization of mildly learning-disabled people can befound in the social turmoil of the early 1900s. Young adults wereplaced in institutions to curb their sexuality, as it was thought thattheir offspring would have intellectual limitations and wouldthemselves have low-IQ children, and that eventually the nationalIQ would fall. After the menopause, many of the women wereallowed out on licence, working as ladies’ maids, for example, andreturning to the asylum when the problem of old age meant theywere of no further use. Many were of normal intelligence, broughtinto institutions because of adverse social circumstances anddetained there. After World War II, life expectancy began toimprove within the institutions with better medical care and morepositive lifestyles 2,3 . Mildly disabled older adults were highlyvalued as a substantial work force in the institution.In 1959, a review of the Mental Health Act allowed patients aninformal status and many became voluntary patients anddischarged themselves, made their way into the world and werelost to helping agencies and statistics. Others stayed on ininstitutions, probably because of infirmity or institutionalization.Many of these will have been discharged as elderly individuals inthe wave of community care in the 1980s, promoted by thephilosophy of normalization and governmental encouragement.Wolf and Wright 3 found that younger, more able people weremore readily discharged into the community and the older andmore disabled population remained in institutions.CAUSES OF DEATHPeople with learning disabilities are living longer overall but thelevel of disability is correlated with longevity and this associationis more marked in the earlier years. Improved standards of care,higher expectations and more positive attitudes to treatment forserious illness have contributed to increasing longevity. Prolongedsurvival is now the norm, even for the most severely disabledchildren. In people with Down’s syndrome, for example, heartdisease is now treated surgically if indicated and overall medicalcare is much improved. The overall increased longevity means thatdisorders such as dementia and cancer have become moreprevalent. There is a tendency for profoundly learning-disabledpeople to be more seriously physically disabled and to have morehealth problems. Even with better care, the life expectancy ofprofoundly and multiply disabled people is still reduced. Themortality rate for people with learning disabilities is highercompared with the general population. Carter and Jancar 4,5studied a hospital population and found marked changes in thecauses of death over a 50 year period. Prior to 1955, tuberculosiswas a major cause of death, and after 1955 non-tubercularrespiratory infection accounted for 46% of all deaths examined.Other identified causes were myocardial infarction, cerebrovascularaccidents, pulmonary embolism and status epilepticus,which accounted for 15%. Epilepsy is both more prevalent andmore likely to occur in a poorly controlled form with significantlyincreased mortality 2 . Hollins et al. 6 reported that death certificateswere not a reliable source of data about cause of death and thatlearning disabilities were rarely mentioned, with respiratorydisease being the major cause of death, suggesting a failure torecognize underlying medical conditions. Those with mild disabilitieshave lifespans close to those of the general population,dying from cardiovascular, neoplastic and terminal infections,similar to those of elderly people of originally normal intelligence 7 .FREQUENCY OF DEMENTIA IN PEOPLE WITHLEARNING DISABILITYEpidemiological studies, whether cross-sectional or longitudinal,are often difficult to do. The assessment of the premorbid state isaffected by limited educational opportunities, social deprivationand the low expectations of many people with learning disabilities.The true intellectual functioning of the person with a learningPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd