Mohammed T. Abou-Saleh

624 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYdisability at baseline is often difficult to measure 1 . Studies suggestthat dementia is about as common in the learning-disabledpopulation as in the general population and has the same range ofclinical phenomena, provided that each patient’s unique intellectualbaseline is allowed for 8 . Cooper 9 surveyed a population ofelderly people with learning disabilities and found that 22% haddementia; however, the small number precluded analysis ofsubtypes. An earlier survey by Reid et al. 15 found a prevalenceof 13.6%. Tait 10 found a prevalence of dementia similar to that inthe general population.THE MEDICAL CONTRIBUTION TO THEDIAGNOSIS OF DEMENTIADementia can only be diagnosed after a careful history is takenand an examination made, the premorbid and presentingpersonalities assessed and other reasons for deteriorationexcluded. Long-standing visual and hearing problems arecommon in people with learning disabilities and may only bediscovered as sensory deficits increase and further affect functioning11 . Hypothyroidism, deterioration caused by inappropriatemedication, communication disorders and psychiatric illness, bothorganic and functional, may all cause pseudodementia. Depressionis often precipitated by loss of caregivers or familiarenvironments and may present, in addition, as behavioural andpersonality change. Symptoms such as incontinence may berelated to the inappropriate architecture of the residence or toshortage of staff.A detailed clinical examination will highlight dental andchiropody needs, general medical disorders and complications oflong-standing disability. Consideration can be given to the needfor aids and appliances to minimize the deficits and ease theburden for carers. People with learning disabilities rarely haveaccess to health education or health promotion, so that screeningfor anaemia, hypertension, glaucoma or carcinoma of breast orcervix will hardly ever have been done.The examination of someone with learning disabilities who mayhave superimposed dementia may therefore offer the opportunityto put right some of the deficiencies of older-style services, identifycurrent social dilemmas, diagnose dementia in the context of longstandingdeficits and consider, with the caregivers and themultidisciplinary team, how needs can be met 12 .Thorough assessment will provide information on the following:1. The developmental intellectual disability.2. Other long-standing disabilities and comorbid conditions.3. Long-standing psychiatric illness and behaviour disorder.4. Illness and disability superimposed and due to ageing.5. Psychiatric illness associated with old age.6. Dementia, if present.7. The skills and needs of the person.8. Recent life experiences.9. The patient’s wishes and those of the caregiver for residentialand social care.DEMENTIA AND DOWN’S SYNDROMEThe association between ageing in adults with Down’s syndromeand the development of dementia attracts interest from bothresearchers and clinicians. There is now a substantial literature onthe genetic link between Down’s syndrome and Alzheimer’sdisease. Several studies, using a variety of diagnostic criteria, havereported increasing age-specific prevalence rates for Alzheimer’sdisease in people with Down’s syndrome. However, whilst theprevalence rates vary across studies, in no study has the ratereached 100%, which might be expected given the neuropathologicaldata 13 . Dementia is often accompanied by epilepsy, loss ofskills (which perhaps were not well developed in the first place)and transient behaviour problems, together with personalitychanges.Families who have cared for their relative with Down’ssyndrome to the point where they develop dementia need support,information and the chance to talk to someone who understandsthe natural history of Alzheimer’s disease. They may feel guiltyand confused. An understanding of their confusion is required,and support is needed as they accept the diagnosis of dementiaand its inevitable outcome. They may need to consider changes totheir lifestyle and to look to the wider network for longer-termcare and support.WHAT OF SERVICES?One of the most challenging ways to think about servicedevelopment is through the proper consideration of the philosophyof normalization, which states that services that are highlyvalued and normative should be used by those who are at risk ofbeing devalued. The difficulty is that both ‘‘the elderly’’ and‘‘people with learning disabilities’’ are potentially devaluedgroups; both services tend to be underfunded and considered tobe bottomless pits of needs.The major debate is whether to use the services the rest of thepopulation use, i.e. the geriatric or psychogeriatric services, tocontinue with learning disability services (improved as necessary),or to develop something new. Probably the best solution is toconsider services for each individual, facilitating access to what isavailable and campaigning for what is not.In England, national policy requires local authorities to offerperson-centred planning to all people with learning disabilities.People living at home with elderly family carers are a prioritygroup for receiving services and supports based on what isimportant for them as individuals and for receiving a regularlyupdated health action plan 16 .REHABILITATION INTO THE COMMUNITYThe closure of long-stay mental handicap hospitals in the UK hascreated new social and medical dilemmas 10 . Some people havebeen in hospital for many years, and moving into the communitypresents many difficulties, with geriatric needs supersedingdevelopmental disabilities. Some hospitals have remained toaccommodate this small group, but many hospitals have closedcompletely and people moved to community residential provision.Many elderly people with learning disabilities have their onlynetwork of friends on the campus of the hospital, and it isimportant to try and maintain this. They are usually out of touchwith relatives and a return to the county or borough of origin isnot always meaningful or in their best interest. With carefulintroduction, these people may usually be accommodated incommunity services and may be far more competent than typicalgeriatric patients 14 . Because their life experience is so different, itmay be better to care for them in an establishment able to takeseveral residents from the same hospital.CARE IN THE FAMILY HOMEThe elderly person with learning disability may be cared for by anageing parent with a similar dependency level. The fragile world ofa person with learning disability has often been prematurely