UOR Aging & Intellectual Disability the Risk of Osteoporosis Discussion

There are four student discussions. Please respond to each discussion.

Question #1. 

I will do, #1 Bastiaanse, L. P., Mergler, S., Evenhuis, H. M., & Echteld, M. A. (2014). Bone quality in older adults with intellectual disabilities. Research in Developmental Disabilities, 35, 1927-1933. 

-Laurel 

Bastiannse, Mergler, Evenhuis, & Echteld (2014) discussed their findings in light of a common disabling condition that generally effects individuals as they age. This study was conducted in the Netherlands, where the prevalence of older adults with osteoporosis increased with age. The authors mention that in men ages 45-64, osteoporosis increased from 1.1% to 8.6% among men over 75 yrs. In women the prevalence of osteoporosis increased from 8.5 % in ages 45-64 to 42.3% in women over 75yrs. In individuals with intellectual disability, osteoporosis is highly prevalent  with rates that vary up to 78.5%. This percentage is thought to increase as adults with ID is even higher than the general population, possibly due to a combination of other ID-related risk factors and age related risk factors.   Osteoporosis is a disease that is commonly associated with the symptoms of low bone mineral density (BMD) that leads to a increased likelihood of fracture risk and as a consequence there is a increased risk of pain, deformity, loss of mobility, and loss of independence. 

Key health characteristic of older people in the general population were listed as: low vitamin D levels, chronic malnutrition, and physical activity are associated with a low BMD. All of these key health characteristics are applicable as well to adults with ID, in addition to other risk factors that are specific to an aging ID population. This study focused specifically on key risk factors for adults with ID living in a residential facility. For individuals with ID living in a residential facility the authors focused on gender (predominantly females), immobility, the use of anticonvulsant drugs, and a more severe level of ID, as they were found to increase the risk for low BMD. In addition it was found that immobility, together with a low body mass index (BMI) and prior fractures, were key indicators to confirming the prevalence of osteoporosis. A brief discussion was described in regards to individual whom also have a comorbid diagnosis of Down Syndrome, the findings showed that there was not a significant difference in prevalence rates between participants with DS and participants with other causes of ID. 

Barriers and challenges related to individuals within this study population of adults with a more severe level of ID were found to be in the abilty or lack of ability due to the method in which osteoporosis is diagnosed. Osteoporosis is typically diagnosed through the use of a dual energy X-ray absorptiometer (DXA) that is often located in hospitals and requires the patient to lie completely still to prevent artifacts. This process was thought be feasible for use with people with ID, due to these factors. Therefore the use of a different method of measuring bone density was utilized with individuals with ID. This method also involved the use of quantitative ultrasound (QUS) as it provides a measurement of the heal bone. Measurements of speed of sound (SOS0 and broadband ultrasound attenuation (BUA) were utilized to provide other indicators of bone quality. Both of these are found to be factors of fracture risk. 

“Being female, being old aged, having moderate ID, having severe ID, sitting in a wheelchair, and using anticonvulsant drugs were positively associated with low bone quality, indicating that people with lower BMI were more likely to have a low bone quality than those with higher BMI.”(Bastiannse, et al. 2014, pg 1931) These health characteristics should cue general practitioners and specialty physicians for people with ID that prevention of osteoporosis and/or fractures should be pursued as part of treatment options. These treatment options may look like educating the population of adults with ID in proper nutrition and exercise leads to the chances of greater bone density (i.e. proper consumption of vitamin D & calcium, exercise to improve mobility, etc..) as aging occurs, along with paying closer attention to avoiding hazards that could cause a fall would be a few methods to be followed.

These recommendations are universal, however as far as families who are caring for individuals with ID it should be discussed with them about the increased risk factors that they are facing with the aging of their loved one. There should also be a discussion with the family to encourage the prevention methods for osteoporosis that have been well established and encouragement to follow the guidelines. 

Question# 2.    

Krinsky-McHale, S. J., & Silverman, W. (2013). Dementia and mild cognitive impairment in adults with intellectual disability: Issues of diagnosis.

People with intellectual disability experience the same age-associated health problems as adults without ID.  This includes dementia.  Individuals with Down syndrome are more at risk.  A condition called mild cognitive impairment (MCI) has been defined as a decline in functioning that is more severe than expected with typical brain aging but not severe enough to meet criteria for a diagnosis of dementia (Krinsky-McHale, S. J., & Silverman, W. 2013).    In addition, in adults with Down syndrome, dementia clearly occurs more frequently and at earlier ages than in other adults with ID. The average age at diagnosis occurs in the early to mid-50s and prevalence increases dramatically with advancing age beginning in the mid to late 40s (Krinsky-McHale, S. J., & Silverman, W. 2013).  Coppus et al. [2006] examined the prevalence of dementia in a prospective longitudinal study of 506 individuals with Down syndrome. For individuals up to 49 years of age prevalence was 8.9%, for individuals between 50 and 54 years it was 17.7%, for individuals between 55 and 59 years it was 32.1%, and for individuals 60 years of age and older it was 25.6%. The drop in prevalence for the oldest group was unexpected and could have been due to an increase in dementia-related mortality or a healthy survivor effect. Zigman et al. [2004] found that individuals with Down syndrome over the age of 50 was significantly more likely to have dementia than individuals with ID due to other causes, with odds ratios ranging from 1.68 to 8.56. (Krinsky-McHale, S. J., & Silverman, W. 2013).  These individuals have difficulty remembering simple things such as tying their shoelaces and recognizing their loved ones.

Assessment of dementia in adults from the general population is based largely on the premise of being able to define “normal” functioning. A substantial deviation from what is defined as “normal” then, constitutes impairment, and when there is evidence, subjective or objective, of decline from previous abilities, a diagnosis of dementia is made. Methods for assessment and valid diagnosis are well-established and include evaluations of mental status, cognitive abilities (employing population normed neuropsychological batteries of test), and functional abilities discussion regarding
Alzheimer’s disease)( Krinsky-McHale, S. J., & Silvman,er W. 201 3). For people with ID, assessing them is much difficult because the applicable term “normal” functions do not apply. Further, premorbid levels of cognitive functioning are generally unknown making it difficult to know if performance at the time of dementia assessment is or is not substantially below any individual’s previous capabilities (Krinsky-McHale, S. J., & Silvman, er W. 201 3).  In order to access this population, one must rely on the caregiver’s opinion of what the person can and cannot do.

It has been estimated that within the foreseeable future, there will be approximately one million “elderly” adults with ID in the United States needing access to a broad spectrum of geriatric services (Krinsky-McHale, S. J., & Silvman, er W. 201 3).  Common sense states that as one ages, specifically people with ID, intellectual functioning even with those with non-ID functioning slows down as one gets older. According to the adage, “The old gray mare, ain’t what she used to be” is applicable to everyone.  

Question# 3.

Oppewal, A., & Hilgenkamp, T. (2020). Is fatness or fitness key for survival in older adults with intellectual disabilities? Journal of Applied Research in Intellectual Disabilities, 33(5), 1016-1025.

• Key health characteristics of older people with an intellectual disability
  • 38.2% of older adults with ID are overweight, 25.6% are considered obese base on the body mass indez (BMI)
  • Obesity and being overweight are important risk factors related to cardiovascular disease, diabetes, musculoskeletal disorders, cancers and mortality
• Barriers and challenges related to these characteristics
  • Older adults with ID  who are unfit have twice the mortality risk, regardless of their BMI
  • These individuals (older adults with ID) typically have lower physical fitness and activity levels. Because of this, they may miss out on excess adipose tissue that can help protect the cardiovascular and metabolic systems (leading to larger coronary arteries and reduced inflammation) that are found in fit individuals. Also, individuals with physical inactivity also miss out on the positive effects such as favorable glucose/insulin levels that come with being physically active.
  • Manual dexterity, visual reaction time, balance, gait speed/comfortability, grip strength and cardiorespiratory fitness are predictive of survival
  • Individuals with severe or profound ID as well as in wheelchairs have a more difficult time performing fitness
  • Older age and smoking consistently shows higher mortality rates.
  • People in this study who were unfit (regardless of being obese or not) were 3.6 to 4.6 times more likely to die within the 5 year followup period.
  • Motivating people with ID to become more active can be challenging due to comorbidities affecting their physiology and cognition. These also impact organizational and environmental barriers. 
• How these health characteristics of older people with an intellectual disability might impact or require change in the healthcare system and adult care system
  • Fitness is key to survival. There is a need to shift the focus from ‘losing weight’ for overweight/obese adults with ID, and shift to a focus on fitness.
  • This is also true for the general population, but older adults with ID are 4 times higher at risk for mortality regardless of being obese or not.
  • Finding ways to motivate these individuals to engage in physical activity is key.
• What these health characteristics mean for individuals with an intellectual disability and their families as the individuals age
  • Teaching individuals with ID of all ages (ideally starting at an early age)  ways to stay physically active is important to support healthy aging
• Also teaching these individuals about overall better lifestyle changes (exercise, diet choices, limited alcohol consumption, eliminating smoking, etc) is just as important
• Question#4
• I have to admit this was a fascinating article for me to read. I was aware that there are issues for people with disabilities as they age, but this gave some facts to some issues that happen as part of aging.
  • Key health characteristics of older people with an intellectual disability
  • Multimorbidity: the occurrence of 2 or more chronic health conditions in individuals with intellectual disabilities.
  • The health issues that individuals with intellectual disabilities “), occurs early in the population with ID.
    Their mean frailty index scores at age 50–59 years are comparable to those in the general population aged 70–79 years
    … This early occurrence of frailty might be an explanation for the perceived early aging.” 
  • More women are affected than men.
  • It’s hard to tell if some of the chronic health conditions are the natural part of aging or may have been aggravated by conditions and medications related to treating health conditions from intellectual disabilities. Also, bad sleeping patterns as children could lead to health problems as they age as adults.
  • Health conditions that are comorbid with aging: Dysphagia (swallowing difficulties), chronic constipation, Osteoporosis, Severe challenging behavior, Hearing impairment, Visual impairment, Epilepsy, Peripheral arterial disease, Gastro-esophageal reflux disease,
    Thyroid dysfunction, Autism, Other cardiovascular diseases, Depression, Anxiety, Asthma/Chronic Obstructive Pulmonary Disease,
    Motor impairment (using a wheelchair), Diabetes mellitus I and II, Dementia, Cerebrovascular accident, Cancer (diagnosed within 5 years). Because of low numbers reported in the study, in the final analysis, only 14 conditions were actually analyzed. What were excluded was motor conditions, “(autism, dementia, severe challenging behavior, and cancer)” and combine cardiovascular accident and other cardiovascular diseases into one condition.
  • Individuals with intellectual disabilities 50 and older were considered.  79.8% had multimorbidity with 2 conditions and 46.8% had multimorbidity of 4 or more conditions. It was pointed out that 80% percent of the population had issues with multimorbidity in individuals with intellectual disabilities older than 50. Individuals with more severe or profound disabilities or with Down Syndrome usually suffered 4 or more multimorbidities. 
  • How these health characteristics of older people with an intellectual disability might impact or require change in the healthcare system and adult care system
  • Doctors were found to be ill-equipped to provide medical examinations and treatments for patients with intellectual disabilities. They weren’t prepared for patient exams that might take longer, have communication difficulties with the patients either unable to communicate or not able to report subjective feelings of pain or issues. Also, doctors tended to treat one chronic condition and not consider the impact of other conditions and if the individual took medications for the other conditions. This could create health issues with the medications for the individuals involved. This led to poorer quality of life outcomes for individuals who struggled with the impact of medications and conditions, with some conditions not being treated.
  • What these health characteristics mean for individuals with an intellectual disability and their families as the individuals age
  • These health characteristics mean that individuals with disabilities had their quality of life impacted by multiple chronic conditions. This could make it harder for their families to care for them, so they might go to group homes or other places for better care. This also shows that families and individuals might have difficulty to find doctors who are willing to be patient to have meaningful exams and communications with individuals and their families seeking treatment. Also, since health conditions aren’t thought of how they impact the individual, untreated conditions could drain the individual of their energy and ability to enjoy their life. Also medications could create unforeseen complications that probably does also impact their quality of life.
  • Thanks for reading!