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Introduction – Learning Disability Psychiatry
Dr Michelle Beaumont SPR to Professor Read
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Aims Introduction Assessment LD specific issues Psychiatric Disorders
Legal issues Physical issues
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Introduction History Epidemiology Aetiology
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Picture 1
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History
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From this… Stainsfield view
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To this….
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Valuing People 2001 Principles Rights - equal Independent living
Control Inclusion Practice LD register Health Education factor Health Action Plans Housing Employment Same rights as anyone else Greater support & choice over living arrangement Information to make informed choices Inclusion all aspects
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Epidemiology
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Epidemiology 210,000 Severe & Profound LD
65,000 children & young people 120,000 working age 25,000 older people 1.2 million Mild / Moderate LD Valuing People 2001
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Epidemiology continued…
Institute for Health Research at Lancaster University 2004 985,000 with LD 224,000 known to social services 761,000 mild / moderate LD maybe unknown Emerson & Hatton total adults with LD increase by 8 % ,000 by 2011 Increase by 14 % - 908,000 by 2021
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Epidemiology continued...
5% live home of own 30% residential care home Significant proportion miles away from family 1 in 10 (known to SS) employment Significant number live with elderly carers Valuing People Now: A New 3 year strategy for people with LD
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Picture 2
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Aetiology
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IQ Distribution Curve
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Aetiology Mild LD 9x more common in lower social class Education
Abuse / emotional factors
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Aetiology Primary disorders with direct effects
Syndromes Primary disorders with secondary effects Inborn error metabolism PKU TS Secondary disorders Antenatal Neural tube defects Infection – syphillis, CMV, rubella Perinatal Hypoxia Infection Trauma Abuse / accident Postnatal Nutrition Encephalopathies Metabolic
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LD levels Severity of LD IQ score ranges Approximate Functional Equivalent Mental Age Percentage of total population affected Associated Features Notes Mild (80-85% of LD population) 69-50 12-9 Communication skills may be mildly affected, some level of independence “Sub cultural” or “cultural familial” Moderate (10% of total LD) Severe (3-4% of LD) 49-35 34 -19 <9-6 <6 -0.5% combining moderate & Severe -Receptive language> expressive -Dependent -High rates of epilepsy physical /sensory impairment As disability becomes more severe, the number of specific organic pathology increases. Profound ( 1-2 % of LD ) <20 <3 0.05 Highly dependent Distinction from severe LD has doubtful value Features associated with various severities of learning disability
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Picture 3
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Assessment
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Assessment considerations
LD criteria Informants / Carers Communication Assessment Risks
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Learning Disability Definition
Global impairment of intellectual functioning > diminished ability to adapt to daily demands. (IQ below 70). Significant deficits / impairments in adaptive behaviours & social functioning. Onset in development period (<18) ICD - 10
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LD - Indicators Special school Statement (can be behavioural)
Educational support NOT Asperger’s Dyslexia / Specific learning difficulty Normal education GCSEs Drive car
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Assessment Informants / Carers
Key worker / family Key knowledge Aid to compliance Stress
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Communication Simple language with short sentences
Avoid jargon and negatives Give concrete examples and avoid abstract ideas Be aware literal meanings & use humour cautiously Sign language /pictures. Consider interpreter Check comprehension
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Accessible information
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Consideration Compliance System Capacity / Best interests
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Picture 5
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Psychiatric Assessment
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Assessment Psychiatric Assessment with carer (known x years)
Presenting Compliant History of presenting compliant Change Illness / pain Developmental history Skills Social history Support Day care Benefits Other peers Forensic Forensic issues Past Psychiatric History Past Medical History Medications / Allergies
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Appearance & behaviour Agitation Eye contact Mood Speech Thoughts.
Assessment MSE Appearance & behaviour Agitation Eye contact Mood Speech Understanding Thoughts. Less guilt / suicidal ideas – cognitive level Delusions. Basic Hallucinations Suicidal ideation Harm to others Insight Illness / not Medication Capacity Best interests
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Assessment Day care reports Family Monitoring charts Other assessments
Social issues Safeguarding issues
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Risks Aggression / violence Neglect Abuse from others Abuse to others
DSH Suicide Domestic Throwing things property damage Eating drinking often with carer but when not !!! Risk of exploitation Hitting/ scaring DSH repetitive injury - broke arm
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Assessment Multi Professional Team working CMN SALT OT Physiotherapy
Psychology Care managers Teachers
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Treatment Medication Research/ evidence poor
Extrapolated from general adult psychiatry If use off license medication should indicate Reduced doses & slow titration
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Treatment Side effects Reduced ability to communicate
Reduced ability to not comply Increased risk of Neuroleptic Malignant Syndrome Tardive Dyskinesia Other Confusion Constipation Weight gain Medication interactions,
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Treatment Review effect Side effects
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Picture 4
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LD Specific issues Challenging Behaviour Behavioural phenotypes Autism
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Challenging Behaviour
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Challenging behaviour
10-15 % of LD use services Most common reason for referral to psychiatrist Behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or delay access to and use of ordinary community facilities. Emerson et al (1988)
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Challenging behaviour
Can present as part of specific psychiatric disorder or independently Need to exclude mental / physical illness May be due to lack of appreciation of social norms. Serious impact on accessing services / quality of life Carers
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Challenging behaviour
Management monitoring, boundary setting, evaluation of environment, medication may be indicated MDT
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Picture 6
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Behavioural Phenotypes
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Behavioral Phenotypes
Known (usually genetic) disorder is associated Pattern behaviour Personality characteristics Psychiatric symptoms Eg
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Fragile X Testicular enlargement Large head circumference
Long & prominent ears High arched palate Connective tissue disorder Lax joints flat feet Mitral valve prolapse
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Fragile X cont.. Mild - moderate LD
Flattening trajectory learning over childhood Abstract reasoning Visuo-motor & spatial deficits Strengths verbal & adaptive behaviour % have autism
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Fragile X characteristics
Social avoidance Gaze aversion Shy rather than autistic indifference Fast garbled speech Litanic pitch Anxious interest in speech Hyperactivity Impulsiveness Distractible Wrist biting Swings of pitch
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Picture 7
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Pervasive developmental disorder
Autism Pervasive developmental disorder
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Temple Grandin “My hearing is like having a hearing aid with the volume control stuck on “super loud”. It is like an open microphone that picks up everything. I have 2 choices: turn the mike on & get deluged by sound, or shut it off.”
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Autism Usually coexists with significant LD Apparent before 3 4/10 000
M>F Increased in certain conditions TS, rubella Recognised by Asperger & Kanner in 1940s’- 50s Autism & Aspergers syndrome part of a spectrum Those with autism likely to have LD Those with aspergers no LD fall between services Parents will often been seeking help for time before diagnosis made
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Wing Continuum Triad of impairments Social relationships Language
Lack empathy Interest in others Language Expressive > receptive Abnormal prosody. Echolalia. Pronounal reversal. 3rd person Literal meaning Imagination restriction Routines. Novelty > catastrophic rage. Unusual interests Continuum of symptoms & severity from normality to ASD Sensory possibly of equal import
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Autism continued.. Sensory Abnormalities Perceptions
Heightened / Reduced Pain Inability distinguish signal from noise Ignore strong stimuli but notice small thread Time / space abnormalities > preoccupation with routines & intolerance of delay Motor Tone Posture Stereotypies Mannerisms
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Autism & Mental illness
Psychosis Self talk General demenour Across all situations paranoia Depression Atypical Self harm Increased withdrawal
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Treatments Behavioural assessment & management Key Aim reduce arousal
structure, predictability, Communication Social stories Intensive interaction Visual diaries Communication boards Aim reduce arousal
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If environmental fail/ risks high
Medications Antidepressants SSRI: citalopram Antipsychotics Atypical: risperidone, olanzapine PRN medications Benzodiazepines: lorazepam Atypical antipsychotics: risperidone NEED PROTOCOL Set targets for assessment of efficacy of medication Monitor risks / side effects Bloods, ECG, Weight & BP
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Picture 8
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Psychiatric Disorders
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Psychiatric Disorders
Vulnerability factors Diagnostic issues Disorders
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Vulnerability for mental disorders
INDIVIDUAL Family Bereavement issues Life-cycle transitions / crises “Letting go” Social / community networks Stress / adaptation to disabilities Protective factors Daytime activity Structure Relationships Social Attitudes / expectations Supports / relationships Inappropriate environments / services Under / over stimulation Biological Brain Damage Vision / hearing impairments Physical illness / disabilities/ epilepsy Genetic - familial conditions Behavioural phenotypes Drugs / Alcohol abuse Medication / Physical treatments Psychological Personality Development Deprivation / abuse Separation / losses Life events Learning Experiences Self-insight / self-esteem
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Mental Disorder Under-diagnosed
Behavioural disorder Insufficient weight to symptoms Psychosocial masking - bland beliefs Consider co-morbidity e.g. physical ill health / epilepsy DC-LD for moderate /severe LD change attributed to LD not MI
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Mental Disorder Diagnostic difficulty Cognitive disintegration
Stress induced disruption of information processing can > bizarre behaviour & psychotic symptoms Baseline exaggeration General increase in pre-existing cognitive deficits can make interpretation of symptoms difficult Diagnostic overshadowing Tendency to attribute symptoms & B associated with illness to LD
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Picture 9
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Schizophrenia Presentation Prevalence
approx 3% (Fraser & Nolan 1994) cf 1 % gen popn Undetected in more severe LD - IQ < 50 Presentation Depends on level of LD Mild & verbally able similar general popn Auditory hallucinations 90% (Meadows et al 1991) Less psychopathology Less complex delusions FTD Less likely passivity, thought echo, running commentary
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Schizophrenia Delusions Adults with severe LD
Can be talked out of - consider if repeated Wish fulfilment Content developmentally appropriate Adults with severe LD Increased catatonic symptoms Consider Major change no significant environmental change Family history Misinterpretation of reality
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FH & hospital
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Schizophrenia Differential Diagnosis Consider BPAD Organic
Autistic Spectrum Disorder “Brief” Reactive Psychosis Consider Self talk Suggestibility & compliance Fantasy Misinterpretation of reality
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Schizophrenia Treatment
NICE Antipsychotics NMS TD Akathisia Weight Metabolic syndrome Interactions - Medications Epilepsy PSI - CBT Family interventions
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Picture 10 Cornelia de lange
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Affective Disorders Prevalence Under-diagnosed especially severe LD
5-10 % major depressive disorder. 3-8% bipolar Under-diagnosed especially severe LD Atypical presentation Historically thought people with LD didn’t experience emotions G 1st degree rels Organic - brain damage - LD & neuro problem inc Psych diagnosis, with E at least 50% have psych diagnosis Learned helplessness
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Depressive episode Depressed / irritable mood and or Either Some of
Loss of interest/ pleasure in activities Social withdrawal Reduced self care Reduced communication Some of Lethargy, fearfulness, somatic concerns, reduced concentration / indecisive, increase behaviour problem, agitation / retardation, appetite / sleep disturbance DC - LD
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Depressive episode Symptoms Anxiety prominent Irritability
Loss of confidence and tearfulness common Irritability Behavioural symptoms - (worsening of pre-existing) Self injury Aggression Screaming, temper tantrums, incontinence & Vomiting Hypochondriacal Regression i.e. loss of skills, social withdrawal Depend on level of LD Clingy
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Affective disorders Severe LD
More biological symptoms e.g. sleep and appetite Regression Psychomotor agitation Catatonia and visual hallucinations more common Cf retardation in milder ld
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Affective Disorders Differential Diagnosis
Environmental change, loss, abuse Medical condition Drug induced Anxiety Dementia Behavioural disorder BPAD / mania (irritability / aggression, pressure of speech > complex verbal symptoms)
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Janet 50 year old lady Moderate LD Supported living Tearful.
Lost confidence. Poor appetite. Weight loss. Withdrawn Reduced mobility. Abnormal gait. Falls Previous similar presentation 15 years ago.
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MSE Wheel chair Anxious. Tearful Denial of symptoms
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Suicide Rarely reported
Attempted suicide rate 0.9% cf 1% gen popn (Sternlicht et al 1970) DSH more men cf women Mild/ borderline More severe LD – self harming behaviour thought be suicidal reluctance
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Skin Picking
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Helen Wheelchair bound limited use of arms Scissors Sink
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Affective disorders Mania/ hypomania
4% adults with LD cyclical changes in behaviour & mood (Deb & Hunter 1991) Mixed affective & rapid cycling more common Rapid cycling M = F
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Bipolar Affective disorder Mania Symptoms
Irritability > euphoria Grandiose ideas & delusions - simple P of speech > flight of ideas Inc / dec appetite Echolalia Crying Overactivity Social inhibitions Reckless Behaviour
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Affective disorders Management
NICE Antidepressants - longer for effect Mood stabilizers PSI Routine / structure CBT Psychotherapy ECT Freud uneducatable Few therapists available need certain level verbal ability
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Picture 11 Fragile X
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Neuroses Anxiety disorder
Mild LD increased neuroticism cf gen popn GAD similar symptoms cf general popn Irritability & restlessness can be marked May not be able to avoid More severe LD only behavioural signs Co-morbidity / Psychiatric illnesses Williams syndrome part of behavioural phenotype ASD Symptoms of A/ avoidance causes suffering Subjective account/ observation from others
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Obsessive Compulsive Disorder
Repetitive behaviour common Compulsive Behaviours 3.5%-40% in mild to profound learning disabilities Symptoms Ordering compulsions most prevalent Thoughts/ acts not due to external source Not pleasurable May not be viewed as unreasonable Resistance may be minimal Compulsions can > aggression if prevented.
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Sue 50 year old lady with Down’s syndrome Living in supported living
Carer’s problems Excess time to leave house – routines Lining up Aggression/ risk of injury No evidence anxiety on examination - with limits set
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PTSD Increased risk of emotional, physical & sexual abuse
Increased risk of PTSD / adjustment disorders
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Anxiety disorders Treatment Treat psychiatric disorder NICE guidance
SSRI Less frequent TCA’s Behavioural treatments Staff training
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Personality Disorder Controversial Overlaps - behavioural phenotypes
Developmental delay when personality complete Stigma Individuals IQ <50 Overlaps - behavioural phenotypes Poor research base More readily diagnosed in mild / borderline LD Age 21 Avoid ICD diagnosis - schizoid, anxious, dependant Small number - mild LD, Antisocial PD, usually male persistent fire setters sex offences With people with developmental delay at what stage is there personality development complete Developmental phase longer cf normal IQ Over 21 Reid & Ballinger used Standardized Ax of personality Fragile X & social anxiety
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Picture 12
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Dementia
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Dementia Increased life expectancy Dementia brought forward all LD
30yr - Downs 10-15yr LD not Downs (Hoffman et al 1991)
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Down’s Syndrome & Dementia
“Precipitated senility” - Fraser & Mitchell 1876 Onset from 30 onwards 30-39 = few % 40-49 = % 50-59 = % 60-69 = %
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Dementia in Downs syndrome
Clinical Features Atypical - personality / behaviour changes precede dementia by some years Maybe onset of seizures or worsening of seizures Middle & later course = gen popn Increase in myoclonic epilepsy & dysphagia Possibly more rapid
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Dementia Differential Hypothyroidism (30% in DS) Medical/ iatrogenic
Sensory impairments Depression / adjustment reaction
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Dementia Assessment MDT Rating scales DSDS & Modified MMSE
Routine screens bloods etc Sensory Neuroimaging - Early stage Alzheimer's - atrophy of medial temporal lobe - Normal in Downs syndrome
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Dementia Treatment NICE Other treatments as for general dementia care
Anti dementia medication Other treatments as for general dementia care Life story work Palliative care
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Conclusion All psychiatric disorders possible
Assessment may take longer Informants Diagnostic overshadowing MDT Treatment according to diagnosis Capacity / best interests Medication Small doses & slow titration Monitor effect / SE Pts are given their medn unable to not comply
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Picture 13
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References Read, S. 1997. Psychiatry in Learning Disability.
Fraser, W. & Kerr, M Seminars in the psychiatry of Learning Disabilities. Second edition. College seminar series. Royal College of Psychiatrists DC- LD British Psychological Society / Royal College of Psychiatrists Dementia & People with LD Code of Practice. Mental Health Act 1983 Fear, C Essential revision notes for MRCPsych. Puri, B.K & Hall, A.D. Revision notes in Psychiatry. Valuing People Now (2007)
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Good books to read Freaks Geeks & Asperger’s syndrome, L Jackson
The curious incident of the dog who barked in the night, M.Haddon.
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Questions Thank you
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