The Physical Health of Older People with Learning Disabilities:
The Nurse’s Role

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Introduction
In the UK, the term “learning disability” is used to depict people who have an impairment of intellectual ability that strongly affects their daily activities. For that reason, they need constant supervision, help and care from authorized nursing personnel, in order to lead a rather normal life. Other countries use terms such as “intellectual disability” or “mental retardation”. (Perry, Hammond and Marston, 2010)
According to Doctor Nicola Davies (2008), older patients that suffer from learning disabilities have greater physical healthcare need than other patients, however due to a lack of proper training of the nursing personnel or a misunderstanding of their requirements, their needs are most often neglected.
People who suffer from learning disabilities are often faced with an inability to learn new skills or understand complex information, and with an impairing of their social function. This affects their development both physically and psychologically. (Davies, 2008)
Lindsey (2002) states that people with learning disabilities have a lower understanding of a healthy lifestyle and have a reduced ability to detect illness. Usually, when people with learning disabilities feel ill, they do not draw the attention of others about their condition. For this reason, it is important for nurses to be highly aware for changes in the behavior of these people and provide regular checks in order to determine their physical state. Another suggestion for addressing this situation would be to provide those people with information regarding health problems. Lindsey (2002) believes that picture based books may help nurses to easily communicate information about basic health issues, such as pain or discomfort.
There is an increasing need for caring for older people with learning disabilities. Even though growing old is a natural process part of life’s cycle, more issues arise for people with learning disabilities. Old age is not only determined by the number of years that a person has. There are physical and psychological factors that determine old age, such as the natural biological changes in one’s body that happen over the years, or the psychological ageing, that has more to do with the person’s state of mind (some people are happy with their old age, while other experience a state of depression).
The fact remains that people with learning disabilities have a poorer health than those who do not suffer from this condition. In the UK, there is an issue regarding unequal access to health care for people with learning disabilities (Emerson and Baines, 2010).
According to the same source, people with learning disabilities have a shorter life expectancy and an increased risk of early death, compared to those who do not present such a condition. Emerson and Baines (2010) state that mortality rates among people with moderate to severe learning disabilities are three times higher than in the general population. A higher mortality is more probable in people with Down’s syndrome, women and young adults.
Body
To understand the physical needs of people with learning disabilities, one must first understand the implications such a condition has upon a person. According to Hannon and Clift (2011), a person diagnosed with learning disabilities has the following characteristics: * A significantly reduced ability to understand new and complex information and to learn new skills * A reduced ability to cope independently, in other words a person with a learning disability is socially impaired
Usually signs of learning disabilities appear in the early stages of a person’s life (usually before the age of 18), presenting itself with long lasting effects on the person’s development. Although intelligence is formally measured through IQ testing, sometimes that is not enough to determine if a person has a learning disability. Rennie (2007) also suggests having neurological and sensorial responses tested, in order to determine an accurate result.
Learning disabilities are formally defined (Rennie, 2007) as disorders “in one or more of the basic psychological processes involved in understanding or using language, spoken or written, which may manifest in an incomplete ability to listen, think and speak, read, write or spell, or to do mathematical computations.” Therefore learning disabilities include dyslexia, dyscalculia, developmental aphasia and brain dysfunctions.
According to Peate and Fearns (2006), some of the general physical dysfunctions that may occur in older people with learning disabilities are: * Weight problems * Personal hygiene issues * The lack of physical fitness * Fatigue * Dental hygiene * Sleep problems and disturbances * Balance problems * Joint and muscle pain * Bowel dysfunction * Bladder dysfunction * Mobility problems * Injuries due to accidents * Injuries due to self harm * Medication side effects
In order to establish the role of nursing personnel in caring for people with learning disabilities, one must first understand how physical problems occur and how they affect the patient’s well being.
According to Peate and Firnes (2007), in people with Down’s syndrome for example, several issues of the musculoskeletal system arise from an abnormal production of collagen. The result is dramatic: people with Down’s syndrome have an increased laxity of the ligaments that attach muscles to bones and bones to each other. These, along with a low muscle tone, contribute to major orthopaedic problems.
One of those problems is atlantoaxial instability, which means that the patient has an increased mobility at the articulation of the first and second cervical vertebrae. This condition may be severe enough to injure the spinal cord, and it has numerous neurological symptoms, such as fatigue, neck pain, limited neck mobility or even difficulties in walking. In the case of the injury of the spinal cord, the result may be motor neurological damage, spasticity and the loss of bowel or bladder control.
Nursing staff must be attentive to people presenting such a condition and offer proper support for the patient’s neck. Usually in nursing homes this means special pillows or, in severe cases, the use of a foam collar to stabilise the patient’s neck.
The risk of osteoporosis is higher in people with intellectual disabilities. Mainly due to physiological factors, such as small body size, hypogonadism or Down’s syndrome, osteoporosis is much more common in people with learning disabilities than in the general population. Additionally, hypogonadism may cause sexual dysfunctions and lead to early menopause in women. (Prasher and Janicki, 2002)
Another pressing issue is improper bowel movements. Constipation is very common in elderly patients with learning disabilities, appearing either as a side effect of the medication received, or due to the lack of exercise or refusal of food. (Prasher and Janicki, 2002) Due to behavioural issues caused by learning disabilities – dementia is a known issue that may occur – patients may refuse food. This will not only cause bowel dysfunctions, but it may also lead to malnourishment. Usually, in severe cases, such patients are fed artificially. Although this practice solves the malnourishment problem, it will however not solve bowel dysfunctions.
According to the same source, cancer incidence in people with learning disabilities is much higher than in the general population. Some of the most common types of cancer include intestinal cancer, with a lower incidence of lung cancer, breast cancer or prostate cancer. However, it is more important to screen for breast cancer in women who suffer from learning disabilities than to screen for cervical cancer. Additionally, prostate cancer has been found to be more common in men that suffer from Down’s syndrome. (Prasher and Janicki, 2002)
Also, hepatitis A and B are likely in patients in institutions with overcrowding and insanitary conditions. This issue can be prevented by the Health Department, with periodical controls. Also, the nursing personnel must know and act according to precise regulations in order to provide the patients with a sanitary space.
Another common occurrence in patients with learning disabilities are injuries resulted from accidents and falls. According to Prasher and Janicki (2002), in 2001 11 per cent of nursing homes reported injuries among their residents, 50 per cent of them being caused by falls. Such occurrences are as common nowadays, and, in order to prevent them, nursing staff should either supervise patients with learning disabilities, or design a safe environment for them, where they cannot injure themselves. Sometimes, in patients with severe dementia, self harm is a common occurrence. These patients are often restrained to their beds to prevent them from harming themselves.
According to Emerson and Baines (2010), other diseases are more frequent in people with learning disabilities, than in the general population. Coronary heart disease and respiratory disease are more common in older people with learning disabilities.
The same source explains that coronary heart disease is a leading cause of death amongst people with learning disabilities, and rates are expected to increase due to longevity and lifestyle changes associated with community living. Almost half of all people with Down’s syndrome are affected by congenital heart defects, which will eventually lead to heart failure and death.
Additionally, people with asthma and learning disabilities were found to be twice more likely to be smokers than patients with learning disabilities who do not have asthma. More than half of women with learning disabilities and asthma are also obese.
Epilepsy is also a problem for people with learning disabilities. Uncontrolled epilepsy can have serious negative consequences on both quality of life and mortality. Often, people with learning disabilities may refuse treatment and their disease may get more and more serious as time passes. Epileptic episodes can happen more often, leading to the patient’s death. (Emerson and Baines, 2010)
Also, because of their condition, people with learning disabilities do not take much care of their oral health. Unhealthy teeth and gums and poor hygiene are some of the issues that arise in older people with learning disabilities. Therefore, the nursing staff should pay more attention to this are and either teach them to brush their teeth, or do it for them, every morning and evening, in order to maintain a good hygiene. Regular visits to the dentist are also recommended. (Emerson and Baines, 2010)
Sometimes, older people with learning disabilities have trouble eating, drinking and swallowing. This may have severe consequences over the patients health, and it may lead to problems such as dehydration, malnourishment or even asphyxia. Eating troubles lead to constipation and diabetes.
Probably the best attitude towards older people with learning disabilities is compassion. Nursing staff must firstly understand the problems those people are faced with, and understand that their needs are more pressing than the needs of the general elderly community.
People with learning disabilities have been treated differently by society their entire lives and they need constant supervision and extensive care. Their life expectancy is shorter and those who reach an older age often have much more physical health issues than people who are not disabled.
Additionally, persons presenting with an intellectual disability should have expert care to identify and treat associated developmental disabilities such as cerebral palsy, epilepsy, autism, and disorders of vision.
People with learning disabilities, also need to receive appropriate and ongoing education regarding healthy living practices in areas such as nutrition, exercise, oral hygiene, safety practices, and the avoidance of risky behaviours such as substance abuse and unprotected or multiple partner sexual activity. Sexual education in people with learning disabilities is very important. People with learning disabilities often have few opportunities to socialise, develop loving relationships and have their sexual needs met. Even so, they have a hard time understanding what they need to know about sexuality, protection, contraception and pregnancy. Additionally, they are very likely to be abused and stigmatised. In nursing homes where they reside at an older age, together with more people that are the same as them, those presenting learning disabilities may find it easier to develop relationships with other people.
Every human has the right to a private life, a family, and the right to marry. Unfortunately, people with learning disabilities, especially those with profound and complex disabilities, are often denied their fundamental human rights. People with learning disabilities may have more limited opportunities to develop relationships through school, work, hobbies or leisure activities. The social skills, sense of identity and self esteem that are at the root of our ability to develop healthy and respectful personal and sexual relationships are therefore more difficult to acquire.
People with learning disabilities are sometimes regarded as incapable of sexual feelings or as sexually deviant because of inappropriate behaviour in public. As in many families, carers can find it difficult to deal with their loved ones developing their sexual identity or may be worried about the risk of abuse. (Emerson and Baines, 2010)
That is why people with learning disabilities may not have many chances in their lives to develop relationships, find love and get married, therefore they explore these feelings at an older age, in a nursing home, where there are more people like them. People with learning disabilities will probably require special sex education, even at an older age. In order to avoid sexual transmitted diseases and other issues of the reproductive organs, they need to be properly instructed.
The nursing staff needs to be very careful with the administration of drugs. Drug selection should be guided by the patient’s clinical status (symptoms, severity of illness) and organ function, especially cardiovascular, renal, and hepatic functions. In patients with learning disabilities, drug interactions are extremely important. The nurse should not select drugs that interact with the regular medication a patient receives. Dosage requirements may vary considerably among patients and within the same patient at different times during an illness. A standard dose may be effective, subtherapeutic, or toxic. Thus, it is especially important that initial dosages are individualized according to the severity of the condition being treated and patient characteristics such as age and organ function, and that maintenance dosages are titrated according to patient responses and changes in organ function, as indicated by symptoms or laboratory tests. (Kim, 2001)
The route of administration should also be guided by the patient’s clinical status. Most drugs are given intravenously because critically ill clients are often unable to take oral medications and require many drugs, rapid drug action, and relatively large doses. In addition, the IV route achieves more reliable and measurable blood levels. Sometimes, patients with learning disabilities are more difficult to control during IV medication. They may not stand still, or understand why they are supposed to remain in bed, and they are likely to pull the IV and thus hurt themselves. For elderly patients with learning disabilities, it would be better and less troubling to administer pills, rather than IV drugs. (Kim, 2001)
The nurses should observe for adverse effects at all time, especially when the patient requires new drugs. The most vital aspects to check for are drug interactions. Interactions may occur whenever the patient is receiving two or more drugs concurrently and the number of possible interactions is very large. Although no one can be expected to know or recognize all potential or actual interactions, it is helpful to build a knowledge base about important interactions with commonly used drugs.
The nurse must consider a possible interaction when a patient does not experience the expected therapeutic effects or develops adverse effects. The nurse must look for signs and symptoms of new problems or worsening of previous ones and compare the patient’s symptoms with previous knowledge about interactions associated with the drugs. If the nurse can not explain the interaction, he or she must either consult a doctor or consult a drug reference to validate the observations.
Conclusively, it is a proven fact that older people with learning disabilities require more care than other people. Due to their inability to differentiate ill health from normality and to express themselves when they feel pain or discomfort, they must receive more care from nurses and proper guidance. Nurses need to check their health state periodically, be aware of changes in behavior, and explain how they can describe various health problems.

References Davies, N., 2008. Caring for older adults with learning disabilities. Nursing Standard, vol. 22, no. 24, pp. 42 –48 | Eric Emerson, E. and Baines, S., 2010. Health Inequalities & People with Learning Disabilities in the UK. Department of Health | Hannon, L. and Clift, J., 2010. General Hospital Care for People with Learning Disabilities. John Wiley & Sons | Kim, R. B., 2001. Handbook of adverse drug interactions. New Rochelle, NY: The Medical Letter, Inc. | Lindsey, M., 2002. Comprehensive health care services for people with learning disabilities. Advances in Psychiatric Treatment, vol. 8, pp. 138–148 | Peate, I. and Fearns, D., 2006. Caring for People with Learning Disabilities. John Wiley & Sons | Perry, D., Hammond, L. and Marston, G., 2010. Caring for the Physical and Mental Health of People with Learning Disabilities. Jessica Kingsley Publishers | Prasher, V. P. and Janicki, M. P., 2002. Physical health of adults with intellectual disabilities. Wiley-Blackwell | Rennie, J., 2009. Learning disability: physical therapy treatment and management : a collaborative approach. John Wiley & Sons |