It is estimated that 17% of children in the United States have a developmental disability and that 1% to 2% of children are diagnosed with mental retardation.1 Of interest to hospitalists: Those with intellectual disability (ID) use healthcare services more than those in the general population.
During a 12-month period, 16% of adults with ID were hospitalized, and 30% were seen in an emergency department (ED).2 Because the average age at death in this population has increased—to 66.1 years in one study—hospitalists must become familiar with the medical management of these patients.3 Achieving comprehensive care presents a challenge because of the atypical presentation of symptoms and the behavioral and communication problems found in many hospitalized patients with ID.
In this article, I will address some of the major clinical issues hospitalists confront when caring for this population.
Where to Begin
One key to understanding how to care for this population is ascertaining whether there is underlying etiology of ID. A diagnosis can be established in approximately 50% of patients who have ID.4 For example, patients with Down syndrome are more likely to have celiac disease, hypothyroidism, leukemia, atlantoaxial subluxation, obstructive sleep apnea, Alzheimer’s dementia, seizure disorder, and behavioral and psychiatric disorders than are patients in the general population.5
Table 1 (see p. 21) lists common medical conditions found in patients with ID. Hospitalists should make it a priority to obtain a comprehensive medical record from the patient’s healthcare provider or to gather the necessary information from a caregiver who knows the patient well; this person may assist the hospitalist in interpreting mannerisms of the nonverbal patient that reflect symptoms such as pain.
Swallowing Difficulties: Problems and Solutions
The risk of aspiration and subsequent mortality because of oral dysfunction and dysphagia is increased in patients with profound ID. The presence of choking and coughing during feeds identifies patients at significant risk of asphyxiation.6
In one study involving patients with severe ID, the absence of respiratory distress during meals or the lack of chronic lung disease identified 85% of patients who did not aspirate.7 Clinical assessment by speech-language therapists and the use of video fluoroscopy may be helpful in patients who experience either frequent aspiration pneumonias or episodes of coughing or choking during feeds. Cramming food into the mouth, eating too fast, and losing the bolus into the pharynx prematurely were factors predictive of asphyxiation risk.6 Speech-language therapists and nutritionists may assist hospitalists by recommending diet and feeding modifications that ensure the safe speed and size of bolus delivery, along with adjustment in food textures to reduce the risk of asphyxiation.
Patients with swallowing difficulties are also vulnerable to dehydration and malnutrition. In fact, more than 60% of children and adults with ID are underweight, with a body mass index less than or equal to 20. Food-intake surveys have demonstrated adequate protein intake but reduced fat, carbohydrate, and energy-food intake. Increasing energy-dense fats and sugar-containing foods, while monitoring for adequate fluid intake, is recommended in these individuals.8