Strategies Recommended for Screening and Treating Patients With Intellectual Disabilities

August 31, 2007 — Strategies for screening and treating patients with intellectual disabilities (ID) in the primary care setting are reviewed in the July-August issue of the Journal of the American Board of Family Medicine. Because obesity, osteoporosis, and smoking are more common in adults with ID, enhanced screening for these conditions is recommended. In contrast, abnormal Papanicolaou tests and cervical cancer are less prevalent in adults with ID, so screening recommendations for these conditions should be individualized.
"Adults with intellectual disabilities need thoughtful, well-coordinated primary care from family physicians," write Joanne E. Wilkinson, MD, MSc, from the Boston University School of Medicine, Boston Medical Center in Massachusetts, and colleagues. "Adults with ID have expressed a preference to be treated by physicians like their nondisabled peers. However, despite recent summaries of health disparities and health risks for people with ID, few guidelines exist in the literature to help practitioners make decisions about the health of their adult patients with ID, especially when screening for cardiovascular disease and cancer."
Using the US Preventative Service Task Force guidelines, the study authors reviewed screening recommendations for common preventable conditions, and they set these in the context of a literature review about the prevalence of these conditions in adults with ID. They also present strategies designed to reduce the stress associated with screening procedures in patients with ID.
"Intellectual disabilities" is defined as significant limitations in cognitive function, as well as in conceptual, social, and practical adaptive skills, beginning before age 18 years. Although the term is synonymous with "mental retardation," ID is preferred because it is less stigmatizing.
Based on current evidence, specific screening recommendations for adults with ID vs adults without ID are as follows:
Obesity/body mass index (BMI): All adults should undergo annual BMI measurement and counseling for patients who are obese; those with ID should have BMI measurement for at least once a year and individualized counseling (level of evidence, B).
Cholesterol and lipid profile: All men older than age 35 years and women older than age 45 years at average risk should undergo annual screening; this should begin earlier for high-risk patients (level of evidence, A). Clinicians should be aware that adults with ID have a higher incidence of risk factors (level of evidence, C).
Diabetes: Patients with hypertension or hyperlipidemia should have yearly glucose screening (level of evidence, B). Clinicians should be aware that risk factors are more common in adults with ID (level of evidence, I).
Hypertension: All adults 18 years of age or older should undergo yearly blood pressure measurement (level of evidence, A). Clinicians should consider that adults with ID have a higher incidence of risk factors (level of evidence, C).
Tobacco and smoking cessation: All smokers should have regular counseling at least once a year (level of evidence, A). Individualized counseling is recommended for adults with ID (level of evidence, I).
Colon cancer: After age 50 years, all adults should undergo annual fecal occult blood screening, with or without colonoscopy (level of evidence, A). For adults with ID, clinicians should be aware that risk factors are more common than in the general population, and they may wish to combine colon cancer screening with other tests while the patient is sedated (level of evidence, B).
Breast cancer: All women, regardless of whether they have ID, should have a mammogram every 1 to 2 years after age 39 years (level of evidence, B for those without ID and C for those with ID).
Cervical cancer: Sexually active women without ID should have an annual Papanicolaou test (level of evidence, A). In women with ID, the Papanicolaou test generally can be done less often, but frequency should be individualized based on specific risk factors (level of evidence, B).
Prostate cancer: Evidence is insufficient to recommend for or against screening for all men (level of evidence, I). In men with ID, screening generally can be done less often, but frequency should be individualized based on specific risk factors (level of evidence, I).
Skin cancer: Evidence is insufficient to recommend for or against screening for all adults (level of evidence, I). In adults with ID, screening generally can be done less often, because skin cancer is probably less prevalent in this population, but frequency should be individualized based on specific risk factors (level of evidence, I).
Osteoporosis: Bone densitometry is recommended for all adults (level of evidence, B).
For adults with ID, annual screening is recommended, beginning at age 40 years for patients who live in institutions and at age 45 years for community-dwelling patients (level of evidence, B).
Vision and hearing: All adults should have annual screening. Those with ID should be screened at least once a year, with modified or individualized methods as needed, depending on specific disabilities (level of evidence, B).
Mental health: All adults should have regular screening for depression and mood disorders; those with ID should be screened yearly with attention to physical symptoms of mood disorders (level of evidence, C).
Logistic considerations that may facilitate screening patients with ID include weighing at home on a regular bathroom scale and in a more familiar environment, use of a larger scale for patients who are unstable when standing or have comorbid physical disabilities, portable electronic blood pressure monitors to reduce "white-coat hypertension," blood draws at home within certain circumstances, and sedation if needed for routine procedures.
"Any decision about screening, whether it pertains to a patient with ID or a patient with typical intelligence, should be informed by the patient's comorbid medical conditions, life expectancy, and quality of life," the study authors conclude. "These issues should be carefully considered in both populations with the caveat that many people with ID consider their quality of life to be good; the mere presence of ID should not be considered grounds to eschew screening.... To provide appropriate care, physicians need updated, evidence-based recommendations specific to adults with ID."
This study has received no funding, and the authors have disclosed no relevant financial relationships.
J Am Board Fam Med. 2007;20:399-407.