The universal GP Training website for everyone, not just Bradford.   Created in 2002 by Dr Ramesh Mehay

Learning Disability

Bradford VTS Clinical Resources

WEBLINKS

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Some basics

According to Public Health England, about 2.5% of the population has a learning disability (LD). Yet most GP LD registers show only about 0.4% of their practice population. The ‘missing’ 2% might be people with a mild learning disability, or with other diagnoses which appear on the disease register but are not separately recorded. This includes, for example, people with Down’s Syndrome, autism or cerebral palsy that also have a learning disability.

Why is this area important?

Because people with a learning disability face many distinct health inequalities:

  • Significantly reduced life expectancy, 18 years lower for women and 14 years lower for men (NHS Digital 2017-18).
  • Poorer nutrition and increased likelihood to be either obese or underweight. They are less likely to have help for their obesity, including screening for thyroid disease and diabetes.
  • Very low attendance in the three national cancer screening programmes (breast, bowel and cervical).
  • Very low uptake of flu immunisation yet respiratory infection is one of the most frequent causes of preventable deaths.
  • The Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD) found, over a quarter of deaths could be prevented with better-quality healthcare. Recently, the learning disabilities mortality review (LeDeR) raised this figure to over a third.
  • Greater prevalence of epilepsy and severe mental health illnesses. Also, multimorbidity, complexity, polypharmacy and greater likelihood of adverse events from incompatible interventions (PHE 2017).
  • A person with Learning Disability is NOT the same as someone with a learning difficulty.   For example, someone with Down’s syndrome has a learning DISABILITY.    But someone with Dyslexia is someone with a learning difficulty.  In general, a learning disability constitutes a condition which affects learning and intelligence across all areas of life, whereas a learning difficulty constitutes a condition which creates an obstacle to a specific form of learning, but does not affect the overall IQ of an individual.   In other words, a learning disability is a reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life. People with a learning disability not only take longer to learn but may need support to develop new skills, understand complicated information and interact with other people. 
  • Many people with learning disabilities can access mainstream services and just need some reasonable adjustments making – like longer appointments, quiet environments or carers to support at appointments.    Don’t always think you need to go straight to the help of a specialist LD service first.   There are things you can do which are straight forward, often common sense, and don’t require massive complex changes.
  • But most areas in the UK will have a specialist LD service should you need them.  They provide health support to adults with a learning disability (NOT learning difficulty) who need additional support to get their health needs met. Primary care must have tried using mainstream services and making reasonable adjustments to their care before they refer to such specialist teams. 
  • If a patient with a learning disability doesn’t have the capacity to consent to bloods, tests or treatment – then a Restrictive Intervention may be required.
  • Restrictive Interventions are deliberate acts on the part of the other person(s) that restrict a patient’s movement,  liberty and/or freedom to act independently in order to
      • Take immediate control of a dangerous situation where there is a real possibility of harm to the person or others if no action is undertaken, or
      • End or reduce significantly the danger to the patient or others.  (MHA CoP, 2015)
  • Restrictive practice is making someone do something they don’t want to do or stopping someone from doing something they want to do (Skills for Health, 2014)
  • KEY POINT: The use of Restrictive Interventions (safe holds) are a last resort as they impact on the person’s human rights – they must be reasonable and proportionate as they can be traumatising for people
  • If you are considering a Restrictive Intervention…
      • Consider a referral to the specialist Learning Disability unit forst – to ensure the person gets the right health treatment.
      • There must be a significant clinical need for the intervention to be done.  For example, in the case of bloods – these must be necessary and urgent.  So, for example, this does NOT include routine annual health checks unless there has been a change in the person’s health or presentation (these must be identified in the referral and on the consent form)
      • Attach something like Consent Form 4 (in Downloads section above) to your referral letter to the Learning Disabilities unit.
          • Document that restrictive interventions (safe holds) are required on the Consent Form 4
          • State what has been tried previously to evidence restrictive interventions are required
          • State why it is in the person’s best interests to have the bloods and that the risk of a potential health issue outweighs the risk of using restrictive interventions
          • Without a clear rationale and completed forms the specialist Learning Disability team will be unable to support you.
          • Put a contact name and direct phone number on the referral form so they can contact you with any queries

Admission

Admit to hospital if the person is at risk of a hyperglycaemic emergency (vomiting, abdominal pain reduced conscious level, heavy ketonuria, dehydration requiring IV fluids, hypotension, and serious intercurrent problem).

Same day referral

Refer to be seen on the same day if the patient is acutely ill, consider Type 1 Diabetes/pancreatic insufficiency if ketonuria present, the patient is slim and has a short history of marked symptoms (weight loss, thirst, and polyuria).

Early Referral

Diabetes and pregnancy requires referral to the hospital diabetes team

LIFESTYLE

BMI                        
Aim for healthy BMI <25 – consider dietition, Orlistat, other dietary measures & EXERCISE

ALCOHOL            
Not to exceed recommended limits. (14 units men and women)

SMOKING          
Stop!

BLOOD PRESSURE

Active management is essential!

Over half of all diabetics are hypertensive. Trials have shown that excellent BP control reduces retinopathy, nephropathy, strokes, heart failure and MI. BP control is as important as glycaemic control! TARGET < 130/80

Treatment

  • 1st line – ACEi, ARB if they cannot tolerate it.
    Ramipril starting regime derived from the  HOPE study regime and BNF guidelines
    If U&Es pre treatment reveal a creatinine < 150 micromol/l and a sodium >130 mmol/l then 2.5 mg Ramipril daily (1.25mg if on lower dose concomitant diuretics) for one week with check U&Es and an increase to 5.0 mg Ramipril for a further two weeks. Re-check U&Es and if indicated increase to 10mg Ramipril and repeat U&Es at least on an annual basis. If eGFR falls > 25% or creatinine rises by > 30% stop or back titrate treatment – see NICE guidelines. Don’t forget BNF cautions and contraindications.
  • 2nd line – CCB or, thiazide like diuretic or, Beta blocker (especially if there is a history of ischaemic heart disease),. Follow hypertension protocol

LIPIDS AND CVD RISK (see lipid modification protocol)

Offer generic Atorvastatin 40mg (Bradford Healthy Hearts) if their Q risk >10% (aged between 18-84 yrs), have been diabetic for > 10 years or, over 40 years old.  Target chol <4mmol/l

For diabetics with established CVD offer secondary prevention or Chol > 4mmol/l – Atorvastatin 80mg

Triglycerides:

If TG level remains high (above 4.5mmol/l) please ref to CKS guidance on lipid modification or in-house lipid modification protocol.

Do not routinely offer Nicotinic acid or Omega fish oils.

MICROALBUMINURIA  AND CKD

  • All diabetics need testing annually for microalbuminuria and eGFR – microalbuminuria is the first sign of diabetic kidney disease and occurs before eGFR falls.
  • SEE CKD PROTOCOL

ANTIPLATELETS

  • Do not offer anti-platelets unless there is evidence of CVD

NICE recommended Hba1c targets are:

  • 48mmol/mol – people who are managed by lifestyle and diet
  • 48mmol/mol – people who are managed by lifestyle and diet combined with a single drug not associated with hypoglycaemia (such as metformin)
  • 53mmol/mol – people who are taking a drug associated with hypoglycaemia (such as sulphonylurea), combination treatment

See table below for suggested targets for frail/elderly patients.  Please exempt from QoF if you follow these targets putting an explanation in the notes.

Hba1c Target: aim for 48mmol/mol (if on diet or single drug not affected by hypoglycaemia ) or <53mmol/mol (if on SU, or more than one medication).  Caution: elderly

  • Start Oral treatment usually Metformin at diagnosis. Metformin 500mg ideally with evening meal, increasing to 1 gram a week later if they have no side effects.
  • Please remember Metformin is very effective, reduces cardiovascular risk, retards weight gain and is not usually associated with hypos – but is contra-indicated if Creatinine > 150 (or eGFR < 40) in CCF or significant hepatic dysfunction.
      • Metformin has to be stopped if eGFR fall below 30!
      • Metformin MR can be used if they run into problems with GI side effects.
  • Don’t forget that on starting hypoglycaemics to complete the prescription exemption form for those patients under 60 years of age.
  • If you are starting a sulphonylurea (ideally Glimepiride) – ensure they are counselled and documented about:
      • symptoms of hypos
      • hypo management
      • hypos and driving and remind them about informing their car and travel insurer AND document this in their records. If they hold HGV or PSV license then check with the 6 monthly updated DVLA guidance with respect to them having to inform the DVLA.
      • Ensure they have been given a glucometer and a sharps bin, test strips and lancets are added to their repeat prescription
    •  
  • DISCUSS AKI SICK DAY RULES ADVICE – see hypertension protocol for full advice.

FUNCTIONALLY DEPENDENT

  • Due to loss of function, having impairments of ADLs
  • Increased likelihood of requiring addition medical &/or social care
  • HBA1c target: 53 – 64mmol/mol

FRAIL

– Combination of significant fatigue, recent weight loss,       severe restriction in mobility & strength, increased propensity for falls & increased risk of institutionalisation

 – A recognised condition & accounts for 25% of older people with diabetes

 – Clinical Frailty scale or CHSA 9-point scale (assessment tool)

HBA1c target: 60-70mmol/mol

DEMENTIA

– Degree of cognitive impairment leading to sig. Memory problems, a degree of disorientation, or a change in personality & unable to self care

 – MiniCog tool (easy to use assessment tool)

HbA1c target: 60-70mmol/mol

END OF LIFE CARE

  • Significant illness or malignancy & have life expectancy reduced to <1 year
  • Glycaemic aim – hypo and symptomatic hyperglycaemia avoidance

Medication

Mode of action

Side effects

Cautions (check BNF for more detail)

Dose

METFORMIN

1st line treatment, unless BMI <25 (23 in South Asian population)

Low Hypo risk

Reduces CVD risk, weight neutral

Helps to stop the liver producing new glucose.

It helps to overcome insulin resistance by making insulin carry glucose into muscle cells more effectively.

 

Main side effect if GI affects, generally dose dependent-can be reduced with gradual increase in dose over several weeks or trying modified release Metformin

Also: metallic taste, reduced absorption of vitamin B12, build up of lactic acid in the blood, allergic reaction and liver problems.

STOP/DO NOT USE IF eGFR <30 ml/min

*Lactic acidosis- care if eGFR < 45ml/min.

Document that advice has been given to stop these tablets if they become dehydrated (restart when eating normally again)

*GI side effects. Titrate dose slowly to reduce side effects

NOTE IF ALT> 3 TIMES NORMAL

Start at 500mg ideally with evening meal, increasing to 1g with evening meal after a week if they have no side effects.

Max dose 2 gram  over 4 weeks.

Consider slow release for to reduce tablet load or if they are struggling with GI side effects.

 

SGLT-inhibitor

Empagliflozin

Low hypo risk

Can help with weight loss

Sodium-glucose co-transporter 2 (SGLT2) inhibitor that prevents glucose reuptake in the kidney, leading to the excretion of excess glucose in the urine.

Polyuria, polydipsia, thrush. UTI, fluid depletion

Increased risk of amputation- avoid if h/o leg ulcers

Only start if Cr Clearance > 60.

Care if > 75 years. Risk of postural hypotension.

Care needed if they have skin ulcers – risk of amputation.

Document advice about normoglycaemic ketoacidosis and give ketostix.

Empagliflozin 10mg. Can be increased to 25mg.

Expensive so only continue if there is a clear response after 6 months

SULPHONYLUREA (SU)

Glimepiride

Risk of hypos

Good if rapid response is needed.

They work by stimulating cells in the pancreas to make more insulin.

They also help insulin to work more effectively in the body.

 

Weight gain.

Hypoglycaemia, gastrointestinal side effects, low sodium, facial flushing and intolerance of alcohol, allergies etc.

 

Can cause hypoglycaemia, particularly if there is renal impairment or they are elderly.

Consider occupation – hypos if not eating regularly, fasting.

Make sure you give and document advice about hypos.

Make sure they are able to test their blood glucose – issue glucometer, test strips, lancets and sharps bin. (SGBM)

Document advice about driving/insurance.

Start at 1mg and titrate up to 4mg depending on glucose level.  Should have an effect on Hba1c over a 2 month period.

GLIPTIN

Do not cause weight gain and encourages patient satiety. Although they probably reduce Hba1c levels less than other drug treatments.

Low hypo risk

They work by blocking the action of the enzyme, DPP-4, which destroys the hormone Incretin.

 

Gastro-intestinal effects, oedema, headache,

 Avoid if h/o Pancreatitis or heart failure or liver problems.

*Expensive- only continue if they meet NICE guidance.

*Not v powerful max likely reduction ~ 11 mmol/mol

*Do not use if a h/o pancreatitis

*Monitor egfr at reviews

*Don’t use if heart failure risk

Linagliptin 5mg if eGFR < 50

GLITAZONE

Pioglitazone

Low hypo risk

Consider in people with very significant features of metabolic syndrome.

South Asian

Reducing insulin resistance.

Improving insulin sensitivity.

 

Oedema esp if heart failure or at risk.

Rare reports of liver dysfunction.

Weight gain,

gastro-intestinal side effects, headache, dizziness.

 

Discuss with member of Level 2 team before starting.

Avoid if they have heart failure or risk of fluid overload

Avoid if h/o bladder cancer, undiagnosed haematuria

Avoid if fracture risk

Monitor LFTs at each diabetic review.

Annual urine dip looking for haematuria

Pioglitazone:15mg-30mg.

A six month period may be needed to really see an effect from these tablets. NICE recommends that they are only continued if at least a 11 mmol/l reduction in Hba1c is seen within 6 months of starting the treatment.

 

GLP-1 mimetic/insulin

Discuss with Level 2 doctor

  

 

  • At first warning of episode of hypoglycaemia:
      • Immediately treat with a 15-20g of a short-acting carbohydrate such as:
          • 200 mls of Lucozade (please note Lucozade formula has changed so lower in sugar- need 200ml)
          • 200mls of non-diet drink
          • 4-5 glucose tablets
          • 3-4 jelly babies
          • 200mls of fruit juice
  • If the hypo is more severe, and the patient cannot treat themselves:
      • applying Glucagel (or treacle, jam or honey) on the inside of cheeks and gently massaging the outside of cheeks.
      • if unconscious, Glucagon can be injected if the person treating has been trained to use it.
      • Otherwise call an ambulance immediately
  • Important:
      • If unable to swallow or unconscious, do not give anything by mouth (including Glucagel, treacle, jam or honey). Make sure family and friends are aware of this. If unconscious, place patient in the recovery position (on side with head tilted back) so that tongue does not block throat.
  • Follow-on treatment:
      • To prevent blood glucose levels dropping again, follow sugary foods with 10-20g of a longer-acting carbohydrate such as:
          • half a sandwich
          • fruit
          • a small bowl of cereal
          • biscuits and milk
          • the next meal if due
      • Patients experiencing regular episodes of hypoglycaemia require prompt review by the diabetes team.
      • Severe episodes of hypoglycaemia require urgent review by the diabetes team.

Advise patients the following: if you do go down with a cold, flu or any other illness…

  • The Basics
      • Rest.
      • Drink plenty of sugar-free fluids.
      • Avoid too much caffeine as this could make you dehydrated.
      • Take painkillers in the recommended doses as necessary.
      • Contact your GP to see if treatment with antibiotics is necessary.
      • If you are vomiting uncontrollably, contact your GP or diabetes clinic.
  • Insulin or diabetes medications
      • Keep taking your insulin or diabetes medications even if you are not eating. Stop metformin and blood pressure medication if you are dehydrated.  CONSIDER AKI SICK DAY RULES – see hypertension protocol.
  • Testing
      • Test your blood or urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
  • Ketoacidosis
      • When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
  • Testing for ketones
      • If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.
  • Food and drink
      • It is important to keep taking your medication as normal and drink plenty of sugar-free drinks. Aim to drink at least three litres (five pints) a day. Try to keep to your normal meal pattern, but if you are unable to, for any reason, you can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as yoghurt, milk and other milky drinks, fruit juice or sugary drinks such as Lucozade, ordinary cola or lemonade. You may find it useful to let fizzy drinks go flat to help keep them down

Advise patients of the following:

  • Vaccinations and/or malaria tablets
  • Carry diabetes ID or a GP letter if carrying insulin and list of prescription drugs
  • Carry all medication and blood glucose testing equipment in hand luggage
  • Consider how to keep insulin cool if travelling for long periods
  • Travel insurance: – Allow 2 weeks to buy travel insurance. – Don‟t just buy on price, check the cover and read the small print – – Be honest and declare all medical conditions
  • Plan to take twice the quantity of medical supplies normally used
  • Consider adjusting medication if travelling across time zones
  • Consider adjustment to insulin if travelling to hot or cold climate
  • Carry a European Health Insurance Card (EHIC) if travelling within Europe

www.ehic.org.uk, / 0845 605 0707

Consider availability of insulin if travelling abroad for long periods.

Interpreting blood results on pathology template – Remember frailty

  • HbA1c <48 →select satisfactory→take no action – patient will be reviewed as per recall
  • HbA1c 48-53 →select abnormal →speak to nurse → send task to admin to book tel appt with nurse to discuss abnormal result and document a suggested plan to up-titrate medication based on the above guidance for nurse to discuss with patient – nurse will discuss with patient possible changes to medication and then task Dr back to make changes and issue script.  – if on single drug or diet only
  • HbA1c <53 → select satisfactory  →take no action – if on SU or combination drugs patient will attend at next review 6 months later
  • HbA1c >53 → select abnormal (take into account patients age and fraility) →speak to nurse → send task to admin to book tel appt with nurse to discuss abnormal result and document a suggested plan to up-titrate medication based on the above guidance for nurse to discuss with patient – nurse will discuss with patient possible changes to medication and then task Dr back to make changes and issue script. 

Any concerns – send message to Level 2 team

Using the SystmOne Template (CDM) for Diabetes.
See CDM review table

  • Bloods: U&Es, eGFR, HbA1c, ALT (if first year on statin) and lipid profile  – (Consider other tests if have other chronic diseases.)
  • Urine ACR.
  • BP
  • Lifestyle discussion: smoking status/cessation advice, exercise status, alcohol intake, diet.
  • BMI
  • Retinal review.
  • Foot check annually (in house) and record on the template. If moderate or high risk they need a referral to podiatry
  • Any complications?  erectile dysfunction, neuropathic pain, autonomic neuropathy.
  • Hypo unawareness, ? hypos requiring external intervention (see DVLA guidelines).
  • Review of blood monitoring – if they require monitoring.
  • Medication review: concordance/indications/side effects/if on insulin – injection sites.
      • Record medication review done, move date on till next review
      • Assign diagnosis to repeat template medication.
  • Add/move recall on.    NB: Diabetics well be reviewed at least 6 monthly.

TARGETS AT A GLANCE

  • BP: <130/80 – particularly if there are renal problems
  • Get to non smoking: don’t forget smoking cessation
  • Cholesterol: < 4.0mmol/l
  • HbA1c:
        • Diet alone  or single drug not affected by hypoglycaemia <48mmol/l
        • Medication <53mmol/l.  Patient tailored care needed especially if they are elderly or there are concerns about hypogylcaemia.
  • BMI: <25

Diabetes in pregnancy is associated with risks to the woman and the developing fetus.

Planning a pregnancy

Women planning a pregnancy should be referred to a diabetes pre-conception clinic.

Pre-pregnancy planning includes:

  • Diet and exercise, weight loss advised if body mass index > 27kg/m2
  • Retinal photography unless carried out in last 12months
  • Renal assessment (including microalbuminuria)
  • Folic acid 5mgs for 3 months preconception and continued for first trimester.
  • Establish rubella status, booster organised if required.
  • Blood pressure should be monitored
  • Smoking/alcohol cessation advice

Review of medications

  • Metformin may be used before and during pregnancy, as well as or instead of insulin.  The diabetes antenatal clinic will oversee their care whilst pregnant.
  • Isophane insulin is the first-choice long-acting insulin during pregnancy.
  • Discontinue oral hypoglycaemic agents (apart from metformin), ACE-inhibitors, Angiotensin Receptor Blockers and statins

Gestational diabetes

  • 6 weeks post-partum patients require a HbA1c to establish whether glucose tolerance has returned to normal.
  • All patients require advice on their elevated long term risk of diabetes.
  • All patients require advice on their risk of gestational diabetes in future pregnancies.
  • All patients require advice regarding diet, weight control and exercise

All patients require an ANNUAL HbA1c in view of their elevated risk of Type 2 diabetes. Please add an ‘AT RISK OF DIABETES’ recall to their notes.

Annual Review at a Glance

A collaborative review with the patient and carer (where applicable) of physical and mental health with referral through the usual practice routes if health problems are identified.

  • Clinical systems & Chronic illness review
  • Mental Health & Behaviour enquiry
  • Physical Examination
  •  
  • Specific Syndrome check
  • Health Promotion
  • Epilepsy enquiry
  • Dysphagia enquiry – refer to SALT if any swallowing difficulties.

(CME SHED)

This is recommended by the following methods:

  • A check on the accuracy an appropriateness of prescribed medications
  • A review of coordination arrangements with secondary care
  • A review of transition arrangements where appropriate
  • A discussion of likely reasonable adjustments should secondary care be needed
  • A review of communication needs, including how the person might communicate pain or distress
  • A review of family carer needs
  • Support for the patient to manage their own health and make decisions about their health and healthcare, including through providing information in a format.
  • Enter information onto appropriate S1 template.
  • Document smoking – offer smoking cessation
  • Record BP
  • Record BMI – offer weight loss/lifestyle advice if overweight (look at weight management protocol)
  • Dietary advice – Dietician referral/Weight management clinic
  • Exercise advice – consider BEEP

Also..

  • Document QRISK
  • Any Sexual Health issues including contraception
  • Cancer screening and check engagement with screening programmes (cervical, breast, bowel, AAA (abdominal aortic aneurysm)

 

 

  • Review medical history – review any chronic diseases as per protocols
  • Ask specifically about the following
      • Don’t forget about HEARING – examine for earwax (easy to solve if present!)
      • Any recurrent CHEST INFECTIONS?   If so, GP to refer to SALT (speech/swallow problems?)
      • Any SWALLOWING difficulties (dysphagia)  – refer to SALT if needs be.   Also look into heartburn/indigestion (dyspepsia) as may affect medication compliance.
      • Don’t forget about CONSTIPATION.   If patient can’t vocalise, the pain can cause aggressive behaviour.
      • Any CONTINENCE issues?
      • Any FITS/FAINTS/FUNNY TURNS (epilepsy enquiry)
      • MENTAL HEALTH SYMPTOMS – have carers noticed signs of depression or anxiety or psychosis?   If new dementia – do 6CIT & bloods.   If existing dementia – review if stable or worsening.
      • Are VACCINATIONS all up to date?
  • Ask about general well being

What to do? 

      • No concerns – managed by Nurse
      • New symptoms depending on severity review with GP by:
          • Pre-book appointment
          • Walk in or on the day
          • On-call appointment

Systm One Things 

  • ENSURE LEARNING DISABILITY HEALTH EXAMINATION AND LEARNING DISABILITY HEALTH PLAN BOXES ARE TICKED. 
  • A HEALTH PLAN CAN BE PRINTED IF REQUESTED BY PATIENT OR CARER. 
  • REMEMBER TO MOVE ON RECALL
  • Mental health  – anxiety, depression, psychosis?
  • Behavioural issues – like aggression.   Explore if in pain as often this can result in aggression.  If problematic, please book appt with GP to review
  • Memory problems
    • If already coded as Dementia please do review
    • If memory concerns – screen with 6CIT score and do bloods as per template, follow up review with GP

No symptoms  – managed by Nurse

New symptoms depending on severity, review with GP by:

  • Pre-book appointment
  • Walk in or on the day
  • On-call appointment

The Minimum

  1. Blood Pressure
  2. Weight & BMI
  3. Check hearing – examine ears
  4. Mental State Examination – any unusual behaviour?  Overt depression?  Anxiety?

What Clinical Systems to Examine

You may wish to do a general review of all the clinical systems.   It doesn’t take long.

  1. Respiratory
  2. Cardiovascular
  3. GIT

Of course, do others as appropriate.  For example,  if there is something in the medical history, like diabetes, then a vascular check might be worthwhile.

  • Neuro examination
  • GU system
  • Vascular System
  • The Skin
  • The STOMP (Stopping over medication of people with learning disabilities and autism) is asking that when psychotropic medications are prescribed to people with learning disabilities and autism, prescribing clinicians should regularly review these to justify their ongoing use.
  • Awareness raising is also being done with local LD service providers to ensure everyone is aware. MESH might be an option for some.
  • There is a reminder about STOMP on the LD Annual health check template (DQT ES Learning disabilities)
  • The first step for practices is to identify people on their learning disability registers who are being prescribed these medications.
  • There is also guidance from the specialist LD psychiatry and pharmacy services to support prescribers who are considering medication reductions. Guidance for Reduction in Psychotropic Medications – http://nww.bradford.nhs.uk/GP/Pathway%20Library/Guidance%20for%20Reduction%20in%20Psychotropic%20Medications.docx
  • It is crucial to talk to the person with learning disabilities and their family/main-carer before making any decisions – they may be able to provide information to identify whether medications are appropriately prescribed or not. If you decide to go ahead and reduce medications, attached is information that may be helpful for the person and carers in the community.
  • Patient Information – Medication Reductions – STOMP http://nww.bradford.nhs.uk/GP/Pathway%20Library/Patient%20Information%20-%20Medication%20Reductions%20-%20STOMP.docx

Key Points

  • Any medication reductions need to be done very slowly.
  • Only one medication should be changed at a time.
  • Even small reductions are worthwhile and can make a big difference to the person’s quality of life.

 

  • ALL patients need: FBC, HbA1c, Total cholesterol:HDL (if not on a statin)
  • Downs Syndrome: TFTs
  • On antipsychotics : follow SMI protocol – may also need an ECG
  • Any CDM review bloods are per Chronic Disease Management Bloods table

Hba1c Target: aim for 48mmol/mol (if on diet or single drug not affected by hypoglycaemia ) or <53mmol/mol (if on SU, or more than one medication).  Caution: elderly

  • Start Oral treatment usually Metformin at diagnosis. Metformin 500mg ideally with evening meal, increasing to 1 gram a week later if they have no side effects.
  • Please remember Metformin is very effective, reduces cardiovascular risk, retards weight gain and is not usually associated with hypos – but is contra-indicated if Creatinine > 150 (or eGFR < 40) in CCF or significant hepatic dysfunction.
      • Metformin has to be stopped if eGFR fall below 30!
      • Metformin MR can be used if they run into problems with GI side effects.
  • Don’t forget that on starting hypoglycaemics to complete the prescription exemption form for those patients under 60 years of age.
  • If you are starting a sulphonylurea (ideally Glimepiride) – ensure they are counselled and documented about:
      • symptoms of hypos
      • hypo management
      • hypos and driving and remind them about informing their car and travel insurer AND document this in their records. If they hold HGV or PSV license then check with the 6 monthly updated DVLA guidance with respect to them having to inform the DVLA.
      • Ensure they have been given a glucometer and a sharps bin, test strips and lancets are added to their repeat prescription
    •  
  • DISCUSS AKI SICK DAY RULES ADVICE – see hypertension protocol for full advice.

Ask about carers and record who the carer is. 

Carers (especially if family members) will often struggle and not admit to it.   Sometimes they may even become irritable with the patient because their lives are so pressured.   Explore this area sensitively.   Is the carer irritable or showing signs of anxiety or depression.   Are they smoking excessively or using alcohol to cope?   Empathise.

Ask the carer to book a separate appointment for themselves if you feel they need a health review.

CARER SUPPORT ORGANISATIONS

Think about referral to

  • Carers Support Services – www.carersresource.org
  • Benefits Advice Services
  • Housing advice
  • Social Services – to make  adjustments the home or arrange respite care
  • At first warning of episode of hypoglycaemia:
      • Immediately treat with a 15-20g of a short-acting carbohydrate such as:
          • 200 mls of Lucozade (please note Lucozade formula has changed so lower in sugar- need 200ml)
          • 200mls of non-diet drink
          • 4-5 glucose tablets
          • 3-4 jelly babies
          • 200mls of fruit juice
  • If the hypo is more severe, and the patient cannot treat themselves:
      • applying Glucagel (or treacle, jam or honey) on the inside of cheeks and gently massaging the outside of cheeks.
      • if unconscious, Glucagon can be injected if the person treating has been trained to use it.
      • Otherwise call an ambulance immediately
  • Important:
      • If unable to swallow or unconscious, do not give anything by mouth (including Glucagel, treacle, jam or honey). Make sure family and friends are aware of this. If unconscious, place patient in the recovery position (on side with head tilted back) so that tongue does not block throat.
  • Follow-on treatment:
      • To prevent blood glucose levels dropping again, follow sugary foods with 10-20g of a longer-acting carbohydrate such as:
          • half a sandwich
          • fruit
          • a small bowl of cereal
          • biscuits and milk
          • the next meal if due
      • Patients experiencing regular episodes of hypoglycaemia require prompt review by the diabetes team.
      • Severe episodes of hypoglycaemia require urgent review by the diabetes team.

Advise patients the following: if you do go down with a cold, flu or any other illness…

  • The Basics
      • Rest.
      • Drink plenty of sugar-free fluids.
      • Avoid too much caffeine as this could make you dehydrated.
      • Take painkillers in the recommended doses as necessary.
      • Contact your GP to see if treatment with antibiotics is necessary.
      • If you are vomiting uncontrollably, contact your GP or diabetes clinic.
  • Insulin or diabetes medications
      • Keep taking your insulin or diabetes medications even if you are not eating. Stop metformin and blood pressure medication if you are dehydrated.  CONSIDER AKI SICK DAY RULES – see hypertension protocol.
  • Testing
      • Test your blood or urine four or more times a day and night (ie at least eight times in a 24-hour period) and write the results down. If you are not well enough to do this, ask someone to do it for you.
  • Ketoacidosis
      • When diabetes is out of control as a result of severe sickness, it can lead to a condition called diabetic ketoacidosis or diabetic coma if you have Type 1 diabetes. The body produces high levels of ketone bodies causing too much acidity in the blood.
  • Testing for ketones
      • If you have Type 1 diabetes and your blood glucose level is 15 mmol/l or more or you have two per cent or more glucose in your urine, you will also need to test your urine or blood for ketones. They are a sign that your diabetes is seriously out of control. Ketones are especially likely when you are vomiting and can very quickly make you feel even worse. If a ketone test is positive, contact your GP or diabetes care team immediately.
  • Food and drink
      • It is important to keep taking your medication as normal and drink plenty of sugar-free drinks. Aim to drink at least three litres (five pints) a day. Try to keep to your normal meal pattern, but if you are unable to, for any reason, you can replace some or all of your meals with snacks and/or drinks that contain carbohydrate such as yoghurt, milk and other milky drinks, fruit juice or sugary drinks such as Lucozade, ordinary cola or lemonade. You may find it useful to let fizzy drinks go flat to help keep them down

Advise patients of the following:

  • Vaccinations and/or malaria tablets
  • Carry diabetes ID or a GP letter if carrying insulin and list of prescription drugs
  • Carry all medication and blood glucose testing equipment in hand luggage
  • Consider how to keep insulin cool if travelling for long periods
  • Travel insurance: – Allow 2 weeks to buy travel insurance. – Don‟t just buy on price, check the cover and read the small print – – Be honest and declare all medical conditions
  • Plan to take twice the quantity of medical supplies normally used
  • Consider adjusting medication if travelling across time zones
  • Consider adjustment to insulin if travelling to hot or cold climate
  • Carry a European Health Insurance Card (EHIC) if travelling within Europe

www.ehic.org.uk, / 0845 605 0707

Consider availability of insulin if travelling abroad for long periods.

Interpreting blood results on pathology template – Remember frailty

  • HbA1c <48 →select satisfactory→take no action – patient will be reviewed as per recall
  • HbA1c 48-53 →select abnormal →speak to nurse → send task to admin to book tel appt with nurse to discuss abnormal result and document a suggested plan to up-titrate medication based on the above guidance for nurse to discuss with patient – nurse will discuss with patient possible changes to medication and then task Dr back to make changes and issue script.  – if on single drug or diet only
  • HbA1c <53 → select satisfactory  →take no action – if on SU or combination drugs patient will attend at next review 6 months later
  • HbA1c >53 → select abnormal (take into account patients age and fraility) →speak to nurse → send task to admin to book tel appt with nurse to discuss abnormal result and document a suggested plan to up-titrate medication based on the above guidance for nurse to discuss with patient – nurse will discuss with patient possible changes to medication and then task Dr back to make changes and issue script. 

Any concerns – send message to Level 2 team

Using the SystmOne Template (CDM) for Diabetes.
See CDM review table

  • Bloods: U&Es, eGFR, HbA1c, ALT (if first year on statin) and lipid profile  – (Consider other tests if have other chronic diseases.)
  • Urine ACR.
  • BP
  • Lifestyle discussion: smoking status/cessation advice, exercise status, alcohol intake, diet.
  • BMI
  • Retinal review.
  • Foot check annually (in house) and record on the template. If moderate or high risk they need a referral to podiatry
  • Any complications?  erectile dysfunction, neuropathic pain, autonomic neuropathy.
  • Hypo unawareness, ? hypos requiring external intervention (see DVLA guidelines).
  • Review of blood monitoring – if they require monitoring.
  • Medication review: concordance/indications/side effects/if on insulin – injection sites.
      • Record medication review done, move date on till next review
      • Assign diagnosis to repeat template medication.
  • Add/move recall on.    NB: Diabetics well be reviewed at least 6 monthly.

TARGETS AT A GLANCE

  • BP: <130/80 – particularly if there are renal problems
  • Get to non smoking: don’t forget smoking cessation
  • Cholesterol: < 4.0mmol/l
  • HbA1c:
        • Diet alone  or single drug not affected by hypoglycaemia <48mmol/l
        • Medication <53mmol/l.  Patient tailored care needed especially if they are elderly or there are concerns about hypogylcaemia.
  • BMI: <25

Diabetes in pregnancy is associated with risks to the woman and the developing fetus.

Planning a pregnancy

Women planning a pregnancy should be referred to a diabetes pre-conception clinic.

Pre-pregnancy planning includes:

  • Diet and exercise, weight loss advised if body mass index > 27kg/m2
  • Retinal photography unless carried out in last 12months
  • Renal assessment (including microalbuminuria)
  • Folic acid 5mgs for 3 months preconception and continued for first trimester.
  • Establish rubella status, booster organised if required.
  • Blood pressure should be monitored
  • Smoking/alcohol cessation advice

Review of medications

  • Metformin may be used before and during pregnancy, as well as or instead of insulin.  The diabetes antenatal clinic will oversee their care whilst pregnant.
  • Isophane insulin is the first-choice long-acting insulin during pregnancy.
  • Discontinue oral hypoglycaemic agents (apart from metformin), ACE-inhibitors, Angiotensin Receptor Blockers and statins

Gestational diabetes

  • 6 weeks post-partum patients require a HbA1c to establish whether glucose tolerance has returned to normal.
  • All patients require advice on their elevated long term risk of diabetes.
  • All patients require advice on their risk of gestational diabetes in future pregnancies.
  • All patients require advice regarding diet, weight control and exercise

All patients require an ANNUAL HbA1c in view of their elevated risk of Type 2 diabetes. Please add an ‘AT RISK OF DIABETES’ recall to their notes.

Key clincal things

  • The main thing is to optimise psychotropic medication in line with STOMP and STAMP.
  • The other thing is to do an Annual Health Check – because these group of patients get missed – but then go on to develop morbidity and mortality from unrecognised disease.

How to improve care in Learning Disabilities

To focus on improving care of people with a LD to:

  1. Develop a system to identify people with LD
  2. Increase the uptake of annual health checks (AHC)
  3. Optimise psychotropic medication in line with STOMP
  4. Identify & record reasonable adjustments
  5. Help the patient engage with community resources via social prescribing to health & wellbeing
  6. Link up with other GPs.  Form a network peer review meetings

Full info: 

Anyone with LD > Age 14 should:

  1. Be offered a specific LD related Annual Health Check
  2. Have a health action plan to address health issues identified in the check. You could include the social prescribing contact in your practice to support people to be able to address these actions.

Practices must:

  • Maintain a ‘health check register’ of patients aged 14 & over with LD
  • Check the number on their LD register reflects the current prevalence (at least 0.5%). 
  • Nominated lead for LD who coordinates: staff training, delivering the ES and provides the AHCs
  • Have a MDT education session

DNACPR in Learning Disability and/or Autism

An analysis by Kings College London of the deaths of people with a learning disability in 2021 indicates that there were still a significant percentage of cases where good practice in DNACPR decision making was not demonstrated. 

Remember the document “Universal principles for advanced care planning and ensuring that DNACPR decisions” for people with a learning disability and autistic people.

Decisions are to be made on an individual basis and that conversations are reasonably adjusted. The NHS is clear that it is unacceptable that people have a DNACPR decision on their record simply because they have a learning disability, autism or both. 

The terms ‘learning disability’ and ‘Down’s syndrome’ should never be a reason for DNACPR decision making, nor used to describe the underlying, or only, cause of death. Learning disability itself is not a fatal condition: death may occur as a consequence of co-occurring physical disorders and serious health events. Every person has individual needs and preferences which must be taken account of, and everyone should always receive good standards and quality of care.

Blanket decision making is never acceptable. Discussions regarding cardiopulmonary resuscitation (CPR) preferences should take place as part of a wider conversation regarding a person’s preferences, wishes and needs related to their future care. It is very important that people are supported to talk about what they want and need if they become seriously ill and when they reach the end of their life. Some people will need reasonable adjustments to be able to have this conversation. 

To support and encourage patients to discuss their individual wishes and concerns regarding their treatment preferences, NHS England published the Universal principles of advanced care planning in March 2022.  High quality personalised decision making is key to eliminating poor and inappropriate practice when considering DNACPR. 

Other Top Tips - practice tips.

THiNK LD campaign

How do I THiNK LD?

Use my mnemonic LEAF.   L is for Learning Disability.   E is for Equality.  A is for Access.  F is for Flexible.    So, in Learning Disabilities, think E, A, F. 

  1. THiNK ACCESS
    Is there anything stopping people with learning disabilities using the service our surgery provide?
  2. THiNK FLEXIBLE
    Can our surgery offer any adjustments that could improve people’s experience?
  3. THiNK EQUALITY
    Will people with learning disabilities have the same outcomes as anyone else?

REASONABLE ADJUSTMENTS

What could be a reasonable adjustment? 

  • Longer appointments? 
  • Quiet end of the day

 The Accessible Information Standard (AIS) 




The NHSE introduced the AIS to help clarify what is reasonable under the Equality Act 2006 to ensure people who have a disability, impairment or sensory loss receive information they can easily read or understand, and get support so they can communicate effectively with health and social care services. It covers patients, their parents and carers.   

 

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