UKPPG Bulletin archives Learning Disabilities study days

Dave Branford reports on the second study day on drugs in learning disabilities, in Leicester on 30.10.96

1st ANNUAL THERAPEUTICS IN LEARNING DISABILITIES STUDY DAY (1996)

Leicester hosted the second therapeutics in learning disabilities study day, which was a joint study day between the UKPPG and the departments of learning disabilities of Leicester and Nottingham. It was attended by over 90 delegates from medical, pharmaceutical and nursing backgrounds.

The first presenter was Dr Paul Shattock, Director, Autism Research Centre, Sunderland University who spoke about opioids and naltrexone in autism and learning disabilities. He proposed that the "Opioid Excess" theory provides an intellectually satisfying explanation for the cause of autism. Although there is a considerable body of evidence to suggest that the theory may be correct, it cannot be accepted as proven. Acceptance of these theories will indicate a number of biomedical interventions which could usefully be employed in autism and related syndromes. Some of these involve dietary and other environmental manipulations but there will also be important implications for drug therapy. The potentially beneficial effects of naltrexone have not been exploited largely as a consequence of inappropriate use whereas the use of many of the drugs most commonly employed in autism is not only irrational but often useless and sometimes very harmful. Whilst paying particular attention to naltrexone, he reviewed the use of these medications in the context of the understood aetiology of the condition.

Dr. R. Ridley, from the University of Cambridge, presented a fascinating insight into the aetiology and presentation of stereotyped behaviours. She stated that abnormal repetitive behaviours can be motor e.g. head banging or they can be cognitive e.g. rumination. Stereotypy is defined as the excessive production of a limited number of behaviours while perseveration is the term used to describe behaviour which is very restricted in its variability. Stereotypy can be environmentally induced. This form, which usually involves locomotion, can be rectified by improving the environment. Stereotypy which arises in infancy can affect the development of the nervous system and is much more serious. It arises because a failure of integration of input and output mechanisms in the brain. A schema was described which predicts when stereotypy will occur. This was compared to several neuropsychiatric conditions with dysfunction in different parts of the brain. Finally some experiments in animals were described which support the theory.

After a much needed coffee break two papers were presented about epilepsy in Learning disabilities. Dr. S. Bhaumik, from Leicester, presented a naturalistic study of vigabatrin, lamotrigine and gabapentin. He stated that epilepsy is a common condition in people with learning disabilities, with many patients continuing to suffer from seizures despite anti-epileptic drug treatment. The advent of newer anti-epileptic drugs offers hope for better treatment but there is a need to compare the efficacy of each new anti-epileptic drug in adults with both drug-resistant epilepsy and learning disabilities.

He described a retrospective case note study, which involved the analysis of the outcome for those adults treated with either vigabatrin, lamotrigine or gabapentin. The information obtained from the case note analysis was used to both compare the efficacies of the three drugs and also the side-effects and drop-out rates, including the reasons for drop-out. The total number of patients involved was 51, who underwent 71 treatment episodes. All three anti-epileptic drugs had similar efficacies. Although vigabatrin was found to be associated with a higher incidence of behaviour problems, behaviour problems occurred with the other drugs as well. Lamotrigine caused increased seizures in 24% of patients, especially when prescribed at a higher dose. Gabapentin appeared to be associated with fewer serious side-effects.

The second paper was presented by Dr. Dave Branford, Consultant Pharmacist, Fosse Health Trust and Principal Lecturer, De Montfort University. He presented the background to the survey of people with epilepsy and learning disabilities. The presentation spanned the following areas:-
The current performance of the treatments of epilepsy suffered by people with learning disabilities, the setting of standards to audit that performance, the alternative approaches to the prescribing of new anti-epileptic drugs and the survey of people with epilepsy and learning disabilities who live in Leicestershire.

In the afternoon there were three workshops. The first on reducing doses of anti-psychotic drugs was led by Dr. Z. Ahmed, Clinical Research Fellow, Welsh Centre for Learning Disabilities. The workshop looked at the issues which operate when antipsychotic drug reduction is contemplated in people with learning disability, the role of the professionals involved in the process, what factors may influence the outcome and how to improve the chances of a successful dose reduction.

The second workshop was led by Dr David Hutchins, Senior Lecturer in Pharmacology, De Montfort University, Leicester, Honorary Principal Pharmacist, Towers Hospital and Leicester General Hospital on differentiating stereotypes and abnormal involuntary movements. He stated that movement disorders, including stereotypy, have diverse characteristics and aetiologies. Stereotyped behaviours may range from the gross level, such as pacing, to the local level, such as repetitive movements in highly localised regions of the body. These movements are classically associated with cerebral dopaminergic overactivity since such movements can be readily induced by amphetamine and its analogues which stimulate dopamine release. Stereotyped movements are not always easily distinguished from other dyskinesias and their persistence can be self injurious but they are potentially accessible to resolution through dopamine antagonists. The workshop sought to distinguish stereotyped movements, non-stereotyped dyskinesias and mannerisms with the use of video material of patients.

The third workshop was led by Dr G O'Brien, Consultant Psychiatrist/Senior Lecturer in Learning Disabilities on protocols in epilepsy. He stated that the use of protocols in clinical practice has a long history. Most notably perhaps in nursing practice, the value of systematic prescribed approaches for a given clinical problem or treatment situation is well established. Similarly, in many surgical and oncological specialities, a variety of protocols are now available and in widespread use. At present, therefore, there is widespread debate concerning the development and adoption of a range of protocols to therapeutic approaches in learning disability. The workshop concerned the issue of protocols for epilepsy in people with learning disabilities. The workshop began with a resume of the general principles of protocols, including an exploration of some of their advantages and potential disadvantages.

This was followed by a detailed discussion of protocols for epilepsy in people with learning disabilities including;-

The need for protocols for epilepsy in learning disability, as opposed to epilepsy in the general population and in other populations.
The principles to be followed in the development of protocols for people with epilepsy in people with learning disability.
Practical considerations for the development of such protocols, including - who should develop them; how they should be developed; implications for audit and monitoring of clinical practice.

The final session of the afternoon was three short presentations. The first was by Chris Knifton and Sharon Jackson, Research Nurses, Fosse Health Trust on their project to eradicate, wherever possible, drug administration from day centres. They presented the initial findings of their day centre project. In Leicestershire, 1317 people with learning disabilities attend day centres and 12.6% require lunchtime medication. The project has, to date, studied the advantages and disadvantages of drug administration by day centres, and has identified the problems associated with lunch time prescribing, staff implications for both day centres and carers and the attitudes of staff, carers and clients about administration of medication in day centres.

The second presentation was by John Lawton, Senior Pharmacist, Nottingham NHS Healthcare Trust on the advantages and disadvantages of depot formulations of antipsychotic drugs. He stated that recent surveys have shown that 8-10% of hospital in-patients with learning disabilities and up to 5% of adults with learning disabilities living in the community are prescribed depot antipsychotic drugs. The use of depots have clearly been demonstrated to help reduce relapse rates in schizophrenic patients poorly compliant with oral medication. What evidence, however, is available to support the use of depot antipsychotics in people with learning disabilities? During this short presentation, he reviewed the literature evidence in terms of the advantages and disadvantages of prescribing depot formulations of antipsychotics to people with learning disabilities.

Finally Dr. Jo Jones, also from Nottingham Healthcare NHS Trust, presented a paper on the treatment of catatonia in learning disabilities. She stated that the literature on catatonia and its treatment in learning disability is sparse. The case of a young man with autism and catatonia is presented and the therapeutic problems posed was discussed. He developed neuroleptic malignant syndrome (NMS) after haloperidol relieved his catatonic symptoms. He failed to respond to other modes of treatment. Some authors suggest catatonia and NMS are related by dopamine depletion and that neuroleptics are thus contraindicated. The response of this man to treatment illustrated that this is not always so, but that extreme caution should be taken.

In the final summary session the chairman thanked Janssen for their generous support. The third study day on therapeutics in learning disabilities is planned for November 1997 to be hosted either in Nottingham or Leicester.

Report contributed by Dr. David Branford, who at the time was Consultant Pharmacist at Leicester Frith Hospital in Leicester.
April 1997