Common Chronic Health Conditions (PD) Course Number: 016-08 … · 2016-03-11 · Common Chronic Health Conditions (PD) Course Number: 016-08-01 3 of 83 Slide 3 Certificates of Achievement

Common Chronic Health Conditions (PD) Course Number: 016-08-01

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This webcast includes spoken narration. At the bottom of the viewing pane are the play and pause buttons as well as

buttons to go back and forth. There are also buttons to adjust the volume and view the closed captioning. There are also

times when buttons may appear on the screen. They will typically appear at the bottom. The webcast may pause until you

click the button.

To continue, click the Continue button that appeared in the lower right hand corner.


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Slide 3

Certificates of Achievement will be available to Administrative Entity staff, Providers, Supports Coordinators, and SC

Supervisors after completing all course requirements. Please view and then save or print your certificate in order to

receive credit for this course. For SCs and SC Supervisors, course requirements include successful completion of a pre-

test and post-test.


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Hello. My name is Linda Ulinski and I will be your presenter.

I am an RN certified in developmental disabilities and the Clinical Education Manager for Philadelphia Coordinated Health

Care, Southeast Pennsylvania’s Health Care Quality Unit (or HCQU). I am also certified in Mental Health First aid, and the

Alzheimer's Association essentiALZ TM Advanced, a certification program for learning quality dementia care. I have

worked in the field for more than thirty years.

The Commonwealth of Pennsylvania, Office of Mental Health and Substance Abuse Services (or OMHSAS) and the

Office of Developmental Programs (or ODP) have undertaken a joint initiative to address the needs of people who have

intellectual disability as well as mental health challenges. People who have both of these challenges are commonly

referred to as people who have a dual diagnosis. The curriculum is designed for Direct Support Professionals who work in

either the intellectual disability or the mental health field.

The ultimate goal of this training curriculum is to provide information that can aid in the understanding of the struggles and

the triumphs of people you support or will support. This curriculum was designed to demonstrate the complexity of dual

diagnosis and the factors that need to be considered to best support people with whom you come into contact. The Dual

Diagnosis Direct Support Curriculum was also designed to demonstrate that all people in this world, regardless of their

challenges, are much more alike than they are different.


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Slide 5

The information presented to you today is to increase your awareness of the medical conditions presented in this

webcast. It is not intended to replace medical advice. If you believe you or someone you support has these conditions or

concerns, please seek the advice of a physician.

Information in this webcast is not to be used to self-diagnose or self-treat. A physician’s support and advice must always

be obtained if you believe you or someone you support has any of the signs and/or symptoms discussed in this webcast.


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Slide 6

This webcast is not all inclusive. Rather, it provides an overview of some common chronic health conditions. There are

many chronic conditions that are not covered. Each condition could be an entire presentation in itself. Also, the webcast

does not address conditions that are not chronic, such as acute or episodic conditions.

If you or anyone you support would like further information or training on any health condition, please feel free to contact

your local HCQU. A link to the HCQUs is provided on the slide.


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Slide 7

By the end of this course, you will understand how chronic health conditions affect people with an intellectual disability or

dual diagnosis. The main objective of this webcast is to increase awareness that people with an intellectual disability or

dual diagnosis may have chronic medical conditions. This is important in order to help individuals who are ill get the care

they need and to help avoid mistaking physical health symptoms for symptoms of mental illness.

You will recognize how chronic health conditions may affect lifestyles. These conditions may affect a person’s quality of

life and behavior.

You will become familiar with tools to help support people with an intellectual disability and chronic health condition. The

webcast also will provide you with tools that may be used by someone supporting people with chronic conditions to

capture trends and other valuable information to be shared with physicians.


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This is the Main Menu page. The webcast is divided into three parts to make viewing more convenient. The three parts

are designed to be viewed in order. You can choose to view them all in one sitting or to take a break between each part.

From this page, you can elect to view any of the three parts of the webcast. At the end of each part, you will have the

option of continuing to the next part, returning to this menu page, or ending your viewing of this presentation.

At this time, please select the button that corresponds to the part you want to view.


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Slide 9

Welcome to Part 1 of the webcast Common Chronic Health Conditions.


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Slide 10

Medical causes must be ruled out when there is a change in the baseline of a person, or a change in challenging behavior

– new, increased, or decreased. Many individuals express themselves through their actions, including attempting to

communicate to us that something is wrong.

The difficulty that many people with intellectual disability have in describing their pain or other symptoms of illness, even if

they have verbal skills, increases the possibility of living with a chronic condition without diagnosis or treatment, and of

living in pain. Anyone supporting someone with developmental disabilities needs to be aware of these things.

Throughout this webcast, real life examples will be provided on how behavioral episodes resolved when the underlying

medical cause or causes were addressed.


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Slide 11

According to the journal Public Health Reports, adults with a developmental disability are much more likely to have

sedentary lifestyles than people without disabilities. They also have a higher rate of having inadequate emotional support

and often do not receive the services that their health conditions require. These factors can contribute to higher risk for

development and/or worsening of chronic health conditions.


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This slide shows just a few of the common chronic health conditions people may experience. There are many more. This

webcast will present a brief overview of each of these conditions and some others. Again, I would recommend contacting

your Health Care Quality Unit for further information and education on any medical condition.


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Slide 13

An acute condition or disease is one that develops suddenly, is treated, and is usually resolved. Examples include a

fracture and bronchitis.

A chronic condition develops over a period of time and worsens as time goes on. Treatment may be obtained to slow the

process, decrease flare-up occurrences, or control pain. Examples are osteoporosis and arthritis.

Some acute conditions may become chronic if the cause of the condition cannot be eliminated. Examples are bronchitis

and pneumonia.

Now that we understand the difference between acute and chronic conditions, let’s look at some common chronic health

conditions in more detail.


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Slide 14

Dysphagia is difficulty chewing, swallowing, or passing food or fluid from the mouth to the stomach. It is not a disease. It

is a condition caused by another medical condition such as a reaction to medication or medication toxicity, or the result of

a stroke.

There are many medical or central nervous conditions which may cause an increased risk for dysphagia, including

medications, strokes, and cerebral palsy depending on its severity. Dysphagia may occur or worsen with an acute illness.

Many of the people we support have had poor dental care and, as a result, they have a multitude of dental issues which

may lead to dysphagia. People with dysphagia may refuse to eat and/or have challenging behaviors prior to, during, and

after meals or anytime they eat or drink.


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Included as a resource where you accessed this webcast is the Southeast Regional Dysphagia Task Force’s Eating,

Drinking and Swallowing Checklist. This tool does not take the place of a professional evaluation. It is merely a check

list that Direct Support Professionals, families or anyone may complete to gather information while observing an individual

to share with a physician.

During ISP or team meetings or even monitoring, Supports Coordinators can encourage the use of the tool by the direct

supporters to help gather this important information. The Eating, Drinking and Swallowing Checklist contains risk factors

for dysphagia.

Once completed, the results need to be shared with the primary care physician, along with any other concerns the team

has determined. The physician will then determine whether to change the level of diet or fluid, order a speech language

evaluation regarding eating, or order an occupational therapy evaluation. The physician may also order a special video

swallow test to assist in determining if the person has dysphagia. The test will show what phase of the eating/drinking

process may be a problem.


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Slide 16

Once it is determined a person has dysphagia, a diet change may be ordered such as soft, pureed, ground, mechanical

soft. Different consistencies of fluids may be ordered. An individual with dysphagia will have a meal plan that is specific

to him or her. The plan describes to the person and the support staff food textures, fluid consistency, recommended body

posture during meals, pace at which to eat or drink, and/or what special equipment the person may need for meals such

as a scoop dish, sippy cup, modified utensils, etc. This meal plan needs to be shared with all staff, family, and friends

who support the person who has dysphagia.


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Slide 17

Take a few moments to think about what you can do in your role as someone who may support people with dysphagia to

help them stay safe and healthy?

Type your thoughts in the text box on the slide. When you are done, click [submit].


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Slide 18

There are many ways you can help keep someone with dysphagia safe and healthy. Some of these things are shown on

the slide. But there are others you may have thought of.

Staff members and other support persons need to be educated on how to prepare the correct consistencies and textures

of food and drink. By being familiar with the checklist and specific food preparation needs of the person, the Supports

Coordinator can, during monitoring, look for opportunities to observe the person eating or drinking, and confirm that

preparation recommendations are being followed. The Supports Coordinator can also review the checklist to help him or

her know what to look for and to advocate for the person to seek the advice of a physician when needed.

It is important to understand that the diagnosis of dysphagia can change depending on the cause; it may become worse

or improve. It is necessary that people be constantly observed for changes while eating or drinking, and that changes be

reported promptly. There have been cases where people consumed items not prepared as ordered. For example, a

person getting in the refrigerator and eating a piece of cubed cheese and having it become lodged in their throat and

dying. There have also been times when people without a diagnosis of dysphagia have choked. This is why it is so

important for all meals and food consumed by individuals to be supervised.

If you think you know someone with dysphagia, please seek the advice of a physician.

Included as a resource where you accessed this webcast is a sample of a Meal Profile form.


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Gastroesophageal reflux disease (or GERD) is a condition in which the stomach contents reflux back into the esophagus.

The lower esophageal muscle should be closed after eating to prevent food from reentering the esophagus. But due to

certain conditions such as obesity, pregnancy, poor muscle tone, and medications, the muscle malfunctions. Certain

conditions increase the risk factor for gastroesophageal reflux disease, such as cerebral palsy, scoliosis, pregnancy,

obesity (specifically increased abdominal girth), and genetic conditions such as hypotonia (which is a decreased muscle

control). Certain medications can also increase the risk of GERD. Symptoms may include heartburn, chest pain, difficulty

swallowing, vomiting, rumination, food refusal, mealtime agitation, weight loss, dental erosions, vomiting blood, anemia

(which is decreased red blood count), coughing, wheezing, asthma, repeated pneumonia, hoarse voice, awakening from

sleep, self-injurious behavior, depression, screaming, and aggression.

Stomach contents were never meant to reach the lining of the esophagus, mouth, or lungs. When this occurs,

inflammation of the esophagus may occur. This may result in scarring of the esophagus, which may cause it to narrow

and inhibit the normal digestive process. This inflammation may also lead to Barrett’s esophagus, which is a

precancerous condition, and to esophageal carcinoma. People with GERD are also at an increased risk for aspiration

pneumonia and/or erosion of enamel of the teeth.

There are several tests to identify GERD and the medical complications it may cause. An upper endoscopy done by the

gastroenterologist and an upper GI barium swallow are the most common.


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Here is an example of how a person’s dual diagnosis can effect GERD diagnosis. Bill has a dual diagnosis and does not

use words to communicate. One of his target symptoms is self-injurious behavior. The staff have noticed that Bill is

having an increase in becoming extremely agitated and hitting himself in the chest. They have shared this increase with

the psychiatrist who has increased Bill’s medication to address his mental health diagnosis. The target symptom does not

improve.

Subsequently, Bill is seen by his primary care physician, or PCP. During the visit the PCP discovers that Bill has lost

weight. Upon questioning the staff, the physician discovers that the self-injurious behaviors have increased after meals.

He refers Bill to a gastroenterologist. Bill is diagnosed with GERD. Medication to address the GERD is started and his

symptom of self-injurious behavior subsides.

Ruling out medical conditions even though someone has a mental health diagnosis should always occur first. Any change

in baseline could indicate a medical condition.


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There are several types of medications that can be ordered for GERD. There are antacids which neutralize the stomach

acid, H-2-receptors which decrease acid production, proton pump inhibitors which block acid production and heal the

esophagus, and medications to strengthen the lower esophageal muscle. H-2-receptors and proton pump inhibitors may

lead to other conditions such as bone loss and increased risk for bone fractures. Some medications for other conditions

may worsen GERD. It is important to have the physician evaluate all current medications to identify ones that may

worsen GERD.

The physician may recommend the avoidance of caffeinated drinks, chocolate, fatty foods, and citrus. Other

recommendations include avoiding over-eating at meals by having six smaller meals each day rather than three large

meals, and avoiding any constriction of the abdomen, which can cause pressure on the stomach and force the lower

esophageal sphincter muscle open. Elevating the top of the bed rather than lying flat (perhaps by the use of blocks under

the bed posts at the top of the bed) and not eating 2-3 hours prior to bedtime allows gravity to help keep the contents in

the stomach.


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Aspiration is any inhalation of food, fluids, medication, saliva, or foreign objects into the lungs or any part of the airway.

People with dysphagia and/or gastroesophagel reflux disease are at an increased risk for aspiration pneumonia, which is

an infection of the lungs due to introduction of a foreign substance. Other people at increased risk for aspiration are

people with neurological disorders (such as seizure disorders, cerebral palsy, and dementia), structural defects of the

upper GI system, poor dental health or missing teeth, or obstructions in the mouth, throat, or esophagus, such as cysts or

tumors.

However anyone without those diagnoses can also be diagnosed with aspiration pneumonia. It is important that anyone

who has a choking episode, even if the airway has been cleared, should be seen by a physician. Anytime there is

respiratory difficulty or choking, 911 must be called.

Symptoms of aspiration may be a change in respiratory status, rapid difficult breathing, color change, coughing, wheezing,

gurgling, wet sounds from the throat, or unexplained fever. There are individuals who, due to their conditions, do not

cough and are at risk for aspirating on their own saliva. These individuals are referred to as having silent aspiration.

If you notice any signs or symptoms of aspiration, please seek the immediate advice of a physician.


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People with frequent respiratory infections or pneumonia need to be evaluated for possible aspiration. It may be

diagnosed by chest x-ray, CT of the chest area, or bronchoscopy.

Treatment of aspiration consists of antibiotics, or, depending on the cause of the aspiration, surgical intervention such as

a gastrostomy tube (which is placement of a tube in the stomach for feedings) or a jejunostomy tube (which is placement

of a tube in the jejunum – the second part of the small intestine – for feedings). It should be mentioned that a tube

placement does not always prevent aspiration from occurring.

When a person is diagnosed with aspiration, an aspiration protocol needs to be followed. This can be ordered or

recommended by the physician and it is imperative that all supporting staff be educated and follow the specific guidelines

for the person.


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Aspiration can have several short-term and long lasting effects. The short-term effects can include wheezing, difficulty

breathing, increased mucus production, and pneumonia.

Long-term effects can include creation of scar tissue on the lungs which may eventually lead to a decrease of lung

function and death.


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As mentioned previously, to prevent aspiration, follow the specific aspiration guidelines for the person you support. Each

person may have a problem in a specific area so it is important to have a personalized plan for each person. Aspiration

plans may be developed with the collaboration of the physician, speech therapist and other professionals. Supporters

should stay at the table with people as they eat to assist them and to make sure that they are adhering to their meal plans.

Environmental factors, such as distractions and noise level during meals, may increase the risk of choking and aspiration.

If music is playing during meal time, it should be quiet and slow paced. The faster the beat of the music, the faster

someone tends to eat.


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This concludes Part 1 of Common Chronic Health Conditions.

If you wish to continue to Part 2, click the “Part 2” button on the screen. If you wish to view Part 2 at another time, click

the “End” button.


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In Part 1, we covered the importance of ruling out medical causes for changes in a person's baseline, and health

disparities experienced by people with intellectual and developmental disabilities. We also discussed the difference

between acute and chronic health conditions. Lastly we looked at the chronic conditions of dysphagia, gastroesophageal

reflux disease (or GERD), and aspiration.

Now we’re going to look at some other common chronic health conditions.


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A seizure occurs when abnormal electrical activity occurs in the brain. There are multiple possible causes. For example,

a person may have an extremely high fever and this can trigger a seizure. It may be a one-time occurrence and never

happen again. It is extremely important that if a person has never had a seizure or has a history and has not had one in a

long period of time, or has a seizure lasting longer than five minutes, or experiences respiratory problems, that 911 should

be notified.

Causes of seizures may include a head injury, family genetics, dementia, or injury to the brain before birth. These may

trigger more than one seizure event. This is referred to as epilepsy. There is an increased risk of epilepsy for people with

intellectual disability, cerebral palsy, including people with genetic syndromes such as Down syndrome, Angelman

syndrome, fragile X, tuberous sclerosis, Rett syndrome, and many others. Seizures may be induced as a side effect of a

medication or a medication being abruptly stopped. There are many possible triggers for seizures such as infections,

sleep deprivation, exercise, sensory stimulation such as light or sound, videogames, menstrual cycles, and medications.

These triggers may interfere with the effect of the anticonvulsant blood level needed to control the seizure disorder.


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There are many types of seizures. However there are two main categories: partial seizures and generalized seizures.

The category of partial seizures involves abnormal electrical activity in a specific part of the brain.

Partial seizures can be simple partial or complex partial seizures. Simple partial is an involuntary twitching of muscles or

of the arms and legs, change in vision, dizziness, or an unusual taste and/or smell. A person does not lose

consciousness.

Complex partial seizures are similar to the symptoms of simple partial but the person loses awareness. The person may

repeat an act over and over such as picking at a button or piece of clothing.


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Generalized seizures involve abnormal electrical activity over much or all of the brain. General seizures can be absence

seizures (also known as petit mal), such as staring with a brief loss of consciousness; myoclonic seizures, which involve

jerking or twitching of limbs on both sides of the body; or tonic clonic seizures, also called grand mal seizures, which

consist of loss of consciousness, shaking or jerking of the body, and/or loss of bladder control.

Some people may have what is called an aura, or unusual feeling or sensory experience, prior to the seizure as a type of

warning.


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Slide 32

It is important that all seizure activity be documented. It is not necessary for the type of seizure to be documented. It is,

however, important to document the activity prior to the seizure, what you see occurring to the person during the seizure

(for example, started to blink, right foot began to twitch, moved to right leg, right arm, etc.), how long it lasted, what

occurred after the seizure and the frequency of the seizures. All of this information needs to be documented and shared

with the physician. This type of reporting enables the physician to determine in what part of the brain the occurrence

began and assist with determining the correct anticonvulsant to be ordered.

A sample of a seizure chart is included as a resource where you accessed this webcast.


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Slide 33

Diagnosis of epilepsy is determined by information reported and an electroencephalograph (or EEG). An EEG picks up

and records electrical activity in the brain. EEGs may give a false positive or false negative reading and are not 100

percent accurate. However, the information gathered from the person and supporters, in conjunction with the EEG report,

aids the physician in making a diagnosis. At times a physician may order a 24-hour EEG or ask for video of the person

experiencing a seizure.

Treatment of epilepsy may consist of anticonvulsant (also called anti-seizure) medications, sedatives, implants, or surgical

procedures. Not all epilepsy can be stopped; it depends on the person and the type of seizures that occur. This needs to

be discussed with the person’s treating physician.

As a Supports Coordinator, if you support someone with epilepsy, you should become familiar with the condition and its

treatments. You should also review documentation, frequency of physician appointments, and treatment effectiveness.

Further information may be obtained from the Epilepsy Foundation. Their web address, as well as the addresses of other

helpful websites, can be found on the Common Chronic Health Conditions Resources document where you accessed this

webcast.


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This slide shows guidelines for when 911 should be called in response to a seizure. Your local HCQU is available for

training regarding 911 situations.


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Slide 35

Atherosclerosis is a condition that occurs due to the arteries becoming stiff as cholesterol builds up in them. It is also

called hardening of the arteries. The coronary arteries are arteries which supply blood flow to the heart muscle itself.

These arteries may become partially occluded or blocked due to a build up of plaque. Atherosclerosis is an under-

recognized health problem in people with intellectual disability.

There are no early signs of atherosclerosis. In later stages, there may be chest pain or no symptoms until a myocardial

infarction (heart attack) occurs. However some literature indicates that people with intellectual disability may exhibit

unexplained agitation and change in skin color, and may have sleep difficulty.

Common methods of determining atherosclerosis are laboratory tests, stress test, and cardiac catheterization. It is

usually diagnosed when a patient sees his or her doctor for intermittent chest pain, especially upon exertion.


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Slide 36

An important part of preventing heart disease is to know your lipid levels. Lipid levels are ordered by the physician. There

are different lipids the doctor will evaluate. High density lipoprotein (or HDL) is usually referred to as “good” cholesterol;

low density lipoprotein (or LDL) is referred to as “bad” cholesterol.

In addition to knowing a person’s total cholesterol level, it is important to know how much of it is HDL and how much is

LDL. Why is that important? The HDL protects the cardiovascular system. It helps to remove LDL and carries it to the

liver for eventual elimination. It also acts as an anti-inflammatory and anti-oxidant. If HDL levels are too low, LDL packs

on the walls of the arteries and forms fatty plaque. This can lead to atherosclerosis. The higher the LDL, the greater risk

for atherosclerosis.

Risk factors include heredity, medications and a sedentary life style. People with a dual diagnosis may be ordered

medications, such as typical and atypical antipsychotics, which increase lipid levels. This needs to be discussed with the

physician.


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Slide 37

Treatment for hyperlipidemia (or high lipids in the blood) is exercise, low cholesterol diet, and, possibly, a cholesterol

lowering medication. If the disease process continues, treatment includes various medications as well as surgical

interventions.

A physician needs to be consulted before any exercise program is begun. The physician’s orders for diet, exercise, and

frequency of lab work must be followed. Lifestyle changes are the best prevention against atherosclerosis.

For someone at risk, the individual and his or her team could decide on a plan to support the person in making these

lifestyle changes. This plan could be included in the ISP as a potential Outcome or as a part of the Outcome Action Plan

for a related Outcome. Additional strategies for the staff to encourage these lifestyle changes could also be included in

the Health Promotion section of the ISP. The Supports Coordinator can monitor the medical treatments as well as the

implementation of the Outcome Action Plan or Health Promotion strategies during monitoring visits.


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Slide 38

Everyone has a blood pressure. High blood pressure is called hypertension. Hypertension may be caused by a variety of

factors, including heredity. A person’s family history and race can influence his or her risk of developing hypertension.

African Americans are at higher risk than other Americans. Gender and age also effect risk. A higher percentage of men

than women have hypertension until age 45. After age 64, a higher percentage of women than men have it. Obesity, lack

of physical exercise, regular or heavy alcohol use, high salt intake, stress, smoking, and sleep apnea can also lead to

hypertension. Women using birth control medication may have an increased risk for hypertension.

Hypertension that results from a pre-existing health problem is referred to as secondary hypertension. Conditions that

could lead to secondary hypertension include abnormalities of the kidneys, certain structural abnormalities of the aorta,

and the narrowing of certain arteries.


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Slide 39

Hypertension is diagnosed by taking several blood pressure readings, not just one. This is because there are many

factors that may cause blood pressure to fluctuate. For example, cleaning and driving can temporarily increase blood

pressure. For an accurate reading, blood pressure should be taken after a person is calm and sitting for about 15 minutes.

If the physician orders blood pressure monitoring, information should be obtained as to the frequency and times of day the

reading should be taken. The physician should also specify the parameters for when he or she would like to be contacted

and when emergency services should be contacted if the blood pressure is too high. If staff are directed to obtain blood

pressure readings they need to be educated by a medical professional on how to obtain an accurate reading and the

correct cuff size to use, as this will affect the reading.


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Slide 40

In blood pressure readings, the top number is referred to as the systolic pressure. It is the pressure in the arteries when

the heart beats. The bottom number is the pressure in the arteries when the heart muscle is resting and refilling with

blood. This is referred to as the diastolic pressure. The American Heart Association defines normal blood pressure as a

systolic reading of less than 120 and a diastolic reading of less than 80. Blood pressure readings for the different stages

of hypertension are shown on the slide.


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Slide 41

The National Institute of Health reports that over a period of time, hypertension can cause the heart to work too hard and

become enlarged or weaker, which can lead to heart failure. It may cause blood vessels in the kidneys to narrow which

may cause kidney failure. Changes in vision may occur due to the blood vessels narrowing. This may lead to bleeding in

the eye, which may cause further vision changes or may result in blindness.


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Slide 42

Treatment for hypertension may consist of change in lifestyle, exercise, proper diet, and medications as ordered by the

physician. As mentioned earlier, these changes in lifestyle, exercise and diet could be incorporated into the ISP as

specific Outcomes, parts of Outcome Action Plans for related Outcomes, or as strategies for staff to support or encourage

the changes in the Health Promotion section of the ISP.


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Slide 43

The following estimated statistics were released from Centers for Disease Control (CDC) January 2011. There are

approximately 25.8 million Americans with diabetes. An estimated 79 million Americans have pre-diabetes. There were

1.9 million new cases of diabetes diagnosed in people aged 20 years or older in 2010. 12.6 million women in the United

States have diabetes.

When a person is diagnosed with diabetes it means that the body does not produce or properly use insulin. Insulin is a

hormone produced in the beta cells of the pancreas. Insulin is used to transport glucose and other nutrients into the cells.

The cells have receptors to accept the glucose. Think of the small receptors as doors on cells that need to be unlocked to

permit glucose into the cells. Insulin is a hormone which unlocks those doors to transport glucose and other nutrients into

the cells. Glucose to the cell is like gas to your car. It gives you energy.


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Slide 44

There are three types of diabetes: Type 1, Type 2, and Gestational diabetes. Type 1 diabetes is an autoimmune disease.

The beta cells do not produce any insulin. Your body has enough doors, but not any keys to open the doors to permit

glucose into the cells. Type 1 most often occurs in children and young adults. Treatment is daily injections of insulin.

Type 2 is a metabolic disorder. The beta cells either don’t produce enough insulin or the body doesn’t use the insulin

properly. This type of diabetes is associated with older age, obesity, family history of diabetes, prior history of gestational

diabetes, impaired glucose tolerance, physical inactivity, and race or ethnicity. In type 2 diabetes, there may be enough

doors but not enough insulin (or keys) to open the doors and transport glucose into the cells. Or the doors (receptors)

may be unavailable due to blockage. This is referred to as insulin resistance. With this type of diabetes, activity and

weight loss are factors. In some cases, as people lose weight, exercise, and eat a healthy diet, more doors (or receptors)

become available. This then permits the insulin (the keys) to open the doors and transport the glucose into the cells. The

person with type 2 diabetes may then be in remission.

Gestational diabetes is diabetes that involves glucose intolerance that develops during pregnancy. According to the

American Diabetes Association, after pregnancy, five to ten percent of women who had gestational diabetes are found to

have type 2 diabetes. Women who have had gestational diabetes have a 35 to 60 percent chance of developing diabetes

in the next ten to twenty years.


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Slide 45

The signs and symptoms of diabetes are gradual and subtle. There may be no signs at first. Later, there can be fatigue,

frequent infections, wounds that are slow to heal, blurry eyesight, dry, itchy skin, and increased hunger, thirst, and

urination.

Diabetes can affect all systems of the body. It can lead to blindness, kidney failure resulting in the need for dialysis,

neuropathies (which is numbness or tingling), lack of sensation to no sensation, or severe pain. This is usually in the feet

or lower extremities and can result in amputations of the extremities. Diabetes may also cause cardiovascular disease.


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Slide 46

There are many different blood tests to determine elevated blood glucose. A hemoglobin A1C blood test captures what

the glucose has been doing over a three-month period of time. Fasting blood glucose (or FBG) is a test performed in the

morning before breakfast in which the person does not eat or drink anything except water for eight hours prior to the test.

If the fasting blood glucose is greater or equal to 125 milligrams per deciliter, it is considered an elevated glucose level.

An oral glucose tolerance test (or OGTT) is a two-hour test in which the blood is checked before eating and 2 hours after

drinking a special sweet drink. It is to determine how the body processes glucose. A random plasma glucose test is

when the blood is tested at any time of the day.

The American Diabetes Association has put together a set of Professional Tools which may be used by patients and

professional personnel (such as clinicians, and caregivers) on how to assess people regarding antipsychotic medications

and the risk for diabetes and cardiovascular disease. These tools may be accessed at the web address shown on the

slide.

The first treatment for Type 2 Diabetes is often meal planning, weight loss, and exercise. Always talk with the physician

before beginning any diets or exercise. Meal planning, weight loss, and exercise are steps in the right direction; however,

sometimes medication is also needed. There are multiple medications to assist in the stabilization of blood sugar. There

are six different classes of medications and each class works in a different way to decrease glucose levels. People who

have Type 1 diabetes always receive insulin injections.

It is extremely important to follow the orders received from the physician regarding treatment. Diabetes educators can

educate the person and his or her supporters regarding diabetes, including diet, exercise, medication, and much more.

Contact the person’s Managed Care Organization’s (or MCO’s) special needs unit if assistance is needed.


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Slide 47

Hypothyroidism is a condition in which the thyroid gland doesn’t produce enough of certain important hormones. The

condition varies depending on the amount of hormone deficiency. Symptoms develop slowly over a period of time.

According to the Mayo Clinic, symptoms of hypothyroidism may include fatigue, increased sensitivity to cold, constipation,

unexplained weight gain, puffy face, hoarseness, muscle weakness, increased blood cholesterol level which may lead to

cardiac conditions, and muscle aches, tenderness and stiffness. Also joint pain, stiffness or swelling, heavier than normal

or irregular menstrual periods, thinning hair, slowed heart rate, depression, and impaired memory. Advanced

hypothyroidism (or Myxedema) is rare. Symptoms may be decreased blood pressure, decreased breathing, decreased

body temperature, and in extreme cases, coma and death.

Untreated hypothyroidism may lead to a goiter (which is an enlargement of the thyroid gland), heart problems, depression,

slowed mental functioning, and/or peripheral neuropathy, which is damage to the peripheral nerves resulting in numbness,

tingling and loss of sensation.

Risk factors for hypothyroidism include, heredity, treatment for other thyroid conditions, and autoimmune diseases.

Women age 60 and older are at higher risk for developing hypothyroidism. People with Down syndrome are at an

increased risk for thyroid conditions.

It is important that the need for and frequency of thyroid function testing be discussed with the primary care physician.


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Slide 48

There are many tests used to diagnose hypothyroidism. The physician may order a thyroid stimulating hormone (or TSH)

test. This hormone is produced by the pituitary gland and stimulates the thyroid gland. Other tests are for

Triiodothyronine (or T3) or thyroxine (or T4). These are hormones produced by the thyroid gland. Diagnosis is also

determined by symptoms and the thyroid studies.

Once hypothyroidism is diagnosed, it is treated with a synthetic thyroid replacement. People receiving thyroid

replacement will need to have periodic thyroid studies done to determine if the dosage of medication is correct.

There are medications that may contribute to hypothyroidism. One of these is Lithium, which is prescribed for some

people with a dual diagnosis. When a person is receiving Lithium, it is important to ask how often laboratory work is

needed for Lithium levels, thyroid tests, and kidney function tests. Check with the pharmacist to find out if any

medications taken by the people you support may cause thyroid problems.


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Slide 49

There are many causes for daytime sleepiness. Physical illness, psychiatric conditions, and environmental factors can

cause someone to be overly tired. A person may have an undiagnosed medical condition, or the status of a current

diagnosis may have become unstable. It may be as simple as the environment not being quiet during the night or as

complicated as a person having an undiagnosed urinary tract infection which causes them to have frequent visits to the

bathroom during the night. A person may be suffering from depression or merely be bored with his or her current lifestyle

or job. There may be a sleep disorder such as insomnia or sleep apnea. People with dual diagnosis may be on

medications that cause them to be tired.

It is always important that medical, environmental and psychiatric causes be ruled out. Changes in the person’s baseline

should be documented and a sleep chart completed in order to gather all the pertinent information to share with the

appropriate physician. Whatever the cause, it is important that it be determined and corrected.

A sample sleep chart is included as a resource where you accessed this webcast.


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Slide 50

Sleep apnea is a sleep disorder in which a person has pauses in breathing or shallow breathing while asleep. There are

many causes for sleep apnea such as the throat and tongue relaxing more than normal during sleep, the tongue and or

tonsils being enlarged, being overweight resulting in extra soft tissue, the shape of the head and neck, and aging. As a

result of these factors, not enough air gets to the lungs. The amount of oxygen in the blood drops, which triggers the

brain to disturb sleep.

If left untreated, there is increased risk for hypertension, heart attack, arrhythmias (or irregular heartbeats), and even heart

failure. Sleep apnea also increases the risk for obesity and diabetes. People with Down Syndrome or who have specific

physiological features may be more prone to sleep apnea.

Signs and symptoms of sleep apnea are usually loud snoring with periods of coughing. However, snoring does not

always accompany sleep apnea. People who experience sleep apnea may have morning headaches, memory problems,

dry mouth, or sore throat. They may get up frequently during the night and/or have irritability, depression, mood swings,

or personality changes. It is important that sleep apnea be ruled out if you see a change in a person’s baseline.


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Slide 51

Suspected sleep apnea should be discussed with the person’s primary care physician. A sleep study may be ordered.

This is done in a sleep lab overnight.

If the sleep apnea is not severe, treatment may include lifestyle changes, losing weight if overweight, sleeping on the side

instead of the back, and quitting smoking if a smoker. There are also oral appliances that may be ordered. In moderate to

severe sleep apnea, the person may be ordered a breathing device. This device assists in keeping the airway open

during sleep. There are many types of devices and/or masks. If the one a person has is not comfortable, share that

information with the physician so that a different type may be ordered. In some instances, surgery is recommended to

correct the physiological cause.


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Slide 52

Dementia is a neurological condition that causes permanent cognitive decline. The dementia most familiar to everyone is

Alzheimer’s disease. As a result, when most people hear the word dementia they only think of Alzheimer’s disease.

However Alzheimer’s disease is just one type of dementia. There are others such as vascular dementia and

frontotemporal dementia. Some conditions, such as Parkinson’s and Pick’s disease, can cause dementia.

People with intellectual and developmental disabilities are at the same risk as the general public for developing dementia.

However there is an increased risk factor for individuals with Down Syndrome. Not everyone with Down Syndrome will

have dementia.


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Slide 53

The prevalence of dementia in persons with an intellectual disability is about the same as in the general population.

Dementia appears in about 6% of the population of adults with intellectual disability over the age of 60 years, and 12% of

the population over the age of 80 years.

But how much greater is the risk of dementia for someone with Down Syndrome than the general population? On the

slide, choose the answer you think is correct. Then click [submit].


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Slide 54

The National Task Group on Intellectual Disability and Dementia Practices reported that 60 percent of adults with Down

Syndrome age 60 and older have dementia. There is also a higher rate among younger age adults with Down syndrome

with about 20% of adults age 40 and older developing dementia. So, not everyone with Down Syndrome will develop

dementia, but the risk is much higher.


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Slide 55

It is important that before the diagnosis of dementia is given, all other causes for the cognitive decline are ruled out. Think

of some of the other conditions discussed in this module. You may remember that there are some conditions that may

look similar to dementia. How about depression, thyroid conditions, sleep disorders, or medication reactions? Since

there is no actual diagnostic test for dementia, it can only be diagnosed by ruling everything else out. Some other

conditions that should be ruled out are visual and/or hearing deficits, hydrocephalus, brain tumors, and vitamin

deficiencies.

The Southeast Pennsylvania Dementia Screening Tool (DST) is one tool that may be used by families and supporters to

gather valuable information to be shared with the physician.

The tool, possible test and instructions are available as resources where you accessed this webcast. The National Task

Group on Intellectual Disabilities and Dementia Practices, or NTG, has an early detection and screening instrument that is

available at the address on the slide.


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Slide 56

This concludes Part 2 of Common Chronic Health Conditions.

If you wish to continue to Part 3, click the “Part 3” button on the screen. If you wish to view Part 3 at another time, click

the “End” button.


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Slide 57



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Slide 58

In Part 2, we covered these common chronic health conditions: epilepsy (also referred to as seizure disorders), heart

disease, hypertension, diabetes, hypothyroidism, sleep disorders, and dementia.

Now we’re going to look at some other common chronic health conditions, along with some preventative measures, and

strategies you can use to support people with common chronic health conditions.


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Slide 59

Arthritis is a musculoskeletal disorder consisting of over 100 different diseases and conditions. Some examples are

osteoarthritis (due to wear and tear) and autoimmune disorders such as rheumatoid arthritis, Lupus and Raynaud’s

Disease. The most common type is osteoarthritis. The warning signs may include pain, stiffness, occasional swelling

and/or tenderness, difficulty moving a joint, and redness of a joint area. People with arthritis may also be at increased risk

for falls.

So what might this look like in someone who has difficulty expressing themselves? Let’s think about it. What might you

see? Refusal to get up in the morning? Change in activity level? Anger towards others? Moving more slowly? Refusal

to climb stairs? Difficulty with activities of daily living such as opening jars or getting out of cars? Refusal to attend work,

or to do work? Some of these may be mistaken for symptoms of a person’s mental illness.

Diagnosis of arthritis is through signs and symptoms reported to the physician, a physical exam, and subsequent tests

ordered by the physician.

There are a wide variety of treatments. Treatment may consist of weight loss, a healthy diet, exercise, medication,

physical or occupational therapy, surgery, or other therapies and treatments.

Further information may be obtained from the Arthritis Foundation. Their web address, as well as the addresses of other

helpful websites can be found on the Common Chronic Health Conditions Resource document where you accessed this

webcast.


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Slide 60

Arthritis affects people of all ages, including children. So how many people in the United States have some form of

arthritis?

On the slide, choose the answer you think is correct. Then click [submit].


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Slide 61

According to the Arthritis Foundation, one in five people in the United States have some form of arthritis.


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Slide 62

Osteoporosis is a condition that results in a loss of bone mass and deterioration of the bone, leading to fragile bones and

fractures. Osteopenia is when there is a low bone density but not enough to meet the criteria for Osteoporosis. A person

with osteopenia is at a greater risk for developing osteoporosis.

There are factors we can control and others we cannot control. For example, some risk factors are not eating a balanced

diet, an inactive lifestyle, weight loss, drinking alcohol, and smoking. These are all factors we can control. There are

factors out of our control such as being over the age of 50, gender (females are at greater risk), family history, low body

weight (being small and thin), and certain medications.

Many individuals with intellectual disability or dual diagnosis are at risk for osteoporosis. The people we support may not

have had healthy lifestyles when they were young, and bone mass is determined in a person’s youth. Peak bone mass is

around 20 years of age.

People may have genetic conditions which increase their risk for osteoporosis. Many people take medications that can

cause bone loss, such as antacids, proton pump inhibitors, anticonvulsants, SSRIs (which are medications used to treat

certain mental health diagnoses), and steroids. People with mobility problems are at risk because walking helps us build

bone mass.


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Slide 63

On the slide are some of the signs and symptoms of osteoporosis. Fractures that occur easily or unexpectedly are of

concern. Loss of height occurs due to the collapse of the vertebrae. This is why it is important to have heights measured

and recorded, for comparison with previous measurements. Back pain can be caused by collapse of the vertebrae and

fractures. Stooped posture may also be a sign of osteoporosis and may cause pain. The presence of risk factors should

also be reviewed. Osteoporosis is a major cause of broken bones and progressive pain over time.

Bone strength, called mineral density (or BMD), is measured by a special test called a DXA scan. This is done as an

outpatient procedure. The scan may be done of the hip, wrist, and/or spine.


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Slide 64

At any age, you can take steps to keep your bones strong. Be sure to consume adequate amounts of calcium and Vitamin

D. Women over age 50 should consume 1,200 milligrams of calcium daily. Men between the ages of 51 and 70 should

consume 1,000 milligrams of calcium a day, and men over 70 should consume 1,200 milligrams per day. This can be

done by eating calcium-rich foods and taking calcium supplements. Any use of vitamins and dietary concerns needs to be

discussed with the primary care physician. Calcium intake can be increased by consuming dairy products such as low-fat

milk, yogurt, and cheese. Many dark green, leafy vegetables such as broccoli, collard greens, and bok choy are high in

calcium, as are sardines, soybeans, tofu, and nuts such as almonds. Some foods, such as orange juice and cereals, are

fortified with calcium. Discuss with the physician the appropriate amount of Calcium and Vitamin D for the person you

support.

If a person is unable to ambulate, the physician needs to be consulted regarding activities that may prevent further bone

loss. Medications such as a hormone replacement may be used in both males and females; bisphosphonates, another

class of medications to prevent loss of bone mass, may be ordered. However, all medications have side effects and this

needs to be discussed with the physician. People with osteoporosis may have chronic pain and may be treated for this by

their physician or referred to pain management clinics. Treatment may consist of medications and or physical therapy. In

some cases, surgical intervention is needed to stabilize the area and decrease pain.


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Slide 65

Think about what we use our senses for. Everything we do involves some type of sensory input. Just listening to this

webcast you are using hearing; if you are watching it or reading the transcript, you are using visual input. People with

intellectual disability have an increased risk of loss of sensory input due to neurological and genetic conditions and normal

aging. It is important that routine screenings are done as recommended by the physician.

It is important to be knowledgeable regarding these screenings and examinations. It is important to know the difference

between an optician, an optometrist, and an ophthalmologist. Visual screenings done in a physician’s office by the

physician or a nurse just indicate that a person can see. Visual acuity testing is done in an optometrist’s office and may

determine if the person needs glasses. Examinations for eye diseases and conditions, along with visual acuity tests, are

performed in an ophthalmologist’s office.

A hearing screening done in a physician’s office just indicates that a person can hear; an audiological test is an actual

hearing test to determine if there is a problem and how much hearing the person does or does not have.

If a person is having a problem with vision or hearing, it is important for the person to be examined by a specialist and

have the correct test performed to assist in determining the correct diagnosis.


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Slide 66

Sensory changes can occur at any time. It is important that when there is a change from baseline, sensory issues be

ruled out. For example, Valerie has a dual diagnosis. Lately she appears to be hallucinating – speaking to the walls.

However, upon examination by an ophthalmologist it is discovered she has very limited vision due to cataracts. She

undergoes surgical treatment. After the surgery the so-called “hallucinations” stop.

Valerie wasn’t having hallucinations. She thought the shadows she was seeing due to the cataracts were other people. It

is important that the correct evaluation is done and the recommendations are followed as ordered.


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Slide 67

There are many types of dental conditions. Listed on the slide are just a few. Some causes of dental conditions include

inadequate oral hygiene, lack of routine preventative dental care, and medications.

It is important that routine dental examinations be done and treatment for dental issues occurs when recommended.

Untreated dental issues may have devastating results. For example, a severe enough oral infection may lead to sepsis.

Sepsis is an infection in the blood that can lead to body systems failing and death may occur.


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Slide 68

People with dual diagnosis are at an increased risk for dental conditions. They often have had limited dental care, may

have chronic unrecognized conditions (such as the previously discussed GERD) which affect their teeth, and may take or

have taken medications that can cause gum disease. These are just a few possible risk factors.

It is extremely important that if a change in baseline occurs, dental problems are always ruled out. Not everyone can

verbally say “my tooth hurts.” However, people will communicate. Any change in behavior at mealtime should be followed

up on. People may refuse to eat or to chew using a particular part of the mouth. They may suddenly refuse to eat their

favorite foods. Refusing to do oral hygiene, or indicating sensitivity in an oral area while brushing are also possible signs

of dental problems, as are being irritable, head banging, striking the face, crying, etc.


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Slide 69

Only the person knows what pain he or she is experiencing. Pain is perception. It is individualized and needs to be

treated so. Pain is extremely difficult for some people to explain. When people are unable to tell us they have pain, they

will communicate it somehow. When people with a dual diagnosis communicate pain through behaviors, it is possible for

their supporters to assume the behaviors are symptomatic of the mental health issues.

We need to be observant and attempt to determine what people are telling us. For example, Raymond was always up

early, busy getting ready for work, always concerned he may be late for work. Lately he had been very slow to get up and

taking a longer time to get ready for work. Work reported he was irritable, refusing to do his job. Upon evaluation,

Raymond was diagnosed with severe arthritis of his spine. Once diagnosed, Raymond was treated with medication for

pain, made some lifestyle changes and he is back to his old self.


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Slide 70

It takes the whole team to identify how, what, where, and when a person communicates pain. The fact that pain is often

overlooked or misdiagnosed indicates a need for staff and family training, physician’s awareness, and a plan for ongoing

assessment to address the impacts of pain.


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Slide 71

When trying to determine if pain is present in another person, knowing the person’s baseline is critical. Any change in

baseline could indicate the presence of pain. Always ask the person if he or she is experiencing pain. Also, look at what

the person is telling you through behaviors.


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Slide 72

In order for a physician to diagnose and treat a condition, he or she must have all the pertinent information. As a

Supports Coordinator, facilitating teams and monitoring supports, it is important for you to know what needs to be shared

with any treating physician.

In order for preventative treatment and testing to be done, the physician needs to be aware of the person’s history. This

includes, when available, the person’s lifetime medical history, and family history including medical and mental health

diagnoses. The physician needs to know all the signs and symptoms exhibited by the person, what the person’s baseline

was and how it has changed, all test results, and consults from previous visits and from other physicians.

When possible, the team needs to meet prior to the appointment to discuss any questions they may have. If there is an

agency nurse, he or she needs to be included in the process. Written documentation both to and from the physician

needs to be reviewed and shared with team members.


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Slide 73

What does having a chronic condition mean to a person? It can mean a lifestyle change, such as using a ramp instead of

stairs, having food textures and/or fluid consistencies changed, having to take more frequent breaks from tasks,

performing tasks sitting down rather than standing, attempting to lose weight, or decreasing activity level – perhaps even

giving up a favorite activity. It may mean using special equipment to perform simple tasks such as putting on a sock.

Things that most people might think of as no big deal, may be, for a person no longer able to do them may be devastating.

People with chronic conditions are at an increased risk for depression, due to untreated pain and/or changes to their

lifestyle. People may also experience fear and worry about what will happen to them. Will they be able to continue to

work at the job they currently perform or to do things they enjoy?


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Slide 74

For example, for a person diagnosed with diabetes, there may be many lifestyle changes that include change in eating

habits, medication, frequent medical appointments and tests, and the concern of developing complications.

The people we support need to be supported in all aspects of their condition – both physically and emotionally. We need

to educate people regarding their conditions. Not providing people with information and support regarding their conditions

can make them extremely fearful. Supporters should also be educated on the conditions of the people they support so

that they can provide the needed support. This information could be included in the Health Promotion section of the ISP.


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Slide 75

Based on the information we’ve provided in this webcast, what can you do, as a Supports Coordinator or someone who

supports people with intellectual disability, to help support them to have healthy lifestyles and to minimize the impact of

chronic health conditions?

Take a few moments to think about this question. Then type your thoughts in the text box on the slide. When you are

done, click [submit].


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Slide 76

There are numerous ways that Supports Coordinators, support staff, family, and others who support people with

intellectual disability, can help them live healthy lifestyles. Many of these supports strategies are discussed on the

following slides. You may have thought of some of them in your answers to the question on the previous slide, and you

may have even thought of others that aren’t discussed in the next slides.


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Slide 77

With any change, the person and supporters need to be aware that choices can be offered. For example, if a person

needs to make dietary changes, the Supports Coordinator, Direct Support Professionals, and other supporters can help

the person choose foods he or she prefers that may come in lower fat or low calorie varieties. Supporters can also

support the person to participate in meal planning, shopping, preparation, or another part of the meal process that will

make it special. If a person can no longer work at his or her current job, the Supports Coordinator and support staff can

discuss with the person what other work might be of interest to him or her and support him or her to pursue that work.


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Slide 78

How a change in a person’s life is experienced depends in part on how the people around them react. A positive attitude

is a must!!

Supporting means talking, explaining, and helping the person through the difficult times. As mentioned previously, the

Health Promotion section of the ISP can be used by the Supports Coordinator and the team to ensure that everyone has a

consistent knowledge of the strategies that should be used to support the person.

When information is needed about a particular chronic condition, discuss it with the physician. There are many

organizations with helpful information. Health Care Quality Units are a good resource. Other possible resources can be

found in the Common Chronic Health Conditions Resource document where you accessed this webcast.


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Slide 79

This webcast provided an overview of a few chronic health conditions. There are many risk factors for chronic conditions

we may not be able to change such as age, gender, and genetics. However, steps can be taken to prevent many chronic

health conditions.

The best prevention is living a healthy lifestyle. What does that mean? For Supports Coordinators and those providing

direct support it means supporting and encouraging the person to eat a variety of healthy foods, watch portion sizes, live

an active life, and socialize with friends and loved ones. It also means supporting routine examinations by physicians,

completion of medical tests as ordered, reporting of any problems or concerns to the physician, and asking questions

when we don’t understand. When a medication is ordered, we should receive information regarding how the medication is

to be taken, its contraindications, adverse reactions, and drug interactions. Supporters should also help people get the

information they need to make good health decisions.


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Slide 80

Supports Coordinators play an important role in this process by documenting medical diagnoses/conditions, signs and

symptoms, medical recommendations and treatments, and supporters’ responsibilities in the ISP. They also monitor that

medical recommendations are followed and that all follow-through occurs. It is also extremely important that the people

we support receive education regarding preventative measures and their diagnoses.

As a Supports Coordinator, if you support someone with any physical or mental health condition, you should become

familiar with the condition and its treatments. You should also review documentation, frequency of physician

appointments, and treatment effectiveness.

If you have any questions or need general information regarding medical conditions please explore the Common Chronic

Health Conditions Resource document that is available in the Resource section where you accessed this webcast, and

also please contact your local Health Care Quality Unit.


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Slide 81

This concludes this webcast series on Common Chronic Health Conditions.


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Slide 83

This webcast has been developed and produced by the Office of Developmental Programs Consulting System on behalf

of the Pennsylvania Department of Public Welfare, Office of Developmental Programs.

Thank you for participating in this lesson.

Documents

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