DESIGNING A SERVICE FOR ADULTS WITH LEARNING DISABILITIES. Caroline Woodward Principal Audiologist The James Cook University Hospital

Transcription

1 DESIGNING A SERVICE FOR ADULTS WITH LEARNING DISABILITIES Caroline Woodward Principal Audiologist The James Cook University Hospital

2 Aims Introduction to define learning disabilities Audit by South Tees Hospitals NHS Foundation Trust Aims Measures Results Conclusion Our current service Future plans

3 Clinics are called complex needs clinics these include: Adults with learning disabilities (AwLD) Patient with dementia. AwLD According to the WHO have an assessment IQ falling below 70 (ICDIO; 1992) with additional functional disabilities.

4 An AwLD with have: Reduced ability to understand new or complex information or to learn new skills. Reduced ability to cope independently. Onset before adulthood (before age 18) with lasting effect on the individuals development.

5 2% of the population have Learning Disabilities. Incidence of hearing loss in this population is significantly higher than the general population. The reported incidence is from 10% - 40% (Yeates 1995; Lavis et al 1997). However incidence of hearing loss in individuals with Downs Syndrome is reported to range between 28% and 73%.

6 If an individual has a hearing loss that is undiagnosed it could be thought that the resulting behaviour is due to the learning disabilities. Typical behaviours: SAL problems / deterioration. Difficulties learning new skills. Communication difficulties. Isolation. Can affect confidence and independence can start to show challenging behaviour.

7 Audit 2012 audit was performed to assess the audiology service which was at the time being provided for AwLD. The aim was to take a sample from this patient group. To analyse the service we were providing and to improve the service if required. We used five measures based on the: - Most recent guidelines/ recommendations at the time. - Audiological clinical expertise.

8 Measure 1 All patients with a Learning Disability and hearing aids should have their hearing aid reviewed at least biennially. Measure 2 All patients with downs syndrome should have their hearing assessed biennially (according to DSMIG Surveillance guidelines). Measure 3 All patients with Learning Disabilities and wearing hearing aids should have been fitted with hearing aids incorporating digital technology (MHAS 2005). Measure 4 All patients with Learning Disabilities should have the nature and degree of loss diagnosed in both ears. Measure 5 All patients with a Learning Disabilities should have been assessed using more complex objective test/ paediatric tests if needed.

9 Diagnosed Disability 7% 7% downs syndrome 32% 54% General Learning Disability Learning Disability and mental health Other Syndrome (ushers, williams) We assessed 29 patients: 54% had downs syndrome. 32% had learning disabilities ranging form mild Profound. 7% had learning disabilities and mental health issues. 7% had another form of learning disability associated with a syndrome. (Ushers, Williams)

10 Measure 1 When was patient last seen in Audiology for formal review or re-assessment 35% 0% 35% last 6 months 6-12 months 1-2 years 2-5 years 5-10 years > 10 years 5% 15% 10% 60% had had a hearing aid review or reassessment in the last 2 years. 40% had not been reviewed for over 2 years 35% had not been seen for 10 years or more. Standard was not met

11 Measure 2 Patients diagnosed with Downs Syndrome should be seen at least on a bienniel basis 33% seen in last 2 years 67% not seen Of patients known to the service 67% had been reviewed in the last 2 years. 33% had not been seen. However according to the improving health and working lives website in Middlesbrough/ Redcar & Cleveland area. Only 25% of patients with Downs Syndrome are known to the service. Standard was not met

12 Measure 3 Patients with learning disabilities and hearing aids, analogue versus digital 25% digital analogue 75% At that time 25% of patients with learning disabilities were still using analogue hearing aids. Standard was not met

13 Measure 4 What information was gained from testing 21% 7% 47% Full Adult Audiogram AC and BC (no masking) Just AC, no BC No Threshold Informtion 25% 47% of patients assessed completed a full adult PTA. 53% results were incomplete. 21% had no hearing threshold information. 25% had no masked thresholds so the nature of the loss was undiagnosed. Standard was not met

14 Measure 5 What tests were used to diagnose hearing loss 11% Adult PTA 14% Objective Testing Only (ABR, PAMs, OAEs) 57% Paediatric Test (Play, VRA etc) 18% Combination of Objective, Speech testing, Paediatric test 43% of patients could not complete a full audiogram and required further testing using further specialist or paediatric assessment.

15 The audit showed that the standards were not met for any of the measures. Conclusion was that a specialist service was required which could accommodate the complex nature of these patients. The provision of a specialist audiological service was critical

16 We now have clinics weekly. One clinic a month in North Yorkshire (Friarage Hospital, Northallerton) with SALT support. Three/ Four clinics at James Cook University Hospital per month Both clinics are lead by a Senior Audiologist with Adult and Paediatric assessment and rehabilitation experience with a second Audiologist assisting. Three types of clinics: New assessment Monitoring Hearing aid review

17 What will happen during your hearing test? You may be asked to wear some headphones or earphones. You will listen for some sounds You may be asked to press a button or Put a man in a boat or

18 What will happen during your hearing test? Put the ball on the stick or Put the peg on the board or Turn to a sound

19 Your visit to Audiology We will check your hearing in a very quiet room. So, we have two doors to make it very quiet. Shh, it s very quiet in here. Our rooms have lots of toys for us to play games and check your hearing This is what one of our rooms looks like

20 Available in all clinics Pure tone audiometry. Tympanometry including ART. CPA Headphones/inserts/soundfield VRA testing Speech testing (automated or live voice) OAE s (transient & high level distortion product) REM (REIG/ REAR/ RECD) Hearing aid test box Hearing aid data logging Can also refer on for ABR (Auditory brain stem response) or CAEP (Cortical auditory evoked potential) ABR under GA

21 Clinics In each clinic would attempt to complete as much as possible. Each patient is unique (may need several visits or onward referral) This is due to Learning Disabilities being profound to mild. Profound very limited understanding, communication and possible other disabilities. Severe can often use basic words and gestures. Moderate usually have language skills. Mild usually able to hold a conversation.

22 New Assessment 45 minute appointment Referral can come from ENT, GP, SALT or LD Team. History Routine Adult history plus Determination of development/ understanding Education /employment status Speech & language Serious illnesses Family History

23 Testing Aim for ear specific testing at 500, 1000, 2000, & 4000 khz. Management Satisfactory hearing significant loss ruled out. Discharge unless falls under learning disabilities monitoring protocol. Unilateral / bilateral SNHL Hearing aid provision or monitoring if appropriate. Temporary Conductive loss (Unilateral, Bilateral) Initially review 3 months at second appointment review unilateral loss in 3 months. Refer Bilateral loss to ENT. Permanent conductive loss refer to ENT/ hearing aid provision/ monitoring. Hearing levels not determined Consider referral for ERA.

24 Monitoring 30/45 minute appointment Change in history / circumstances since last appointment Otoscopy Testing Management

25 Hearing Aid Review 60 minute appointment History Changes since last appointment Testing Reprogramme/upgrade hearing aid as required REM s Check data logging Run aid through test box Aided speech testing Review as appropriate (Usually in two years)

26 DNA s High level Last 6 months 35% DNA & 12 % cancelled within 24 hours. Unsure why possible due to change in circumstance or change of address. Working with safeguarding adults and Trust AwLD services to try and reduce this.

27 All Clinics Explanation of results Management plan given to patient or carer Report to patient and /or carer, GP, and any other relevant health professionals.

28 Future Plans Although much improved still needs further development Local protocols have been developed Resources not available. Aware patients still not known to the service. Ideally would like to produce a business plan to enable us to expand our services. ideas Do Nothing no change in service Actively seek referral s, advertise service and refer directly to specialist advanced assessment audiology clinic Actively seek referrals, advertise service and screen before referral to specialist advanced assessment clinic