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CPD 38: INTELLECTUAL DISABILITIES Bernadette Flood is a pharmacist who has worked for the past thirteen years full time in a residential centre for people ageing with intellectual disabilities in the Dublin area. Working with this population group has stimulated her interest in healthcare in general and Bernadette has come to appreciate both the resilience and vulnerability of people with intellectual disabilities in healthcare. To support her work she has completed a Certificate Program in Counselling Skills in NUIM and a Master Degree in Primary Health Care in RCSI. She is currently a PhD student in the School of Pharmacy & Pharmaceutical Sciences in Trinity College Dublin and has presented aspects of her project at conferences in UK and the ROI. She is a Module 1 member of The Pharmacy Law and Ethics Association [PLEA].

June 2012

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Chronic Pain5. WHAT – assessment and management in primary care NEXT - At this time you may like

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Intellectual disabilities - An introduction for pharmacists Introduction

60 Second Summary People with

Sheehan et alintellectual reported in 1996 that the estimated cost of The 2007 Pharmacy Act must ensure protection health care professionals. The improvedpain life for 95 patients to the Irish Health Services when added disabilities is one the commonest reasons among for patients seek of the most vulnerable inPain society andofenable expectancy adultstowith a more severe often have Welfare payments received and to the amount of Social pharmacists to meet themedical challenge of an intellectual disability places an increased 1 attention. A recent survey has shown that as many multiple increasingly complex and evolving therapeutic demand on the health services and poses thenew lost earnings of eachInpatient amounted to 1.9 million disabilities. as 8.3 visits per year to primary care physicians in Ireland environment (PSI, 2008) . The population with challenges to pharmacists and other health care at the pounds time of referral.6 The recent data from PRIME 2012, 11,601 2 intellectual disabilities are onedue such professionals. were tovulnerable symptoms of pain. A large scale survey carried [42%] people survey show that the meanwith cost per chronic pain patient group who present with out a unique of needs. in 15 set European countries and Israel in 2006, screening intellectual disabilities People with intellectual disabilities oftenishave estimated had at €5,665 per year across all grades of pain, a physical and/or respondents reported that the prevalence of chronic At the end of December46,394 2012 there were 27,622 multiple disabilities. In 2012, 11,601 [42%] which was extrapolated to €5.34 billion or 2.86% of Irish sensory disability in addition people voluntarily registered onmoderate the National with intellectual disabilities pain of to severepeople intensity in adult Europeans was had a to7 an intellectual disability (Kelly need et al., for cost GDP per year. This demonstrates an urgent Intellectual Disability Database (NIDD) in the physical and/or sensory disability in addition 3 19%. 2013). Some people with intellectual Republic of Ireland (Kelly et al., 2013). This to an intellectual disability (Kelly et al., 2013). effective strategies to manage chronic pain effectively. disabilities have ‘complex needs’ and may represents a 43% increase since 1974 in the Some people with intellectual disabilities have have more than one disability, may show Morewith recent survey data from another study,and carried total number of people living moderate, ‘complex needs’ may out have more than one behaviour that challenges and may not use severe or profound intellectual disability in disability, may show behaviour that challenges in 2,019 people with chronic pain and 1,472 primary Understanding chronic pain words to communicate. Ireland. The past two decades have also and may not use words to communicate. care physicians across 15 European countries, have seen an increase in the life expectancy of The most common multidisciplinary support Chronic pain is defined as pain that outlasts normal healing Two causes of death that are to some demonstrated pain affects 12-54% adultwith intellectual people with an intellectual disability duethat to chronic services availed of by of people time (usually extent three topreventable, six months),and andwere is most frequently connected improved health and well-being, the and control of disabilities in 2012 social work (11,065 2 Europeans, its prevalence in Ireland is upwere: to 13%. The to large numbers of deaths across infectious diseases, the move to community individuals), medical services (10,586 associated with musculoskeletal disorders such as low PRIME (Prevalence,inImpactindividuals), and Cost ofspeech Chronic Pain) study, therapy living, better nutrition, and an improvement and language most groups of people withalso intellectual back pain and arthritis. However, it can be associated the quality of health careon services. This trend (10,136 psychology (8,974 disabilities were: [1]. Lung problems the other hand, determined the individuals) prevalence and of chronic with other disorders such as depression or metabolic is likely to continue and pain the improved life individuals) (Kelly et al., 2013). However to date caused by solids or liquids going down to be as high as 35.5% in Ireland.4 The PRIME study expectancy among adults with a more severe the value of pharmaceutical care provided by wrong way (14% ofsuch deaths where disorders or the neurologic conditions as multiple wasan designed to investigatepharmacists the prevalence intellectual disability places increased with of anchronic interest pain in the healthcare of sclerosis. a condition associated with intellectual demand on the health services andcompare poses the psychological people withand intellectual disabilities was reported), and [2]. Epilepsy in Ireland; physicaldisabilities health has not been new challenges to pharmacists and other widely recognised (Flood and Henman, 2010). or convulsions (13% of deaths where profiles of those with and without chronic pain; and explore Pain (acute or chronic) can be categorised as nociceptive a condition associated with intellectual 4 pain-relatedwith disability. Responses to survey questions or in neuropathic. Nociceptive is caused by an active disabilities was pain reported). Number of people registered the National Intellectual Disabilitywere Database

from 1,204 people. 2012 = 27,622 (Kelly obtained et al., 2013) Level of intellectual disability Mild Moderate Severe Profound Not verified

N

%

5213 6283 2349 526 1581

(32.7) (39.4) (14.7) (3.3) (9.9)

illness, injury and/or inflammatory process associated with Effective communication in relation topain actual or potential tissue damage i.e. Nociceptive of Intellectual Age Group HSE region of medication usage is central to the safe Despite the magnitude of the problem, chronic pain Level is Disability registration results from activity in neural secondary to actual management of pathways people with intellectual 2,5 both under-recognised and undertreated primary care. N in % N% N % disabilities and Nociceptive epilepsy. Medication nonor potential tissue damage. pain is mediated Dublin/ up to 38% of patients Indeed, reported1328 being inadequately Mild 3913 (33.5) 0-4 years (4.8) adherence has reported by pain receptors located inbeen skin, frequently musculoskeletal system, Mid-Leinster 7004 (25.4) Moderate 4774 (40.9) 5-9 years (10.0) 2 In in patients prescribed antiepileptic managed in primary care for their pain 2755 symptoms. 8 South 7832 (28.4) bone, and joints. Neuropathic pain, on the other hand, Severe 1733 (14.9) 10-14 years 3086 (11.2) medications. Health is essential for daily addition, people chronic pain reported waiting up to West 7185with (26.0) Profound 438results (3.8) from direct 15-19 years 3052 (11.0) cognitive and function and asensory injury to physical a peripheral or central 2.2 years between seeking20-34 help and 1.9 verified 812 (7.0) Dublin/ requisite for full participation in society by at yearsdiagnosis, 6186 (22.4)and Not nerve; the affected nerves do not produce transduction North-East 5601 pain (20.3)was35-54 people with intellectual disabilities. years 7677 (27.8) 2 years before their adequately managed. 8 nociceptors. Pain characteristics and associated conditions 55 years and over 3538 (12.8) for both types of pain are shown in Table 1.

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CPD 38: INTELLECTUAL DISABILITIES

Many people ageing with intellectual disabilities may have been ‘invisible’ to pharmacists and other healthcare professionals. The majority of people ageing with an intellectual disability are not married, one third have no formal 1 education, most live in outModule of home placements 2012(McCarron and many experience socialJune isolation et al., 2011). In 2012, 18,330 individuals (66.4%) lived at home with parents, relatives, or foster parents and 8,098 individuals (29.3%) sionals lived in Ireland in full-time residential services, mainly in community group homes, residential centres, psychiatric hospitals, and intensive placements such as those for challenging behaviour (Kelly et al., 2013) . They are vulnerable in healthcare as they experience many common health problems and healthcare inequalities.

anagement in primary care

Common health problems experienced by people with intellectual disabilities (IHAL et al., 2012)

across most groups of people with intellectual disabilities were: [1]. Lung problems caused by solids or liquids going down the wrong way (14% of deaths where a condition associated with intellectual disabilities was reported), and [2]. Epilepsy or convulsions (13% of deaths where a condition associated with intellectual disabilities was reported). Also just over 5% of people with hydrocephalus / spina-bifida died with pressure sores with this leading to an infection of the blood in three quarters of cases. Service providers , pharmacists and other clinicians caring for people with intellectual disabilities should pay particular attention to these problems. FEEDING. EATING, DRINKING AND SWALLOWING DIFFICULTIES

There is research evidence that dysphagia affects around 8% of adults with intellectual disabilities known to services in England , • Respiratory disease approximately 40% of whom experience recurrent respiratory tract infections (Emerson • Coronary heart disease et al., 2011) . Individuals with dysphagia have difficulty in eating, drinking or swallowing, and • Physical impairment with associated risk are in danger of becoming malnourished and of postural distortion, hip dislocation, chest dehydrated . Asphyxia and respiratory-related infections, eating and swallowing problems, mortality are known to be disproportionately gastro-oesophageal reflux, constipation high in people with intellectual disabilities. and incontinence Younger people, especially those with cerebral palsy, with profound and complex physical • Underweight impairments associated with their intellectual ehan et al reported in 1996 that the estimated cost of n for 95 patients to the Irish Health Services when added disabilities are prone to sudden chest • Obesity infections, often linked to dysphagia which he amount of Social Welfare payments received and causes aspiration and complications associated • Mental health problems with epilepsy. Following receipt of 605 reports lost earnings of each patient amounted to 1.9 million 6 • Epilepsy nds at the time of referral. The recent data from PRIME of choking-related incidents involving adults with intellectual disabilities between 30 April vey show that the mean cost per chronic pain patient 2004 and 30 April 2007 the National Patient • Sensory impairments Safety Agency[NPSA] has produced a guidance stimated at €5,665 per year across all grades of pain, document that aims to ensure safer practice HEALTH INEQUALITIES ch was extrapolated to €5.34 billion or 2.86% of Irish for adults with intellectual disabilities who 7 P per year. Thisinequalities demonstrates an urgent need for cost have difficulty in swallowing (NPSA, 2007). It Health are preventable and unjust highlights best practice and provides resource differences in healthchronic status experienced by ctive strategies to manage pain effectively. materials to give practical help. A Speech and certain population groups. People in lower Language Therapist will be able to assess socio-economic groups are more likely to the cause of the dysphagia and advise on the experience chronicpain ill-health and die earlier than derstanding chronic best treatment for the individual, which may those who are more advantaged (IPH, 2008). is concern that significant onic painInternationally is defined as there pain that outlasts normal healing include modifying food and drink consistency, altering the person’s position during mealtimes, in healthcare, especially e (usuallynumbers three to of sixpeople months), and is most frequently pacing the meal and helping the person slow those with intellectual disabilities, mental health ociated with musculoskeletal disorders such low down, and use of specially adapted cutlery. conditions, children, and residents of as care Pharmacists can advise on the suitability homes, do not receiveitthe they deserve k pain and arthritis. However, canservice also be associated of medication form, ensure all prescribed and that which could be provided within current h other disorders such as depression or metabolic medications are indicated and necessary, etc. health care systems (Finlay, 2011). In Ireland orders orthe neurologic such as multiple average conditions age at death of 1,120 people with EPILEPSY rosis. intellectual disabilities who died between 1996 and 2001 was 45.68 years(Lavin et al., 2006) Epilepsy is a costly and complex public health and in England the median age at death for n (acute or chronic) can be categorised as nociceptive problem (The Lancet, 2012). According to WHO, people with intellectual/learning disabilities is epilepsy accounted for about 0.5% of the europathic. Nociceptive pain is caused an active about 25 years younger than for by those who global burden of disease in 2005, or more than not have intellectual/learning disabilities with ss, injurydo and/or inflammatory process associated 7 million disability-adjusted life-years. Epilepsy (Emerson et al., 2012). This is a concern. ual or potential tissue damage i.e. Nociceptive pain is more common in people with intellectual ults from MORTALITY activity in neural pathways secondary to actual disabilities than the general population and seems to increase with the severity of otential tissue damage. Nociceptive pain is mediated Using information from death certificates, intellectual disability. Prevalence rates rise pain receptors located in skin,ofmusculoskeletal the ages and causes death for peoplesystem, with from 15% in people with moderate intellectual 8 intellectual disabilities, or on conditions disabilities to 30% in people with severe and e, and joints. Neuropathic pain, the otherwhich hand, can cause intellectual disabilities, who died profound intellectual disabilities (Lhatoo and ults from direct injury to a peripheral or central sensory in England between 2004 and 2008, were Sander, 2001). ve; the affected nerves do and not produce transduction at examined (Glover Ayub, 2010) . Two causes 8 death that are to some extent preventable, iceptors.of Pain characteristics and associated conditions There were deficiencies in access to and and were connected to large numbers of deaths quality of care of individuals who died from

both types of pain are shown in Table 1.

epilepsy related deaths in the UK, between Sept 1999 and Aug 2000. These were identified in a National Sentinel Clinical Audit, the full report of which is available at report www. sudep.org (Appleton et al.). Particular concern was expressed about access to appropriate specialist care for adults with special needs ie intellectual disabilities. Clinical review suggested that 60 % of epilepsy related deaths were SUDEP and a further 7% were possible SUDEP. SUDEP was defined as “ the sudden, unexpected, unwitnessed, non-traumatic and non-drowning death in patients, with or without evidence for a seizure, and excluding documented status epilepticus, in which post-mortem examination does not reveal a toxicological or anatomic cause of death” . The provision of information and communication between healthcare professionals were 2 areas that were considered poor throughout primary and secondary care. Medication management was considered deficient by an expert panel in 20% of all adults and 45% of children at the time of death. Problem areas of medication management in epilepsy related death (Appleton et al.) • No medication prescribed despite on-going seizures • Inappropriate choice of Anti Epileptic Drug (AED) • Inappropriate combinations of AEDs • Doses too low or inappropriate • Unsupervised/inappropriate management of AED changes • Little consideration of alternative or additional AEDs in cases of on-going seizures • Major drug errors • Although 14% of adults had a problem adhering to their drug regimen, there was little to suggest that this important issue was discussed with patients Effective communication in relation to medication usage is central to the safe management of people with intellectual disabilities and epilepsy. Medication nonadherence has been frequently reported in patients prescribed antiepileptic medications. Satisfying patient information needs has demonstrated improved adherence. Carers play vital roles in supporting individuals with intellectual disabilities to manage their epilepsy and other conditions and the need for effective communication between patients and their carers and health care professionals such as pharmacists is crucially important. Effective communication between patient/carer and pharmacists may lead to improved quality of life and may reduce mortality through the promotion of better understanding of seizures and encouraging efficient and safe use of medication. To be effective communication by pharmacists with people with intellectual disabilities and epilepsy requires developing awareness of each individual with intellectual disability’s communication needs and

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CPD 38: INTELLECTUAL DISABILITIES

expectations (Ninnoni, 2011). [ Pamis had produced a short information leaflet on the subject “Understanding and Managing Epilepsy of People with Profound and Multiple Learning Disabilities” (PAMIS, 2011)].

intellectual disabilities. Medication use is the major therapeutic intervention in this vulnerable population. People with intellectual disabilities must be at the centre of pharmaceutical care provision. The cake analogy below can be used to get to grips with the idea of ‘outcomes’ (Cook and Miller, 2013).

Module 1 June 2012

AMBULATORY CARE SENSITIVE CONDITIONS Ambulatory care sensitive conditions [ACSC]s have been defined as conditions which,distance given Educational learning content for healthcare 'effective management' at the primary care level, should not normally result in an admission to hospital. The most common ACSC in Ireland in 2008 was diabetes with complications (29.8%) (Sheridan et al., 2012). People with intellectual disabilities are more likely to be hospitalised for ACSCs than people without Cake (Balogh et al., 2010) . Crude rate of admissions for ACSCs is 76 admissions per 1000 per year Sugar,flour,eggs Inputs for adults with intellectual disability associated conditions (Glover and Evison, 2013). This is roughly five times the rate for other people [15 per 1000]. For all age groups emergency admissions for convulsions and epilepsy Mixing,baking Processes accounted for 41% of all emergency ACSC admissions and 27% of bed days for people in the intellectual disability group. This is of particular importance because epilepsy and Cake Outputs convulsions play a pivotal role as a cause of death in people with intellectual disabilities. Emergency admissions for this indicate ineffective epileptic control and / or lack of Outcomes Happy person Introduction adequate rescue medication plans. Strategies to avoid these hospitalizations in all population Pain is one of the commonest reasons for patients to seek groups may target after-hours care, optimal use 1 A recent survey has shown that as many attention. of ambulatory services, medical intensified monitoring of high-risk patients, andasinitiatives improve 8.3 visitstoper year to primary care physicians in Ireland patients' willingness andwere ability to to seek timely of pain.2 A large scale survey carried due symptoms help, as well as patients' medication adherence (Freund et al., 2013) . out in 15 European countries and Israel in 2006, screening

professionals in Ireland

Chronic Pain – assessment and management in primary care

46,394 respondents reported that the prevalence of chronic pain of moderate to severe intensity in adult Europeans was 19%.3 People with intellectual disabilities have HEALTH LITERACY

poor health literacy. There is potential for pharmacists to be Health Literacy champions More recent survey data from another study, carried out (Coughlan, 2010) for people with intellectual in 2,019 people chronic pain and 1,472 primary disabilities. Adults with low health literacywith such care physicians as people with intellectual disabilities areacross less 15 European countries, have likely to comply with prescribed treatment demonstrated thatand chronic pain affects 12-54% of adult self-care regimens, make more medication or Europeans, and its in Ireland is up to 13%.2 The treatment errors, and lack the skills needed prevalence to navigate the healthcare PRIME system (Prevalence, . Impact and Cost of Chronic Pain) study,

on the other hand, determined the prevalence of chronic

Main areas in which pharmacy can pain to be as high as 35.5% in Ireland.4 The PRIME study contribute to creating a health-literate environment (Coughlan,was 2010) designed to investigate the prevalence of chronic pain • Oral Communication in Ireland; compare the psychological and physical health

profiles of those with and without chronic pain; and explore

• Written Communication pain-related disability.4 Responses to survey questions were • Medication labelling obtained from 1,204 people. • Patient Information Leaflets (PILs) Despite the magnitude of the problem, chronic pain is

both under-recognised and undertreated in primary care. • Technology, Health Literacy and Pharmacy

2,5

Indeed, up to 38% of patients reported being inadequately

• Pharmacy Education managed in primary care for their pain symptoms.2 In

addition, people with chronic pain reported waiting up to 2.2 years between seeking help and diagnosis, and 1.9 Pharmacists can be involved in improving years before their pain was adequately managed.2 outcomes for the person with an intellectual OUTCOMES

disability and the population of people with

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Services/Care system Staff –attitude, knowledge,awareness, training – issues in intellectual disability population, IT systems – identification of and register of people with intellectual disabilities Assessing eg medication adherence, carers ability to administer epilepsy rescue medication referring eg to speech and language therapist for dysphagia Provision of service eg pharmaceutical care, accessible information, reasonable adjustments eg longer consultation times

Sheehan al reported inwith 1996intelllectual that the estimated Impact on et person/patient disabilitycost of and/or carer/family ie health, quality of life pain for 95 patients to the Irish Health Services when added to the amount of Social Welfare payments received and the lost earnings of each patient amounted to 1.9 million pounds at the time of referral.6 The recent data from PRIME survey show that the mean cost per chronic pain patient is estimated at €5,665 per year across all grades of pain, which was extrapolated to €5.34 billion or 2.86% of Irish GDP per year.7 This demonstrates an urgent need for cost effective strategies to manage chronic pain effectively.

Understanding chronic pain Chronic pain is defined as pain that outlasts normal healing time (usually three to six months), and is most frequently associated with musculoskeletal disorders such as low back pain and arthritis. However, it can also be associated with other disorders such as depression or metabolic disorders or neurologic conditions such as multiple sclerosis. Pain (acute or chronic) can be categorised as nociceptive or neuropathic. Nociceptive pain is caused by an active illness, injury and/or inflammatory process associated with actual or potential tissue damage i.e. Nociceptive pain results from activity in neural pathways secondary to actual or potential tissue damage. Nociceptive pain is mediated by pain receptors located in skin, musculoskeletal system, bone, and joints.8 Neuropathic pain, on the other hand, results from direct injury to a peripheral or central sensory nerve; the affected nerves do not produce transduction at nociceptors.8 Pain characteristics and associated conditions for both types of pain are shown in Table 1.

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CPD 38: INTELLECTUAL DISABILITIES

To improve outcomes barriers to accessing health services including pharmaceutical care need to be removed. Barriers may include problems with understanding and communicating health needs, lack of support for the person to access services, discriminatory attitudes among health care/ Module 1 pharmacy staff and failure to make ‘reasonable June 2012 adjustments’ to pharmacy services so that they can be used easily and effectively by people with intelllectual disabilities. Reasonable sionals adjustments, in Ireland which should be ‘anticipatory’, include removing physical barriers to access but importantly also include making whatever alterations are necessary to policies, procedures, staff training and service delivery to ensure that they work equally well for people with intellectual disabilities (IHAL et al., 2012).

anagement in primary care

Patient Safety Priorities identified by the NPSA (NPSA, 2004) for people with intellectual disabilities Inappropriate use of physical intervention (control and restraint) Patient safety issue: People with intellectual disabilities may be receiving injuries and being harmed when physical restraint is used inappropriately.

ehan et al reported in 1996 that the estimated cost of Vulnerability of people with intellectual n for 95 patients to the Irish Health Services when added disability in general hospitals he amount of Social Welfare payments received and Patient Safety Issue: Peopletowith lost earnings of each patient amounted 1.9 million intellectual disabilities may be more 6 nds at the time of referral. The recent data from PRIME at risk of things going wrong than the vey show that the mean cost perleading chronicto pain patient general population, varying stimated at €5,665of perharm year being acrosscaused all grades of pain, degrees whilst in ch was extrapolated to €5.34 billion or 2.86% of Irish general hospitals. P per year.7 This demonstrates an urgent need for cost ctive strategies to manage chronic (dysphagia) pain effectively. Swallowing difficulties

Patient Safety Issue: Swallowing

difficulties are more derstanding chronic paincommon in

people with intelectual disabilities. If onic pain is defined as pain that they outlasts healing not managed safely cannormal lead to respiratory tract infections, a leading e (usually three to six months), and is most frequently cause of early death for people ociated with musculoskeletal disorders such with as low intellectual disability. k pain and arthritis. However, it can also be associated h other disorders such as depression or metabolic Lack of accessible orders or neurologic conditions information such as multiple Patient Safety Issue: Harm may result rosis. if a person with an intellectual disability unablecan to understand information n (acute orischronic) be categorised as nociceptive relating to illnesses, treatment or active europathic. Nociceptive pain is caused by an interventions. ss, injury and/or inflammatory process associated with ual or potential tissue damage i.e. Nociceptive pain Illnessinorneural disease being secondary mis or ults from activity pathways to actual un-diagnosed otential tissue damage. Nociceptive pain is mediated Patient Safety Issue: Access to pain receptors located in skin, musculoskeletal system, treatment is often delayed because e, and joints.8 Neuropathic pain, on the other hand, symptoms are not diagnosed early ults from direct injuryThis to acould peripheral sensory enough. leadortocentral undetected ve; the affected nerves do conditions not produceand transduction serious health avoidableat iceptors.8 deaths. Pain characteristics and associated conditions both types of pain are shown in Table 1.

Health is essential for daily cognitive and physical function and a requisite for full participation in society by people with intellectual disabilities. Pharmacists should be knowledgeable about and available to persons with intellectual disabilities. The primary principle of the Code of Conduct for Irish Pharmacists (PSI, 2007) requires that the practice by a pharmacist of his/her profession must be directed to maintaining and improving the health, wellbeing, care and safety of the patient. No patient deserves this more than the vulnerable person with intellectual disabilities. REFERENCES APPLETON, R., BLACK, M., BROWN, S., FISH, D., HANNA, N., SANDER, J. & SMITHSON, W. National Sentinel Clinical Audit of EpilepsyRelated Death. Short form report. BALOGH, R., BROWNELL, M., OUELLETTEKUNTZ, H. & COLANTONIO, A. 2010. Hospitalisation rates for ambulatory care sensitive conditions for persons with and without an intellectual disability-a population perspective. Journal of Intellectual Disability Research, 54, 820-832. COOK, A. & MILLER, E. 2013. Talking Points. Personal Outcomes Approach Practical Guide. joint improvement team. COUGHLAN, D. 2010. Health Literacy - The Pharmacy Contribution. Irish Pharmacy Journal, June-Aug. EMERSON, E., HATTON, C., ROBERTSON, J., ROBERTS, H., BAINES, S., EVISON, F. & GLOVER, G. 2012. People with Learning Disabilities in England 2011. FINLAY, I. 2011. GUIDING PATIENTS THROUGH COMPLEXITY: MODERN MEDICAL GENERALISM. In: COMMISSION, I. (ed.). THE ROYAL COLLEGE OF GENERAL PRACTITIONERS , THE HEALTH FOUNDATION. FLOOD, B. & HENMAN, M. 2010. An invisible profession:Pharmacists and the population with intellectual disability. Irish Pharmacy Journal, 170. FREUND, T., CAMPBELL, S., GEISSLER, S., KUNZ, C., MAHLER, C., PETERS-KLIMM, F. & SZECSENVI, J. 2013. Strategies for reducing potentially avoidable hospitalizations for ambulatory care-sensitive conditions. Ann Fam Med, 11, 363-70. GLOVER, G. & AYUB, M. 2010. How people with learning disabilities die. In: IHAL (ed.). GLOVER, G. & EVISON, F. 2013. Hospital Admissions That Should Not Happen. Admissions for Ambulatory Care Sensistive Conditions for People with Learning Disabilities in England. IHAL. IHAL, RCGP & PSYCH, R. 2012. Improving the Health and Wellbeing of People with Learning Disabilities: An Evidence-Based Commissioning Guide for Clinical Commissioning Groups (CCGs) IPH 2008. Tackling Health Inequalities. An

All Ireland Appraoch to Social Determinants. Dublin: Combat Poverty Agency. KELLY, F., KELLY, C. & ODONOGHUE, A. 2013. Annual Report of the National Intellectual Disability Database Committee 2012. LAVIN, K. E., MCGUIRE, B. E. & HOGAN, M. J. 2006. Age at death of people with an intellectual disability in Ireland. Journal of Intellectual Disabilities, 10, 155-164. LHATOO, S. D. & SANDER, J. W. A. S. 2001. The Epidemiology of Epilepsy and Learning Disability. Epilepsia, 42, 6-9. MCCARRON, M., SWINBURNE, J., BURKE, E., MCGLINCHEY, E., MULRYAN, N., ANDREWS, V., S, F. & MCCALLION, P. 2011. Growing Older with an Intellectual Disability in Ireland 2011: First Results from The Intellectual Disability Supplement of The Irish Longitudinal Study on Ageing. Dublin: School of Nursing & Midwifery, Trinity College Dublin. NPSA 2004. Understanding the patient safety issues for people with learning disabilities. PSI 2007. Code of Conduct for Pharmacists. The Pharmaceutical Society of Ireland. PSI. 2008. New Pharmacy Legislation Must Protect the Vulnerable [Online]. [Accessed Jan 11 2013].

Pfizer Healthcare Ireland are committed to supporting the continuous professional development of pharmacists in Ireland. We are delighted to be supporting Irish Pharmacy News in order to succeed with this. Pfizer’s support of this programme is the latest element in a range of activities designed to benefit retail pharmacy. Other initiatives include the Multilingual Pharmacy Tool, Pharmacy Dietitian programme, host your own website with www.mylocalpharmacy.ie and the support of Pfizer for a year, pharmacy Consultation Room brochures and posters as well as a host of other patient-assist programmes including the Quit with Help programme and www.mysterypain.ie. If you would like additional information on any of these pharmacy programmes, please contact Pfizer Healthcare Ireland on 01-4676500 and ask for the Established Products Business Unit. Supported by Pfizer through an unrestricted educational grant. The opinions expressed are the authors and not the sponsors.

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