TABLE 3023 Suggested Ancillary Studies in Developmentally Disabled Adults

Some presentations suggest the need for specific studies:

1. If agitation is the primary complaint, vitamin B12 levels, thyroid abnormalities, and the level of oxygenation as measured by pulse oximetry should be assessed, and impaction should be excluded with an abdominal radiograph.

2. If the agitation is cyclic, consider the possibility of a psychomotor seizure and the need for an EEG.

3. If "spells" are reported, an EEG, ECG, and pulse oximetry are appropriate.

4. If a change in mental status or delirium has precipitated the evaluation, consider infections, seizures, and drug interactions or toxicities. Check thyroid function, carnitine levels (especially if patient is on valproic acid), and serum drug levels. Anticholinergics, antihistamines, and benzodiazepines are frequently associated with delirium and agitation.

5. If the patient presents with ataxia, consider drug toxicities, neuroleptic malignant syndrome (NMS), and atlantoaxial instability.

6. If fatigue is the primary complaint, consider viral illnesses, diabetes, and metabolic disturbances (including calcium, lactate, pyruvate, carnitine, and parathyroid).

7. If movement disorders are observed, withdrawal dyskinesias caused by reduction in antipsychotics and tardive dyskinesia should be considered. FREQUENTLY ENCOUNTERED PROBLEMS

The incidence of medical problems is greater in the developmentally delayed population than in the general population. However, these problems often manifest in unusual ways. A recent study of elderly mentally retarded individuals found that 24 percent had arthritis; 23 percent had gastrointestinal problems (including 7.5 percent with ulcer disease); 23 percent had vascular disease; 16 percent had hypertension; 20 percent had respiratory disorders; and 19 percent had epilepsy. 15 Thirty-five percent of emergency department visits were precipitated by infections (usually respiratory); 33 percent by trauma; 15 percent by seizures; and 5 percent by gastrointestinal concerns.15 In addition, agitation or aggression frequently leads to ED evaluations. In the study of recently deinstitutionalized adults with mental retardation, deaths were caused by respiratory problems (particularly pneumonia) in 24 percent; cardiovascular events in 22 percent; gastrointestinal illnesses in 15 percent; seizures in 15 percent; sudden asphyxiation in 9 percent; nonrespiratory infections in 4 percent; and trauma in 4 percent. 9

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