Comparative Trends of Presentations of People of Determination (Intellectual Disability)

to Al Amal Psychiatry Hospital – Before and During the Covid-19 PandemicDr Madhusudan Deepak Thalitaya – Consultant Psychiatrist/Head of Intellectual Disability Department, Dr Hind Majid Mohammed Al Ali - Psychiatry Resident,

Beena Mathew - Nurse Manager, Nithya Kala Ranganathan, Hamda Al Sammach & Maryam Farid Ahmad Mohammad Sabt – Psychologists

Muna Abdul Karim Walid – Social Worker

Background• Severe Acute Respiratory Syndrome Coronavirus‐2 (SARS‐CoV‐2)

(COVID‐19) is the most pressing current world crisis.

• Globally infected millions and testing the health care systems of countries.

• People with Intellectual Disabilities (PWID) are disproportionately impacted

in social disadvantage, disparity in healthcare provision, physical & mental

health multimorbidity, access to healthcare, income opportunities and

education, low levels of health literacy, low compliance with complex

hygiene rules & reliance on others for care.

• Despite possibly higher risk of severe outcomes from COVID-19 among

PWID, there has been limited reporting of COVID-19 trends for this

population.

• 17.5% more deaths in places that can support PWID in England in April

2020, than reported in the same period 2019.

• This highlights the ongoing segregation and discrimination of PWID.

• Meeting the need to protect PWID from infection and to support those

infected is a challenge to care services often because of the unique

characteristics of PWID to adapt to new circumstances.

• PWID may be forgotten as the pandemic unfolds (Silverman, 2020) &

responses should not exclude PWID (Berger et al. 2020).

• Providing care to PWID & appropriate action must be taken ensure that

disparity of healthcare is addressed during COVID‐19 pandemic.

• The COVID-19 puts to the test the UN Convention on the Rights of Persons

with Disabilities, especially the right to have access to healthcare without

discrimination on the basis of disability.

Context During COVID-19• Most PWID in the UAE live in the community.

• With the lockdown in the UAE since 4th April 2020, many community

resources have closed leading to gaps in care and routines for this group of

patients.

• Al Amal Hospital is the largest Psychiatric facility in the UAE. In the absence

of community care/respite services, it is often the port of call for this group of

patients in crisis.

• Quarantine can be difficult for PWID to tolerate & compounded by not

understanding its importance & implications of not adhering to restrictions.

• Barriers to implementing basic hygiene measures, such as hand-washing &

enacting social distancing because of additional support needs or because

they are institutionalized

• Barriers to accessing public health information.

• Depending on underlying health conditions, PWID may be at greater risk of

developing more severe cases of COVID-19 if they become infected

exacerbating existing health conditions, particularly those related to

respiratory function, immune system function, heart disease or Diabetes.

• Barriers to accessing health care. PWID may also be disproportionately

impacted because of serious disruptions to the services they rely on.

Psychosocial Impact of Covid-19• Lockdown has made things even tougher with an intense sense of being cut

off and ignored.

• Fragile health of PWID makes it less likely they can go outside.

• Jobs/money worries. Working from home is hard while caring for PWID.

• PWID have less access to income based on employment than others.

• With travel restricted, less access to those who might share care.

• Getting help from paid carers has been difficult during the lockdown.

• Day centres, schools & respite services are under pressure on account of

staff shortages due to illness or the need to self-isolate or closures.

• Day centres which run on charity and fundraising has been badly hit and

risk being closed or reduced capacity.

• There is a reliance on help and fears it will be swept away by the pandemic,

or the economic storm that might follow.

• Staffing levels will be stressed with the potential for whole group placements

to break down at short notice.

• With a stark and rapid change in societal expectations as in a pandemic,

people’s ability to adapt and be flexible is tested potentially stressing their

personal resources to adjust to new patterns of social behaviour.

• Pressures are emotionally as well as physically exhausting on top of those

already placed on everyone else.

• Increased calls to helpline & engagement with online community - people

asking for practical and emotional support. (Mencap, UK)

• Only 5% of disabled people feel safe to come out of lockdown. (Scope)

• Many have lost the respite care they usually get through relatives or other

services”. (Scope, 2020)

Mental Health Impact of Covid-19• When PWID is faced with actual or suspected SARS‐CoV‐2 infection, the

inevitable further restrictions may lead to a worsening of distress or mental

health symptoms and/or challenging behavior. It is important not to assume

that this is inherently a relapse of mental illness, as some changes occur

directly as a result of environmental changes, or could be associated with

SARS‐CoV‐2 infection and unknown effects on the nervous system (Wu et

al., 2020) and issues related to diagnostic overshadowing should be at the

forefront of clinical decision making.

• Stress associated with fear of contracting Covid19, social distancing,

quarantine measures (Pfefferbaum & North, 2020).

• Autism or ADHD in PWID may worsen the situation where their usual

routines cannot be fulfilled & with restrictions on their physical environment

(Narzisi, 2020).

• Carers of PWID may need to self-isolate that can lead to breakdown of care

network resulting in exacerbations of behavioural problems.

• Obsession about information related to COVID-19, given that obsessional

thinking and obsessive compulsive disorders are common among people

with Autism (Meier et al. 2015) could be compounded by the need for

scrupulous personal hygiene.

• These triggers can mount to high levels of overwhelming stress, anxiety and

paranoid thinking resulting in behavioural challenges or mental illness.

• Many behavioural/psychological interventions cannot be implemented due to

significantly reduced face to face work by care staff.

• Difficulties with effective communication and understanding the changes,

mental health problems, and other associated functions such as demand

avoidance, access to tangibles inclusive of previously enjoyed activities.

• Changes to key staff including carers, parents and family members (who may

be absent due to isolation and illness) may cause further anxiety and

disruption and will need to be effectively managed, and may have a negative

impact upon the continued successful implementation of positive behavioral

support plans.

Results1. Male patients outnumber female patients in all presentations to

Hospital.

2. The results demonstrate that there has been a spike in the number of

presentations to Emergency Department at Al Amal Hospital by 41%

particularly within the UAE population and less so by the expat

population.

3. There has also been a 7% increase in admissions and a 11.11%

decrease in discharges from the In-Patient wards at Al Amal Hospital.

4. The average length of stay on the wards has also increased by 36%.

5. There is also a noticeable increase in the number of recurrent

presentations to Al Amal Hospital amongst those with Intellectual

Disability by 47%.

6. There is a nearly 73% reduction in the number of patients coming to

OPD during the Covid19 Lockdown period.

Conclusions• This study is the first one of its kind to look at demographic trends for

People with Intellectual Disability presenting to Al Amal Hospital before

and during the Covid19 Pandemic and analyzing the use of facilities and

clinical need.

• The results offer the opportunity to reflect on available services at Al

Amal and compare data which would help to address clinical need and

build resources including in the community.

• COVID-19 has had profound effects on populations worldwide. Attention

has focused on those most physically affected by the pandemic. COVID-

19 deaths will likely be more prevalent among PWID.

• There is no direct evidence currently that SARS‐CoV‐2 infection will

cause an increase in mental health symptoms and/or challenging

behavior currently, but the associated changes that are occurring within

our society and the required treatments are likely to lead to distress and

anxiety among PWID.

• The experiences of the pandemic by PWID need to be elicited in order

to understand the impacts on their lives and how they have protected

themselves from infection.

• Essential that we learn from the pandemic on how to protect PWID on

account of inherent vulnerability to infection & to the social

consequences of the measures put in place to manage the pandemic.

• Work towards preventing admission to inpatient psychiatric hospitals

and continue to work to facilitate timely and appropriate discharge.

• There is an important role for the Specialist ID health & social care

teams along with the provision of psychosocial interventions to help with

challenging behavior & mental health.

• Once the pandemic is over, should not be in a position of having an

increased number of PWID within psychiatric hospitals due to difficulties

with managing risk associated with SARS‐CoV‐2 infection or community

access, or due to a deterioration in mental health or increase in

challenging behavior related to the COVID‐19 pandemic.

• More attention is needed to this vulnerable health population in order to

ensure their safety and well-being during this pandemic.

• It is important that PWID & their carers are not ignored in order to

ensure that they are empowered to face such occurrences in the future.

• The barriers experienced by PWID can be reduced if key stakeholders

take appropriate action.

• Support organizations recognize the need for extra support for families

without which the risk of breakdown is high potentially leading to the

need for hospital admission because of increasing challenging

behaviour (MENCAP, 2020; The CBF, 2020).

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AcknowledgementsThe Authors would like to acknowledge the MOHAP and Cerner teams for extracting the raw data from

the Electronic records that allowed the authors to analyze the data.

V

Aim• This is a comparative study to see how Covid19 Pandemic has impacted

on Intellectual Disability presentations to facilities at Al Amal Psychiatry

Hospital during the period Pre-Covid-19 April to September 2019 and

During Covid-19 April to September 2020.

Design Methodology• We reviewed demographic data and trends around Intellectual Disability

presentations to Al Amal Hospital for the comparative period of 6 months

from April to September 2019 and 2020 respectively.

• Information was extracted from Electronic Records as well as from daily

handover records and analyzed and summarized by our medical team.

Findings