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Journal of Intellectual Disability Research
doi: 10.1111/jir.12074
1
Mental health
A prospective 14-year longitudinal follow-up of dementia
in persons with Down syndrome
M. McCarron,1 P. McCallion,2 E. Reilly3 & N. Mulryan3
1 School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
2 University at Albany, Albany, NY, USA
3 Daughters of Charity Service, Dublin, Ireland
Abstract
Background To examine dementia characteristics,
age at onset and associated comorbidities in persons
with Down syndrome.
Method Seventy-seven people with Down syndrome aged years and older were followed longitudinally. The diagnosis of dementia was established
using the modified International Classification of
Diseases, Tenth Revision (ICD-) criteria and a
combination of objective and informant-based tests.
Cognitive tests included the Test for Severe Impairment and the Down Syndrome Mental Status
Examination; adaptive behaviour was measured
using the Daily Living Skills Questionnaire. The
Dementia Questionnaire for Mental Retarded
Persons (DMR) was added to the test battery in
and this study includes follow-up data for this
instrument.
Results Over the -year period the average age of
diagnosis at . years (SD = .) was in the
higher range of previously reported estimates
(– years) and a median survival of years after
Correspondence: Professor Mary McCarron, Faculty of Health
Sciences, Trinity College Dublin, Dublin, Ireland (e-mail:
mccarrm@tcd.ie).
© John Wiley & Sons Ltd, MENCAP & IASSID
diagnosis. Persons with dementia in the sample were
significantly older than persons without dementia.
The presence of dementia was also associated with
epilepsy and sensory impairments. Among instruments the DMR appeared most sensitive to tracking
change in symptoms over time before diagnosis.
Conclusion The previously reported high risk levels
for dementia among people with Down syndrome
was confirmed in these data as was the value of the
instruments utilised in tracking decline and helping
to confirm diagnosis even in persons with severe
intellectual disability.
Keywords behavioural measurement methods,
Down syndrome, intellectual disability, learning
disability
Background
Life expectancy in people with Down syndrome
(DS) has increased dramatically in recent years
from an average of years in s to age years
and beyond today (Bittles & Glasson ). There
has been signification interest in understanding the
ageing of this population and much research has
focused on change in behaviours and global day to
Journal of Intellectual Disability Research
2
M. McCarron et al. • Dementia follow-up
day functioning with increasing age (McCarron
et al. ). It is generally agreed that dementia
occurs more commonly in people with intellectual
disability (ID) and particularly those with DS with
prevalence rates estimated to be between % and
% in those with DS over the age of years
(Prasher & Krishnan ). There is consensus that
average age of onset among people with DS is
between and years and duration is reported as
averaging between . and years, with individual
cases as high as years (Lai & Williams ;
Prasher & Krishnan ).
There is also emerging consensus on prevalence
rates of dementia in persons with DS by age cohort.
Strydom et al. () in a review of published
studies (–) confirms both a higher prevalence of dementia in persons with DS, and accelerating rates with age with reports of % in those
under years (Coppus et al. ), .–.% in
ages – years (Holland et al. ; Tyrrell et al.
), .–% in ages – years (Holland et al.
; Tyrrell et al. ; Coppus et al. ) and
.–% in those aged – years (Tyrrell et al.
) with one report of % prevalence rate in
adults aged years and over (Visser et al. ).
Some of the variation noted reflects that there are
many challenges in diagnosing and estimating the
prevalence of dementia in this population including
pre-morbid functioning and difficulties in using
standardised tests, communication difficulties,
improvised care environments, lack of base line performance data and the consequences of high staff
turnover (McCallion & McCarron ).
The International Association for the Scientific
Study of Intellectual Disabilities (IASSID) outline a
model of best practice for dementia recognition and
diagnosis in persons with ID (Burt & Aylward
); including () baseline assessment and annual
follow-up of persons with DS > years; () comprehensive diagnostic work-up; and () person
centred approaches to care, including the need for
staff training and service and policy re-design.
However these recommendations are not yet
embedded in health policy and it continues to be
more likely that assessments are carried out in a
crisis, with dementia often already at an advanced
stage when best practice recommendations are for
early testing and longitudinal follow-up to confirm
diagnosis (Burt & Aylward ; Strydom et al.
© John Wiley & Sons Ltd, MENCAP & IASSID
; Coppus et al. ). Furthermore, a number
of the published studies have methodological limitations including a reliance on cross-sectional designs
(Zigman et al. ) with the few longitudinal
studies usually of relatively short duration and with
few points of data collection (see, for example,
Holland et al. ; Margallo-Lana et al. ;
McKensie et al. ) and there are also findings
that longitudinal follow-up is not useful in people
with severe ID (Margallo-Lana et al. ).
In the general population utilisation of memory
clinics is viewed as an effective means of ensuring
prompt and accurate diagnosis of dementia, as well
as offering supports and appropriate referral for
care and treatment (Gardner et al. ). Referral
of people with ID to generic memory clinics
appears to be fraught with difficulties, including
lack of understanding of assessment procedures and
of the recommended assessment tools for persons
with ID among generic professionals, communication barriers and lack of experience in interviewing
people with ID, interpreting decline in the context
of pre-existing impairment, as well as difficulty in
access and eligibility for services which are based on
chronological age versus need (McCarron & Lawlor
). In response to these concerns some attempts
have been made to develop memory clinics within
ID services (McCreary et al. ; Chicoine et al.
; Hassiotis et al. ; Cahill et al. ). The
present analysis results from the development of
such a memory clinic within the Daughters of
Charity Service in Ireland which primarily serves
women with DS. This clinic provides a service to
people with DS over the age of years. The
data reported here examined changes from premorbid level of functioning over a -year period
and assessed the usefulness of specific assessment
instruments and the relationship between age and
cognitive and functional decline, comorbidity and
mortality risk in a convenience sample of persons
with DS who were aged years and older at outset
of the study.
Methods
This is a prospective longitudinal study on symptom
progression, dementia incidence, comorbidities and
mortality in persons with DS reporting on a -year
follow-up of subjects.
Journal of Intellectual Disability Research
3
M. McCarron et al. • Dementia follow-up
Sample
Seventy-seven women with DS, over the age of
years, that is, all women over with DS at the
Daughters of Charity Service were enrolled and
screened in and then assessed for symptoms
of dementia on an annual basis until death, with
assessments completed in a specialist memory
clinic. DS was established from records review. Following recommendations of Alyward et al. (),
dementia diagnosis was confirmed using International Classification of Diseases, Tenth Revision
(ICD-) criteria. Institutional ethical approval for
the study was received.
Assessment protocol
At the time of entry into the study, each person
received a complete comprehensive assessment
including interviews with main caregivers/family; a
detailed clinical screen and a medical records review
to establish past and present physical and/or mental
health disorders including cardiovascular health,
lung disease, diabetes, epilepsy, depression, sensory
impairments and gastric disease; and measures of
cognitive and physical functioning. Chronic conditions were established in a records review and confirmed by a physician. Diagnosis of depression was
by a psychiatrist familiar with the individual and
who had the opportunity to interview the individual
and key informants and to review all records. Premorbid level of ID was also obtained from the
medical records/psychological reports, classified
using the ICD- criteria (World Health
Organization ). The comprehensive clinical
screen and cognitive and physical functioning was
then repeated annually during the years the subject
was still alive.
Cognitive and physical functioning measures
A combination of informant-based (Daily Living
Skills Questionnaire – DLSQ – National Institute
of Aging ) and objective-based (Down’s
Syndrome Mental Status Examination – DSMSE –
Haxby ; Test for Severe Impairment – TSI –
Albert & Cohen ) test instruments were
administered. The utility of these instruments in
measuring cognitive and functional decline in
persons with DS have previously been reported
© John Wiley & Sons Ltd, MENCAP & IASSID
(Tyrrell et al. , ; Cosgrave et al. ;
McCarron et al. ). An additional informantbased questionnaire, the Dementia Questionnaire
for Mentally Retarded individuals – DMR
(Evenhuis ), was introduced in and then
repeated each year.
Diagnosis
A comprehensive diagnostic workup including a full
physical examination, urinalysis, geriatric blood
screen and mental health assessment, in line with
recommendations from Aylward et al. (),
helped in ruling out all other potential causes of
decline. Only then was dementia diagnosis ascertained using the modified ICD criteria and after all
materials were reviewed in a consensus meeting
with members of the person’s multi-disciplinary
team including the clinical nurse specialist in
dementia, caregivers/family, consultant psychiatrist
and psychologist. Consistency in both study team
and assessment protocol was purposefully maintained over the assessment period to overcome limitations reported in prior studies.
Data analysis
After demographics of the sample were examined
and the incidence of dementia over time plotted, the
sample was divided into those with and those as yet
without dementia and the two groups compared
using t-tests for the continuous variables and Chisquare analysis for the categorical variables. In particular, patterns in comorbid health conditions were
examined and compared for those with and without
dementia diagnosis. Then, hierarchical linear
modelling – HLM (Bryk & Raudenbush ;
Bryk & Raudenbush ) was used to examine the
personal characteristics that predicted change in the
individual over the study period. Consistent with
HLM requirements a baseline was established that
described the status of the study cohort at time one
as was a slope that described changes in functioning
across subsequent time periods with the ability to
model individual differences in trajectories of
change. For the analysis here, to the extent possible,
data points were graphed before dementia diagnosis
for four measures (TSI, DLSQ, DSMSE and
DMR) and for time points after diagnosis for
Journal of Intellectual Disability Research
4
M. McCarron et al. • Dementia follow-up
Over the -year follow-up period, (.%) subjects developed dementia. Some individuals were
found at baseline to have a diagnosis of dementia
and others were followed for up to years. The
mean age of dementia diagnosis was . years
(SD = .). Of those classified as having moderate
ID .% (/) had developed dementia by the
end of the study period as did .% (/) of
those classified as having severe ID (n = ). There
were no individuals in the sample with mild ID. Of
those who developed dementia none had confirmed
symptoms before the age of years but based
upon verified age of incidence data, .% had
developed dementia by age years, .% by age
years, .% by age years and .% by age
years.
Based upon these incidence findings, the risk for
developing dementia was also mapped by age. As
can be seen in Fig. a % risk was established at
age years; % at age years and % risk at
age years.
Comorbidities
The clinical characteristics and health comorbidities
in persons with and without dementia are presented
in Fig. .
© John Wiley & Sons Ltd, MENCAP & IASSID
% demenia
35
45
55
65
75
85
Age
Figure 1 Cumulative risk of developing dementia by age.
100
90
80
70
60
50
40
30
20
10
0
No Demenia
Demenia
L
Incidence and risk of dementia
100
90
80
70
60
50
40
30
20
10
0
C
Results
demenia
%
subjects for whom there occurred a confirmed
dementia diagnosis. Similar time points were also
graphed for persons who did not present with
dementia over the study period.
Hierarchical linear modelling was particularly
useful as an analysis approach as it does not require
that all individuals have the same number of data
points; an important consideration for this study
given that some individuals have fewer data points
than others given attrition over time through death
(n = ) and that some subjects were not assessed
at the same data points. A survival curve was used
to plot the survival proportion as a function of time
using the Kaplan–Meier method with a % confidence interval. Finally, logistic regression analysis
was used to consider the respective contributions of
age, presence of dementia and presence of epilepsy
to observed mortality among the cohort.
Figure 2 Prevalence of comorbidities.
Among comorbidities, epilepsy was significantly
more common in subjects with dementia compared
with subjects without dementia. Of those with
dementia diagnosis, .% (/) had epilepsy,
compared with % (/) in those without a
dementia diagnosis (Chi-square = .; df = ;
P = .). Mean age at which people were diagnosed with epilepsy was . (SD = .) and
diagnosis of epilepsy was on average .
(SD = .) years after a diagnosis of dementia.
Depression was not significantly more common in
subjects with dementia (Chi-square = .; df = ;
P = .). By , among those with a dementia
diagnosis .% (/) were also diagnosed with
depression, compared with % (/) for those
without a dementia diagnosis. Vision impairments
were reported in .% of subjects without dementia and in .% of subjects with dementia. Hearing
impairments were reported in .% of subjects
without dementia and in .% of subjects with
dementia.
Journal of Intellectual Disability Research
5
M. McCarron et al. • Dementia follow-up
TSI, DSMSE,DLSQ and DMR vs years since demenia diagnosis
16
-20
-15
-10
80
14
70
12
60
10
50
8
40
6
30
4
20
DSMSE
2
10
DMR
0
0
-5
0
5
10
Years since demenia diagnosis
15
DLSQ
TSI
Median
20
Figure 3 Dementia scale scores by year before and after diagnosis.
TSI, Test for Severe Impairment; DSMSE, Down’s Syndrome
Mental Status Examination; DLSQ, Daily Living Skills
Questionnaire; DMR, Dementia Questionnaire for Mentally
Retarded individuals.
Cognitive and physical functioning measures
As can be seen in both Fig. and Table , decline
on the TSI and DSME was found to occur year
prior to diagnosis and the rate of decline on these
scales after diagnosis was more gradual. The decline
in DLSQ score was over – years and decline prior
to diagnosis on the DMR (measured in increased
scores), despite the shorter period of administration
(only introduced in ), was pronounced and
occurring over a period of years. Rates of decline
in scores in the years before and after diagnosis
for the respective measures in Table are also
broken out by moderate versus severe and profound
levels of ID. There was no significant age difference
in the moderate and severe ID groups.
Mortality
Fifty-eight per cent (n = ) of the study cohort
had died by . Of these all but one died with a
confirmed diagnosis of dementia. The last individual remained dementia symptom free and died age
years with a diagnosis of cancer. Of those who
had developed dementia .% (/) were dead
by and duration of their dementia was .
years (SD = .); if alive, as of , it was an
average of . years (SD = .). A significance difference (t = . P = .) was also noticeable in
the duration of dementia in persons with moderate
ID (mean = ., SD = .) versus subjects with
severe ID (mean = ., SD = .) but not in the
mean age of diagnosis of dementia, .
(SD = .) for those with moderate ID and .
© John Wiley & Sons Ltd, MENCAP & IASSID
Figure 4 Dementia survival curve.
(SD = .) for those with severe ID (t = .,
df = , P = .).
Figure presents the survival curve for the
subjects with dementia using the Kaplan–Meier
method with a % confidence interval. The survival curve plots the survival proportion as a function of time. Time zero represents the year a
subject was diagnosed with dementia. The median
survival time was years, the time at which half the
subjects have died and half are still alive.
Logistic regression examined the ability of the
variables age, epilepsy and level of ID to predict
onset of dementia. Epilepsy was found to be
the only significant predictor of dementia
(P-value = .). Subjects with epilepsy were .
(., .) times more likely to present with
dementia than those without diagnosed epilepsy.
Further use of logistic regression examined age,
epilepsy and dementia as predictors of death among
the sample. Here, epilepsy was found to be the only
significant predictor of mortality (P-value = .).
A subject with epilepsy was . (., .) times
more likely to have died than a subject without
diagnosed epilepsy.
Discussion
The memory clinic approach recommended as best
practice (Burt & Aylward ) and utilised here
proved capable of tracking change suggestive of
dementia and potentially supported earlier diagnosis. Also the risk for dementia established, % risk
at age years; % at age years and % risk at
age years, was in line with many previous studies
(Prasher ; Holland et al. ; Zigman et al.
6
DSMSE
Diagnosis
Moderate
Severe
−5
−4
−3
−2
−1
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15.8
16.17
16.14
15.56
15.6
14.85
11.65
10.07
9.27
7.99
7.43
6.68
6.26
5.86
5.03
5
5.11
4.92
4.84
4.78
2.62
2.67
2.82
2.05
2.69
1.83
0.98
0.73
0.75
1.22
0.32
0.33
0.17
0.17
0.17
0.17
0.17
0.17
0.17
0.17
(6.97)
(7.13)
(7.32)
(7.15)
(7.12)
(6.96)
(7.95)
(8.89)
(8.83)
(8.52)
(8.65)
(8.79)
(8.62)
(9.02)
(8.51)
(8.48)
(8.63)
(8.39)
(8.34)
(8.31)
(1.85)
(2.06)
(2.04)
(1.84)
(1.63)
(2.17)
(1.71)
(0.96)
(1.22)
(2.19)
(0.64)
(0.65)
(0.39)
(0.39)
(0.39)
(0.39)
(0.39)
(0.39)
(0.39)
(0.39)
Moderate
Severe
4.84
4.97
4.84
4.77
4.83
4.80
4.47
3.96
4.62
3.84
3.38
3.15
3.17
2.34
2.09
1.81
1.94
1.81
1.66
1.71
0.92
0.62
0.69
1.00
1.94
1.59
1.59
1.82
1.82
1.73
1.55
1.73
1.64
1.27
1.45
1.27
1.27
1.27
1.27
1.27
(4.41)
(4.39)
(4.45)
(4.63)
(5.07)
(4.97)
(4.51)
(4.27)
(4.97)
(4.65)
(4.4)
(4.74)
(4.95)
(4.44)
(4.5)
(4.4)
(4.99)
(4.88)
(4.37)
(4.43)
DMR
Moderate
(0.92)
(0.62)
(0.69)
(1)
(1.94)
(1.59)
(1.59)
(1.82)
(1.82)
(1.73)
(1.55)
(1.73)
(1.64)
(1.27)
(1.45)
(1.27)
(1.27)
(1.27)
(1.27)
(1.27)
29.40
29.80
33.20
36.20
42.60
60.32
60.69
61.73
64.10
62.02
59.64
64.60
64.97
68.30
68.00
69.30
70.00
70.35
70.13
72.13
(19.51)
(19.06)
(19.71)
(18.77)
(17.98)
(21.06)
(21.03)
(21.01)
(21.08)
(22.81)
(24.46)
(22.5)
(24.22)
(24.6)
(25.29)
(26.05)
(25.24)
(24.5)
(24.82)
(24.12)
DLSQ
Severe
Moderate
Severe
77.00
76.90
77.21
77.10
77.43
77.06
77.06
75.68
77.08
78.22
77.00
79.43
81.67
83.11
83.22
83.22
14.32
14.40
14.34
13.77
13.77
10.57
8.37
7.85
6.92
6.18
5.47
4.78
4.53
4.59
4.16
4.14
4.16
4.05
4.08
4.05
13.23
13.03
12.64
12.72
12.38
9.58
5.72
5.64
6.43
5.61
6.00
4.92
5.17
4.42
3.58
3.58
3.58
3.58
3.58
3.58
(15.65)
(8.66)
(9.88)
(10.27)
(11.67)
(12.23)
(10.65)
(12.08)
(14.24)
(15.51)
(11.24)
(8.44)
(7.22)
(7.22)
(7.22)
(7.63)
(7.8)
(7.22)
(7.57)
(7.28)
(5.81)
(5.48)
(6.29)
(5.86)
(5.66)
(5.65)
(5.82)
(5.66)
(6.03)
(5.7)
(5.72)
(5.73)
(5.7)
(5.7)
(5.7)
(5.8)
(5.86)
(7.17)
(5.49)
(6.03)
(5.43)
(4.9)
(4.87)
(5.49)
(4.88)
(5.59)
(5.25)
(5.86)
(5.26)
(5.25)
(5.25)
(5.25)
(5.25)
(5.25)
(5.25)
TSI, Test for Severe Impairment; DSMSE, Down’s Syndrome Mental Status Examination; DMR, Dementia Questionnaire for Mentally Retarded individuals; DLSQ, Daily Living Skills
Questionnaire.
Journal of Intellectual Disability Research
TSI
M. McCarron et al. • Dementia follow-up
© John Wiley & Sons Ltd, MENCAP & IASSID
Table 1 Measured scale scores by level of intellectual disability, before and after diagnosis of dementia
Journal of Intellectual Disability Research
7
M. McCarron et al. • Dementia follow-up
), but was lower than that reported by Visser
et al. (), and higher than in at least one longitudinal study which reported a % risk at age and
above (Margallo-Lana et al. ). The average age
of diagnosis at . years (SD = .) was in the
higher range of previously reported estimates (–
years) and duration after diagnosis, of .–.
years was similarly at the high end of estimates
(.–. years) (Lai & Williams ; Prasher &
Krishnan ). The survival curve reported here
noted a median survival of years and this may
offer more useful guidance for clinical services,
given prior reports of precipitous decline (Lai &
Williams ); dementia is just as likely to be for
an extended period. Understanding survival in
persons with DS and dementia is of critical importance having major implications from a care and
resource perspective in terms of environmental
capability, staff competency and nursing related
care needs.
A most interesting and previously unreported
finding in this study was that for those with a preexisting severe or profound level of ID, duration
after diagnosis was for an average . years
despite no significant difference in age of onset as
compared with persons with DS at a moderate
level of ID. This has not been examined or
reported upon in other studies, largely because of
difficulties in diagnosing dementia. This study has
demonstrated that its measurement approach will
identify and diagnose symptoms in persons with
DS with a pre-existing severe or profound level of
ID; additional studies using a similar assessment
approach will be able to examine further this
increased duration as compared with persons with
DS at a moderate level of ID. The rigorous
approach taken to diagnosis and the effort to
include people with severe ID proved to be a
strength of this study. The absence of similar findings in other studies probably reflects that sufficient people with severe ID were not included, the
approaches to assessment and diagnosis were not
sufficiently rigorous and/or the individuals were
not followed for a sufficient period.
The DSMSE proved less sensitive than the
other measures and although designed specifically
for people with DS may be most useful for people
with less severe levels of ID. This lack of sensitivity was not a concern for the other instruments
© John Wiley & Sons Ltd, MENCAP & IASSID
and it appears they were also useful in establishing
decline in people with severe ID. This is an
important contribution of the work here as prior
studies have reported that other instruments were
not useful for people with severe ID (see, for
example, Margallo-Lana et al. ). Finally, the
introduction of the DMR in helped establish
the particular sensitivity of this instrument and
some evidence that decline may be noted earlier
when the DMR is utilised. Interestingly a gradual
decrease in functioning prior to the onset of
dementia was observed, suggestive perhaps of preclinical dementia in those with DS, and supporting
the Coppus et al. () recommendation on the
need for more extensive longitudinal studies to
better discriminate between normal ageing and
dementia.
There are a number of methodological issues to
be considered in the interpretation of these findings, not least that this study focused on women
with DS only and represents a small and perhaps
unique (one agency) sample. Also each assessment
was by the same evaluator and subsequent findings
might be more easily influenced by prior impression; however, each diagnosis was a consensus
diagnosis by a multidisciplinary team. Future
studies may benefit from having larger and more
diverse samples and from including men with DS.
However the duration of follow-up, prospective
versus retrospective design, annual assessment and
consistency in use of a memory clinical team and
consensus diagnosis operationalised through a
memory clinic offer guidance for the structuring of
future studies and have demonstrated an ability to
identify clinical symptoms of dementia even in
persons with severe ID. The findings on survival
also highlight that shorter survival reported in
prior studies (Lai & Williams ; Prasher &
Krishnan ) probably reflect the limitations
of shorter follow-up periods and greater
longevity may also reflect earlier diagnosis in this
sample. Again these are issues worthy of further
investigation.
The need for comprehensive assessment was also
confirmed as over time the participants experienced
a range of comorbidities. In particular the previously identified strong association between
comorbid epilepsy and dementia in people with DS
(see, for example, Simone et al. ; Lott et al.
Journal of Intellectual Disability Research
8
M. McCarron et al. • Dementia follow-up
Table 2 Predictors of dementia
95% confidence
interval for OR
Dementia
diagnosis*
Estimate
Std.
error
Wald
df
Sig.
OR
Lower
bound
Upper
bound
Age
ID (moderate)
Epilepsy (yes)
0.092
−0.596
−2.140
0.065
1.110
0.861
2.004
0.288
6.174
1
1
1
0.157
0.591
0.013
1.097
0.551
0.118
0.965
0.063
0.022
1.246
4.856
0.636
* The reference category is: no dementia.
ID, intellectual disability; OR, odds ratio.
Table 3 Predictors of mortality
95% confidence
interval for OR
Dead y/n*
Estimate
Std.
error
Wald
df
Sig.
OR
Lower
bound
Upper
bound
Age
ID (moderate)
Epilepsy (yes)
0.026
−1.868
−1.854
0.042
1.173
0.587
0.405
2.538
9.976
1
1
1
0.524
0.111
0.002
1.027
0.154
0.157
0.946
0.016
0.050
1.114
1.537
0.495
* The reference category is: not dead.
ID, intellectual disability; OR, odds ratio.
) was supported here with almost % of those
with a dementia diagnosis also having epilepsy and
its onset frequently within the same time period as
dementia decline. Indeed, the logistic regression
findings further support that there may be a strong
relationship between presence of epilepsy and the
onset of dementia. That the effect of epilepsy was
not overwhelmed by age in explaining onset of
dementia (Table ) and mortality (Table ) helps
illustrate the critical nature of the experience of epilepsy for people with DS. Documenting the clinical
characteristics of epilepsy and its relationship to
cognitive decline warrants further attention including greater understanding of the linkage with what
has become more recently characterised as senile
myoclonic epilepsy, one of the most common forms
of progressive myoclonic epilepsy (Simone et al.
). The finding that epilepsy was a stronger predictor of mortality than dementia in persons with
© John Wiley & Sons Ltd, MENCAP & IASSID
DS also deserves further investigation with different
and larger samples.
There have also been reports suggesting a strong
association between dementia and depression in
people with DS. For example, Burt et al. ()
reported much higher levels of depression among
people with DS with dementia than among those
without dementia. Here, however, rates of depression were high for both groups (.%/%). This
may be an artefact of longitudinal follow-up as
earlier in the study more distinct differences on
depression were identified (Cosgrave et al. );
after years most of the sample did present with
dementia and it is possible that the remaining
eight non-dementia participants may be at a predementia stage for which depression may be a
co-occurring condition. Understanding the relationship with depression will require further
investigation.
Journal of Intellectual Disability Research
9
M. McCarron et al. • Dementia follow-up
Conclusion
The limitations of a convenience sample notwithstanding, the results here indicate that the model of
best practice recommended by Burt & Aylward
() when operationalised in a memory clinic was
effective in tracking decline and diagnosing dementia in persons with ID. This is in keeping with previous recommendations and an emerging consensus
in the field that dementia diagnosis of persons with
ID should be based on longitudinal follow-up
(Holland et al. ; Zigman et al. ). It is
hoped that the demonstration of the success of longitudinal follow-up and the usefulness of particular
instruments will facilitate the adoption for this
approach and thereby early identification of dementia in persons with DS thus helping to ensure earlier
access to appropriate treatments and programme
redesign.
Conflict of interest
There are no conflicts, financial or personal for the
authors that may potentially bias the work.
Acknowledgement
Support from the Daughters of Charity Service is
gratefully acknowledged.
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Accepted June