Post by laurasnowbird on Feb 1, 2010 21:30:09 GMT -5
From Medscape, I posted the whole article because you have to have a membership to read:
Introduction
Inequalities in health and healthcare across racial, ethnic, and social backgrounds in the United States are well documented. In 2002 and 2005, the surgeon general published reports calling for better healthcare for persons with intellectual and physical disabilities.[1,2] It is estimated that 16% of children ages 18 years and under have intellectual and developmental disabilities,[3] and these patients experience poorer health than the general population.[4,5] Although, previously, patients with disabilities were almost exclusively cared for by pediatricians, 90% of individuals with special needs are now surviving into adulthood.[6] In the peer-reviewed literature, young patients with a wide range of physical, intellectual, and emotional disabilities are referred to as children with special healthcare needs (CSHCN). As a result of increased life expectancies for so many health conditions, CSHCN are living longer with their disorders and will need preventive services from adult-oriented healthcare providers. Down syndrome has a prevalence estimated at 1 in 700-1000 live births, and these individuals are living longer into adulthood than ever before.
People with special needs require unique attention from the medical community[7]; however, the current generation of adult-oriented providers is inadequately prepared to care for this population.[8] The challenges in providing preventive care to this vulnerable group stem from difficulties in transitioning these patients to the adult healthcare system.[9] The medical home concept in conjunction with parental advocacy has helped many CSHCN flourish and reach adulthood,[10] but the realm of adult-oriented healthcare can be extremely difficult to navigate, even for patients without cognitive limitations or complex medical needs. Barriers to care for young adults with special needs are numerous, and may include (among other things) the use of health insurance, access to specialists, transportation to appointments, changes in parental involvement, and desire for autonomy.[11] Like other adults, patients with special needs benefit from knowledgeable and involved primary care clinicians who can function as advocates and ensure that patients receive age-appropriate preventive care.
When CSHCN leave pediatric care for adult care services, they may encounter providers who are not as comfortable with or knowledgeable about their needs, leading to dissatisfaction with care and contributing to healthcare disparities.[12] According to recent reports by the Institute of Medicine, great disparities exist in healthcare for adults with special needs.[1,2] Under the umbrella of "special healthcare needs" are adults with physical, emotional, and cognitive disabilities. One subset of patients with specific preventive care needs is adults with Down syndrome. The US Preventive Services Task Force (USPSTF) does not currently have guidelines for the care of adults with Down syndrome. However, the Down Syndrome Medical Interest Group (DSMIG) frequently reviews the available literature and updates its recommendations for preventive care specific to this aging population. These guidelines are based on expert medical opinion and limited available evidence.[13] A number of clinical conditions occur more frequently in adults with Down syndrome, and some diseases have an earlier age of onset than in the general population.
Several recommendations for the care of adults with cognitive limitations also apply to patients with Down syndrome. For example, during healthcare provider office visits, it is helpful to have someone accompany the patient who is familiar to the patient and with the purpose of the visit. Consider having a "social visit" with the patient prior to the first physical exam, where the patient simply meets the provider and becomes comfortable in the office environment. Also, supplying the patient's caregiver with an encounter sheet to document useful information in advance of the visit can facilitate care (see Patient Encounter Form).[14]
Providers can advocate for these patients by taking the time to coordinate care with specialists. By incorporating a few measures before and during office appointments, primary care providers who treat adult patients with Down syndrome can make these visits run more smoothly.
History and Physical Examination of Patients With Down Syndrome
During a patient interview, providers must be aware that patients may have limited expressive speech, and a tendency to manifest development of new disease as a change in behavior.[15] Providers should consider introducing topics, such as emerging sexuality and socialization, which are typically in the domain of the adolescent provider. Finding out whether a patient is interested in sexual activity will determine the necessary frequency of Papanicolaou (Pap) smears and sexually transmitted disease screenings. In older patients, the interview should assess for loss of independence in an attempt to determine whether it is related to normal aging or to an underlying medical problem, and make referrals and recommendations to caregivers accordingly. For example, if a patient was previously able to independently feed, dress, and perform personal hygiene but now requires assistance, the provider should consider diagnoses, such as hypothyroidism and depression, prior to attributing such a decline in function to the onset of dementia. Establishing a baseline cognitive function at age 40 years has been recommended by the Canadian guidelines for adults with developmental disabilities at risk for dementia.[16]
The following are physical exam findings in patients with Down syndrome of which clinicians should be aware:
* Atlantoaxial subluxation: Patients should have a baseline cervical spine x-ray to assess for atlantoaxial instability, and follow-up x-rays if they are planning to participate in athletic events, such as the Special Olympics.
* Hypothyroidism: clinically difficult to detect in patients with Down syndrome (see screening below).
* Cardiac findings: Listen for evidence of mitral valve prolapse and aortic regurgitation. By the time most patients reach adulthood, they will have been assessed for congenital heart disease; however, mitral valve prolapse can occur from adolescence onward.
Additionally, a provider should be alert for signs of abuse and neglect.[17,18] Although current numbers are primarily derived from convenience samples, it is estimated that persons with intellectual disabilities suffer from more neglect and abuse than the general population. Patients with intellectual and developmental disabilities may be ill equipped to defend themselves against the many forms of neglect, in addition to physical, sexual, or emotional abuse. Providers can seek resources, such as state departments of social services, which should have divisions dedicated to adult protective services, such as the service in North Carolina.[19]
Adult Health Maintenance
Adults with Down syndrome have many of the same healthcare needs as same-age peers; however, in patients with Down syndrome a number of conditions have earlier ages of onset, higher prevalences, or different presentations. When planning an intervention that requires the patient's cooperation or understanding, special consideration must be given to the patient's cognitive limitations.
Light sedation has been used in adults with cognitive limitations who have difficulty tolerating procedures,[14] such as dental cleaning and Pap smears; however, extreme caution should be advised because many patients with Down syndrome have comorbid apnea. Age-appropriate cancer screening, dental and vision care, immunizations, and hypertension screening should occur at regular intervals. As in the general population, obesity is a common problem among adults with Down syndrome; encouraging healthy eating and exercise is an important part of health maintenance (see Down Syndrome Health Care Guidelines for Adults record form).
Screening for Specific Disorders
Autoimmune and endocrine diseases. Diseases, such as celiac, diabetes mellitus, and hypothyroidism, have higher prevalences in adults with Down syndrome than in the general population. Adults with Down syndrome face increased risks for celiac disease that can occur at any time. Current recommendations from the DSMIG include asking whether the patient has excessive diarrhea, nausea, abdominal distension, or unexplained lethargy. The initial blood test should be a complete blood count to assess for anemia. If suspicion for disease is high, the next test to order is an antiendomysial and/or antitissue transglutaminase antibody followed by referral to a gastroenterologist.[20]
Type 1 diabetes is another disorder with a higher prevalence in adults with Down syndrome.[21] Most diagnoses of type 1 diabetes are made in childhood; however, adult healthcare clinicians should be aware of this association and with the increased risk for type 2 diabetes. No specific recommendations exist for ordering fasting glucose tests; however, screening should be considered.
Hypothyroidism is estimated to occur in 10%-40% of all patients with Down syndrome, and can be difficult to detect clinically; it may even masquerade as early-onset dementia.[22] Thyroid-stimulating hormone levels should be checked annually in adults with Down syndrome.
Cancers. Mammography and colonoscopy are recommended at the same time intervals as for similar-age peers.[23,24] If patients are not able to tolerate mammography, annual breast ultrasounds have been proposed as an alternative. Testicular cancer has been noted to have a higher prevalence in men with Down syndrome than in the general population; therefore, performing annual testicular exams may aid in detection of this cancer.[15]
The strong association between Down syndrome and leukemia in childhood is well documented[25]; however, after age 20, the risk significantly decreases.[26] Currently, no screening is recommended for adult patients.
Cervical cancer screening with pelvic exam and Pap smear should be attempted in sexually active patients; however, the screening may be difficult to perform if patient education is not sufficient to gain patient cooperation. If the provider is unable to complete a pelvic exam, a modified exam has been suggested[27] that forgoes a speculum, and instead the provider's gloved finger is inserted to obtain cells for the Pap cytology. Providing reproductive health services to persons with Down syndrome and other cognitive disabilities is extremely important.[27]
Cardiac. From late adolescence on, there is an increased risk for mitral valve prolapse and valvular regurgitation in patients with Down syndrome. Previous expert opinion suggested that bacterial endocarditis prophylaxis was indicated if valvular regurgitation was noted on physical exam.[15,28] The most recent American Heart Association guidelines for prevention of endocarditis have significantly scaled back on the use of antibiotics prior to dental work.[29] It may be advisable to obtain a cardiology consult for management of valvular defects if uncertainty exists with regard to the patient's need for antibiotics. Some evidence suggests that adults with Down syndrome develop coronary artery disease at younger ages than the general population; however, others report a lower overall prevalence of coronary artery disease in patients with Down syndrome. There is insufficient evidence to recommend deviating from the USPSTF guidelines on fasting lipid profile surveillance.[30]
Neurologic. Symptoms of dementia, such as decline in function, memory loss, ataxia, seizures, and incontinence, should first be evaluated for a treatable medical etiology. Spinal stenosis, adult-onset epilepsy, and hypothyroidism have higher prevalences in adults with Down syndrome than the general population.[31,32] If any signs or symptoms of atlantoaxial subluxation arise, such as gait disturbance, weakness, clonus, or spasticity, it is prudent to urgently obtain neck x-rays.[20] An association between Alzheimer's disease and Down syndrome has long been noted. However, before making a diagnosis of Alzheimer's disease, it is prudent to rule out other diagnoses, such as hypothyroidism and depression.[33]
Mental health. Disorders, such as depression, obsessive-compulsive disorder, abuse, and conduct disorder,[34] occur more frequently than other mental health disorders in individuals with Down syndrome. To differentiate between dementia and depression, the Dementia Screen for Down Syndrome (DSDS) is a validated scale for adults.[35] Currently, this scale is only available for use by licensed psychologists; other scales have been used on small numbers of adults with Down syndrome, but the DSDS appears to have the greatest reliability.
Osteoporosis. Osteoporosis is more common in adults with Down syndrome than in the general population. Calcium supplementation of 1000 mg for men and nonmenopausal women and 1500 mg for postmenopausal women (along with vitamin D) has been suggested. Consider obtaining a dual-energy x-ray absorptiometry scan to screen these patients for osteoporosis.[36]
Pulmonary. Sleep apnea is estimated to occur in 50% of people with Down syndrome as a result of physical characteristics associated with the disorder.[37] Sleep apnea can occur in the absence of obesity and can manifest as a change in behavior, such as increased irritability, daytime somnolence, or psychological symptoms -- such as depression.
Vision. Cataracts and keratoconus may develop in adolescence or adulthood and are found to be approximately 4 times more common than in the general adult population.[38] Hypermetropia can develop at any age. Screening by an optometrist or ophthalmologist should occur yearly.
Hearing. More than 50% of patients with Down syndrome may have mild-to-severe hearing loss. Conductive and/or sensorineural loss can begin at any age; therefore, audiometry should be performed at least every 2 years.[39]
Special Issues
Consideration should be given to assessing whether a patient with Down syndrome is able to provide informed consent for procedures, and if not, who will make decisions if parents are no longer available. This also applies to the issue of code status. Laws in some states protect the rights of patients with special needs by requiring a legal process to change code status. Providers must be aware whether their states do not allow healthcare proxies or legal guardians to sign Do Not Resuscitate orders without legal proceedings.
For patients who plan to have children, or become pregnant, referral for genetic counseling to discuss the recurrence of Down syndrome[40] is recommended. Down syndrome can arise from any of 3 well-established genetic mechanisms: trisomy 21 (most common); translocation; or mosaicism. Discussion with a genetic counselor about the likelihood of a parent with Down syndrome passing the genetic alteration on to a fetus should be addressed prior to conception if possible, or after conception has occurred as part of planning for the future healthcare needs of the child.
Understanding patients' living situations is important in determining the type of support that they have after leaving the provider's office. A group home may have structures in place for numerous support services, including medication management, group exercise, and social events. A patient living with aging, ailing parents may benefit from visiting nurse services or available community resources.
Conclusion
Adult-oriented providers are on the frontlines of preventive care for adults with special needs. Patients with Down syndrome, like other special needs adults, greatly benefit from having a dedicated, involved primary care provider. Models of care, such as the Adult Down Syndrome Center in Chicago, Illinois,[41] are excellent resources; however, these models are difficult to replicate due to financial constraints. Individual providers can follow recommendations for care noted on Websites listed under "Resources for Clinicians."
Acknowledgment
The author thanks Dr. Dorothea M.G. Wild for her ongoing encouragement and support in writing about this and other topics related to healthcare for adults with special needs.
Introduction
Inequalities in health and healthcare across racial, ethnic, and social backgrounds in the United States are well documented. In 2002 and 2005, the surgeon general published reports calling for better healthcare for persons with intellectual and physical disabilities.[1,2] It is estimated that 16% of children ages 18 years and under have intellectual and developmental disabilities,[3] and these patients experience poorer health than the general population.[4,5] Although, previously, patients with disabilities were almost exclusively cared for by pediatricians, 90% of individuals with special needs are now surviving into adulthood.[6] In the peer-reviewed literature, young patients with a wide range of physical, intellectual, and emotional disabilities are referred to as children with special healthcare needs (CSHCN). As a result of increased life expectancies for so many health conditions, CSHCN are living longer with their disorders and will need preventive services from adult-oriented healthcare providers. Down syndrome has a prevalence estimated at 1 in 700-1000 live births, and these individuals are living longer into adulthood than ever before.
People with special needs require unique attention from the medical community[7]; however, the current generation of adult-oriented providers is inadequately prepared to care for this population.[8] The challenges in providing preventive care to this vulnerable group stem from difficulties in transitioning these patients to the adult healthcare system.[9] The medical home concept in conjunction with parental advocacy has helped many CSHCN flourish and reach adulthood,[10] but the realm of adult-oriented healthcare can be extremely difficult to navigate, even for patients without cognitive limitations or complex medical needs. Barriers to care for young adults with special needs are numerous, and may include (among other things) the use of health insurance, access to specialists, transportation to appointments, changes in parental involvement, and desire for autonomy.[11] Like other adults, patients with special needs benefit from knowledgeable and involved primary care clinicians who can function as advocates and ensure that patients receive age-appropriate preventive care.
When CSHCN leave pediatric care for adult care services, they may encounter providers who are not as comfortable with or knowledgeable about their needs, leading to dissatisfaction with care and contributing to healthcare disparities.[12] According to recent reports by the Institute of Medicine, great disparities exist in healthcare for adults with special needs.[1,2] Under the umbrella of "special healthcare needs" are adults with physical, emotional, and cognitive disabilities. One subset of patients with specific preventive care needs is adults with Down syndrome. The US Preventive Services Task Force (USPSTF) does not currently have guidelines for the care of adults with Down syndrome. However, the Down Syndrome Medical Interest Group (DSMIG) frequently reviews the available literature and updates its recommendations for preventive care specific to this aging population. These guidelines are based on expert medical opinion and limited available evidence.[13] A number of clinical conditions occur more frequently in adults with Down syndrome, and some diseases have an earlier age of onset than in the general population.
Several recommendations for the care of adults with cognitive limitations also apply to patients with Down syndrome. For example, during healthcare provider office visits, it is helpful to have someone accompany the patient who is familiar to the patient and with the purpose of the visit. Consider having a "social visit" with the patient prior to the first physical exam, where the patient simply meets the provider and becomes comfortable in the office environment. Also, supplying the patient's caregiver with an encounter sheet to document useful information in advance of the visit can facilitate care (see Patient Encounter Form).[14]
Providers can advocate for these patients by taking the time to coordinate care with specialists. By incorporating a few measures before and during office appointments, primary care providers who treat adult patients with Down syndrome can make these visits run more smoothly.
History and Physical Examination of Patients With Down Syndrome
During a patient interview, providers must be aware that patients may have limited expressive speech, and a tendency to manifest development of new disease as a change in behavior.[15] Providers should consider introducing topics, such as emerging sexuality and socialization, which are typically in the domain of the adolescent provider. Finding out whether a patient is interested in sexual activity will determine the necessary frequency of Papanicolaou (Pap) smears and sexually transmitted disease screenings. In older patients, the interview should assess for loss of independence in an attempt to determine whether it is related to normal aging or to an underlying medical problem, and make referrals and recommendations to caregivers accordingly. For example, if a patient was previously able to independently feed, dress, and perform personal hygiene but now requires assistance, the provider should consider diagnoses, such as hypothyroidism and depression, prior to attributing such a decline in function to the onset of dementia. Establishing a baseline cognitive function at age 40 years has been recommended by the Canadian guidelines for adults with developmental disabilities at risk for dementia.[16]
The following are physical exam findings in patients with Down syndrome of which clinicians should be aware:
* Atlantoaxial subluxation: Patients should have a baseline cervical spine x-ray to assess for atlantoaxial instability, and follow-up x-rays if they are planning to participate in athletic events, such as the Special Olympics.
* Hypothyroidism: clinically difficult to detect in patients with Down syndrome (see screening below).
* Cardiac findings: Listen for evidence of mitral valve prolapse and aortic regurgitation. By the time most patients reach adulthood, they will have been assessed for congenital heart disease; however, mitral valve prolapse can occur from adolescence onward.
Additionally, a provider should be alert for signs of abuse and neglect.[17,18] Although current numbers are primarily derived from convenience samples, it is estimated that persons with intellectual disabilities suffer from more neglect and abuse than the general population. Patients with intellectual and developmental disabilities may be ill equipped to defend themselves against the many forms of neglect, in addition to physical, sexual, or emotional abuse. Providers can seek resources, such as state departments of social services, which should have divisions dedicated to adult protective services, such as the service in North Carolina.[19]
Adult Health Maintenance
Adults with Down syndrome have many of the same healthcare needs as same-age peers; however, in patients with Down syndrome a number of conditions have earlier ages of onset, higher prevalences, or different presentations. When planning an intervention that requires the patient's cooperation or understanding, special consideration must be given to the patient's cognitive limitations.
Light sedation has been used in adults with cognitive limitations who have difficulty tolerating procedures,[14] such as dental cleaning and Pap smears; however, extreme caution should be advised because many patients with Down syndrome have comorbid apnea. Age-appropriate cancer screening, dental and vision care, immunizations, and hypertension screening should occur at regular intervals. As in the general population, obesity is a common problem among adults with Down syndrome; encouraging healthy eating and exercise is an important part of health maintenance (see Down Syndrome Health Care Guidelines for Adults record form).
Screening for Specific Disorders
Autoimmune and endocrine diseases. Diseases, such as celiac, diabetes mellitus, and hypothyroidism, have higher prevalences in adults with Down syndrome than in the general population. Adults with Down syndrome face increased risks for celiac disease that can occur at any time. Current recommendations from the DSMIG include asking whether the patient has excessive diarrhea, nausea, abdominal distension, or unexplained lethargy. The initial blood test should be a complete blood count to assess for anemia. If suspicion for disease is high, the next test to order is an antiendomysial and/or antitissue transglutaminase antibody followed by referral to a gastroenterologist.[20]
Type 1 diabetes is another disorder with a higher prevalence in adults with Down syndrome.[21] Most diagnoses of type 1 diabetes are made in childhood; however, adult healthcare clinicians should be aware of this association and with the increased risk for type 2 diabetes. No specific recommendations exist for ordering fasting glucose tests; however, screening should be considered.
Hypothyroidism is estimated to occur in 10%-40% of all patients with Down syndrome, and can be difficult to detect clinically; it may even masquerade as early-onset dementia.[22] Thyroid-stimulating hormone levels should be checked annually in adults with Down syndrome.
Cancers. Mammography and colonoscopy are recommended at the same time intervals as for similar-age peers.[23,24] If patients are not able to tolerate mammography, annual breast ultrasounds have been proposed as an alternative. Testicular cancer has been noted to have a higher prevalence in men with Down syndrome than in the general population; therefore, performing annual testicular exams may aid in detection of this cancer.[15]
The strong association between Down syndrome and leukemia in childhood is well documented[25]; however, after age 20, the risk significantly decreases.[26] Currently, no screening is recommended for adult patients.
Cervical cancer screening with pelvic exam and Pap smear should be attempted in sexually active patients; however, the screening may be difficult to perform if patient education is not sufficient to gain patient cooperation. If the provider is unable to complete a pelvic exam, a modified exam has been suggested[27] that forgoes a speculum, and instead the provider's gloved finger is inserted to obtain cells for the Pap cytology. Providing reproductive health services to persons with Down syndrome and other cognitive disabilities is extremely important.[27]
Cardiac. From late adolescence on, there is an increased risk for mitral valve prolapse and valvular regurgitation in patients with Down syndrome. Previous expert opinion suggested that bacterial endocarditis prophylaxis was indicated if valvular regurgitation was noted on physical exam.[15,28] The most recent American Heart Association guidelines for prevention of endocarditis have significantly scaled back on the use of antibiotics prior to dental work.[29] It may be advisable to obtain a cardiology consult for management of valvular defects if uncertainty exists with regard to the patient's need for antibiotics. Some evidence suggests that adults with Down syndrome develop coronary artery disease at younger ages than the general population; however, others report a lower overall prevalence of coronary artery disease in patients with Down syndrome. There is insufficient evidence to recommend deviating from the USPSTF guidelines on fasting lipid profile surveillance.[30]
Neurologic. Symptoms of dementia, such as decline in function, memory loss, ataxia, seizures, and incontinence, should first be evaluated for a treatable medical etiology. Spinal stenosis, adult-onset epilepsy, and hypothyroidism have higher prevalences in adults with Down syndrome than the general population.[31,32] If any signs or symptoms of atlantoaxial subluxation arise, such as gait disturbance, weakness, clonus, or spasticity, it is prudent to urgently obtain neck x-rays.[20] An association between Alzheimer's disease and Down syndrome has long been noted. However, before making a diagnosis of Alzheimer's disease, it is prudent to rule out other diagnoses, such as hypothyroidism and depression.[33]
Mental health. Disorders, such as depression, obsessive-compulsive disorder, abuse, and conduct disorder,[34] occur more frequently than other mental health disorders in individuals with Down syndrome. To differentiate between dementia and depression, the Dementia Screen for Down Syndrome (DSDS) is a validated scale for adults.[35] Currently, this scale is only available for use by licensed psychologists; other scales have been used on small numbers of adults with Down syndrome, but the DSDS appears to have the greatest reliability.
Osteoporosis. Osteoporosis is more common in adults with Down syndrome than in the general population. Calcium supplementation of 1000 mg for men and nonmenopausal women and 1500 mg for postmenopausal women (along with vitamin D) has been suggested. Consider obtaining a dual-energy x-ray absorptiometry scan to screen these patients for osteoporosis.[36]
Pulmonary. Sleep apnea is estimated to occur in 50% of people with Down syndrome as a result of physical characteristics associated with the disorder.[37] Sleep apnea can occur in the absence of obesity and can manifest as a change in behavior, such as increased irritability, daytime somnolence, or psychological symptoms -- such as depression.
Vision. Cataracts and keratoconus may develop in adolescence or adulthood and are found to be approximately 4 times more common than in the general adult population.[38] Hypermetropia can develop at any age. Screening by an optometrist or ophthalmologist should occur yearly.
Hearing. More than 50% of patients with Down syndrome may have mild-to-severe hearing loss. Conductive and/or sensorineural loss can begin at any age; therefore, audiometry should be performed at least every 2 years.[39]
Special Issues
Consideration should be given to assessing whether a patient with Down syndrome is able to provide informed consent for procedures, and if not, who will make decisions if parents are no longer available. This also applies to the issue of code status. Laws in some states protect the rights of patients with special needs by requiring a legal process to change code status. Providers must be aware whether their states do not allow healthcare proxies or legal guardians to sign Do Not Resuscitate orders without legal proceedings.
For patients who plan to have children, or become pregnant, referral for genetic counseling to discuss the recurrence of Down syndrome[40] is recommended. Down syndrome can arise from any of 3 well-established genetic mechanisms: trisomy 21 (most common); translocation; or mosaicism. Discussion with a genetic counselor about the likelihood of a parent with Down syndrome passing the genetic alteration on to a fetus should be addressed prior to conception if possible, or after conception has occurred as part of planning for the future healthcare needs of the child.
Understanding patients' living situations is important in determining the type of support that they have after leaving the provider's office. A group home may have structures in place for numerous support services, including medication management, group exercise, and social events. A patient living with aging, ailing parents may benefit from visiting nurse services or available community resources.
Conclusion
Adult-oriented providers are on the frontlines of preventive care for adults with special needs. Patients with Down syndrome, like other special needs adults, greatly benefit from having a dedicated, involved primary care provider. Models of care, such as the Adult Down Syndrome Center in Chicago, Illinois,[41] are excellent resources; however, these models are difficult to replicate due to financial constraints. Individual providers can follow recommendations for care noted on Websites listed under "Resources for Clinicians."
Acknowledgment
The author thanks Dr. Dorothea M.G. Wild for her ongoing encouragement and support in writing about this and other topics related to healthcare for adults with special needs.
]
I guess so. I don't look forward to the age fifty. What else will happen? Time will tell I guess.