IDD-MH Prescriber Guidelines

Sensory Considerations for Medication Prescribers

Melanie Hecker, MPA, Karen Weigle, PhD, Alyce Benson, LCSW, and Jeni Yielding, OTR/L

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Sensory sensitivity is a hallmark of many Intellectual and Developmental Disabilities (IDD). Sensory differences impact about 20% of the entire population of people with IDD,1 and can include being over- or under-sensitive to sensory input. Often over-sensitivity can lead to problems with physical exams and the ability to interact with health care providers. This type of sensitivity does not merely cause annoyance or discomfort, but can overwhelm a person, be painful and make the person with IDD unable to function and/or follow requests. If a sensory trigger or strong sensory stimulus is present, a person with IDD may not be able to focus on anything other than the trigger, such as the words you say, your face, gestures, or other things in the environment. Sensory triggers are unique to each individual and patients may have different combinations of triggers. In some cases, exposure to sensory triggers can cause dysregulation, a sure sign that the person is in extreme distress. One patient may be triggered by strong scents and flickering lights, while another may be triggered by high pitch sounds and scratchy clothes.

It is important to ask new patients what their sensory triggers are and how to avoid or mitigate them. Prescribers and office staff should explain or show each and every piece of equipment used and what it is going to do, demonstrating on someone other than the patient (blood pressure cuffs, thermometers, etc.). While these may seem like everyday items to some, they can cause increased stress and sensory arousal for a person with IDD.

The following is a discussion of some common sensory triggers and how to accommodate them. Please note that a patient may have a sensory trigger that is not discussed here.

 

1 Committee to Evaluate the Supplemental Security Income Disability Program for Children with Mental Disorders; Board on the Health of Select Populations; Board on Children, Youth, and Families; Institute of Medicine; Division of Behavioral and Social Sciences and Education; The National Academies of Sciences, Engineering, and Medicine; Boat TF, Wu JT, (Eds). Mental Disorders and Disabilities Among Low-Income Children. Washington (DC): National Academies Press; 2015.

 

Visual

The most common visual sensory triggers involve lighting. Flickering, fluorescent, and strobing lights are all common visual triggers. Most fluorescent lights that bother a person with overreactive visual senses are not seen as bothersome to others, although the flickering is very subtle and recognizable to them. Bright, contrasting colors can also cause visual overstimulation.

Considerations: Avoid fluorescent or strobe lighting in your practice and quickly change any flickering light bulbs. The use of lamps or natural lighting is preferred. Using pastel or pale colors as opposed to bright colors to decorate your office can also help prevent visual triggers. Sometimes a lot of items in the room can cause visual sensory overload; fewer items and wall hangings are more calming. It is also suggested during medical checkups to avoid approaching the person straight from the front, which may be scary, cause anxiety and a fight/flight response. Instead, approach from the side (e.g. for tongue depressor, light in nostril, to palpate the neck, or listen to heart).

Audio

Loud or unexpected noises are the most common sound trigger. High-pitch, low-pitch, or repetitive noises can also be triggering. However, some sound triggers are unique to the individual.

Considerations: Quickly be able to turn off or turn down any music or television you may have playing in your practice. Fluorescent lights also create a low humming noise that can be distracting for many people. Have a quiet, low-sensory space in your practice set aside for patients who may need to leave a common area due to the presence of a sound trigger. You may want to have a few pairs of noise-cancelling headphones (made of material that can be disinfected frequently) that patients may use while in the office.  Also, if a procedure is going to produce a sound (even as common as a blood pressure cuff inflating/deflating), make sure to let them know.

Tactile

There are many common tactile triggers. For many people with IDD, another person’s touch is one such trigger. Other common tactile triggers involve clothing, ranging from scratchy or tight clothes to clothes with seams in them. The feeling of a certain object or material on a person’s hands or skin can also be a tactile trigger (latex, cotton swabs/balls, clay or chalk). Food and medication textures can also be tactile triggers.

Considerations: To accommodate tactile triggers surrounding clothing, have hospital gowns and slippers on-hand that are not scratchy and do not have seams. You may also need to allow the person to leave their clothes on or wear only underclothes without a gown if hospital clothing cannot be tolerated. Also have non-latex gloves available.

Sensory triggers involving being touched by another individual can be difficult to address in a medical setting. Firm touch is usually tolerated better than light touch. Avoid touching a patient with IDD as much as possible, and never touch the person without letting them know. Surprise can result in a startle response.

Considerations: In instances where touch cannot be avoided, briefly distract the patient by talking to them about their interests. Priming techniques can also be used to help the person better tolerate touch. An example is rubbing the arms or legs to “wake up” the sensory system and decrease the startle response to further touch. It is best if the provider directs the patient or their parent/support person (if present) to give themselves 5 firm self-hugs or squeeze clasped hands together 10 times. It is also helpful to tell the patient what you are doing and what to expect so they are not surprised by any procedures and are better prepared for what is to come. Always let the person know you are going to touch them (“I’m going to touch your wrist to count your pulse.” or “I’m going to press around a little on your neck because I need to feel what is there.”)

Taste/Texture

Strong, bitter, sour, and salty tastes can all be sensory triggers. This can pose a problem for prescribers, as medication often has a strong bitter taste. Textures of foods, medications, and even liquids can be disturbing to some people, which again must be considered in the delivery method of prescription medications. Many people have strong gag reflexes to certain textures, which will keep them from being able to swallow.

Considerations: There are a few methods that can help mitigate taste triggers in medication. One approach is to fill the medication with a flavor coating. A prescriber can also recommend taking the medication with a flavored beverage such as fruit juice. Some fruit juices should be avoided with certain medications, so patients should always check with their doctor or pharmacist prior to taking medications with juice.

Taste and texture triggers may also prevent a person with IDD from eating certain foods, which may lead to nutritional issues. If nutrition becomes a problem for a patient with sensory triggers, it is important to work with them on a diet plan that allows them to obtain the nutrients they need while also avoiding foods that trigger them. 

Considerations: The prescriber may make a referral to an occupational therapist, dietician or nutritionist in the event of nutrition issues. One strategy these providers often use is called priming of the face/oral area. Massaging the masseter (chewing muscle) on the jaw area of the face and firmly clamping teeth together 10 times will often decrease an overreactive gag.

 

Table 1. Sensory Considerations for Medication Prescribers

 

Triggers

Considerations

VISUAL

  • Flickering, fluorescent and strobing lights (even very subtle)
  • Bright, contrasting colors
  • Too many “things”
  • Straight on physical approach
  • Avoid fluorescent or strobe lighting in your practice, use lamps or natural lighting as much as possible
  • Change flickering light bulbs as soon as possible
  • Use pastel or pale colors as opposed to bright colors to decorate office spaces
  • Reduce clutter/over-decorating - fewer items and wall hangings are more calming
  • Approach patients from the side (for tongue depressor, or light in nostril, to palpate the neck)

 

AUDIO

  • Loud or unexpected noises are the most common sound trigger
  • High-pitch, low-pitch, or repetitive noises can also be triggering
  • Some sound triggers are unique to the individual
  • Ensure that staff can quickly turn off /turn down music or television in waiting room
  • Avoid fluorescent lighting – these lights also create a low humming noise that can be distracting
  • Have a quiet, low sensory space in your practice set aside for patients who may need to leave an area due to the presence of a sound trigger.
  • Have a few pairs of noise-cancelling headphones available (made of material that can be disinfected frequently)
  • If a procedure is going to produce a sound (even as common as a blood pressure cuff inflating/deflating), let your patient know beforehand

SCENT

  • Strong scents
  • Specific scents (examples: air fresheners, perfumes, ammonia, alcohol, smoke and garbage
  • Make your practice as scent/fragrance free from strong scents as possible (discourage the use of perfumes and colognes, take out garbage promptly (nausea and irritability are strong lasting responses, there is a very strong limbic stress response with aversive odors/scents, and one cannot block this out on his own)

 

TACTILE

  • Human touch – being touched in general, touched without warning, pressure (light vs firm touch)
  • Clothing – fabric type, tightness, tags, seams
  • Textures of certain objects (cotton balls, latex, chalk)
  • Food and medication texture
  • Keep a supply of hospital gowns and slippers that are not scratchy and do not have seams.
  • You may also need to allow the person to leave their clothes on or wear only underclothes without a gown if hospital clothing cannot be tolerated.
  • Have non-latex gloves available.
  • When touch cannot be avoided, a prescriber can briefly distract a patient by talking to them about their interests. “Priming” techniques can also be used to help the person better tolerate touch (rubbing arms or legs to “wake up” the sensory system and decrease the startle response to further touch).

TASTE

  • Strong, bitter, sour, and salty tastes may impact medication administration as well as food eaten in regular diet
  • Fill medications with a flavor coating.
  • Recommend taking the medication with a flavored beverage such as fruit juice.
  • in the event of nutrition issues, make a referral to an occupational therapist, dietician or nutritionist