Journal of Intellectual Disability Research

30
    pp –  

Cause-specific mortality of people with intellectual

disability in a population-based, 35-year follow-up study
K. Patja,1 P. Mölsä2 & M. Iivanainen1
1 Department of Child Neurology, Hospital of Children and Adolescents, University of Helsinki, Helsinki, Finland
2 Special Welfare District of South-western Finland, Naskarla, Finland

Abstract the general population. The disparities in the cause-

The aim of the present study was to investigate
cause-specific mortality in people with intellectual
disability (ID). It was based on a -year follow-up
study of a nation-wide population of  subjects
aged between  and  years. The  deceased
people had accumulated   person-years. The
research took the form of a prospective cohort
study with mortality follow-up. Observed and
expected deaths were calculated as standardized
mortality ratios using the Finnish general popula-
tion as the reference. Cause-specific mortality ratios
were calculated by the level of ID, sex and age. The
three most common causes of death were cardio-
vascular diseases, respiratory diseases and neo-
plasms. Disease mortality was high up to  years
of age, but did not increase thereafter. The differ-
ence between sexes in cause-specific mortality
was smaller than in the general population. Cause-
specific mortality differed significantly from the
general population, with reduced mortality from
neoplasms and external causes, but ageing individu-
als with mild ID had similar mortality patterns to
Correspondence: Kristiina Patja MD, Department of Child Neu-
rology, Hospital of Children and Adolescents, PO Box , 
HYKS, Helsinki, Finland (e-mail: kristiina.patja@huch.fi).
©  Blackwell Science Ltd
specific mortality between younger people with ID
and the general population fade with advancing
age, producing similar health risks. In preventative
work, special attention should focus on common
diseases and accidents in the community.
Keywords cause-specific mortality, intellectual dis-
ability, mental retardation, mortality
Introduction
An excess mortality of individuals with intellectual
disability (ID) has repeatedly been shown in com-
parison with the general population (Forssman &
Åkesson ; Carter & Jancar ; Dupont et al.
). However, relative and absolute mortality
rates have varied considerably, partly as a result
of factors related to patient selection. In many
studies, the subjects were drawn from institutional
care or service registers (Eyman et al. ;
McGuigan et al. ). There have been some
cohort studies with small numbers of deaths, but
there have been no studies reporting mortality
trends in population-based samples (Rantakallio &
von Wendt ).
Previous investigators reported excess mortality
in several categories such as respiratory diseases
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K. Patja et al. • Cause-specific mortality
(Chaney et al. ; Eyman et al. ; Strauss
et al. ) and fatal intestinal obstructions (Jancar
& Speller ), and decreased mortality in cancer
(Raitasuo et al. ). Intellectual disability is often
associated with epilepsy and cerebral palsy, as well
as other neurological disorders and additional ill-
nesses. The living environments of people with ID
differ from the general population, but these have
been integrated over recent decades, a development
that has influenced cause-specific mortality. Life
expectancy has increased in line with the general
population (Walz et al. ), creating a new
ageing population with ID, whose impact on cause-
specific mortality in this group is now becoming
manifest.
The particular aims of the present study were to
determine the cause-specific mortality of males and
females with ID by age and at all levels of ID in
comparison with the general population, and to
identify the most important causes. The authors set
out to provide the first cause-specific risk ratios for
adults with ID.
Methods
Population
The study group was comprised of individuals
included in a large, population-based study in
Finland (population =  million) in . This was
a nation-wide, cross-sectional, multidisciplinary
study undertaken to investigate the number of
people with ID and their needs for services. The
study population of   persons (.% of the
population) lived in  municipalities, which repre-
sented Finland’s prevailing socio-economic struc-
ture (Amnell et al. ).
In , municipal officials were asked to report
all individuals suspected or known to have ID and
the National Board of Health organized examina-
tions of these people. The municipalities reported
 individuals aged between  and  years, 
of whom were examined and  found to have
ID. In addition,  persons were diagnosed with ID
by case records only. The prevalence of ID in the
study was .%. In , the definition of IQ level
included five classes: normal intelligence, limited
intelligence, and mild, moderate and profound ID
(WHO ). In the present study, IQ levels were
©  Blackwell Science Ltd, Journal of Intellectual Disability Research , –
     
divided into six classes: normal intelligence, limited
intelligence, and mild, moderate, severe and pro-
found ID (WHO ).
All people with ID who were identified in 
and were alive on  January  formed the
present study population (n = ). The follow-up
period consisted of the subsequent  years until 
December . Out of those individuals examined
with ID, % were identified in the records .
There were  deaths (Table ), for which 
death certificates (n = ) were obtained from
Statistics Finland, and then reviewed and coded.
Classification of death and inquest practices have
remained the same throughout this period. Infor-
mation on the cause of death was restricted to the
primary cause of death, which was the disorder,
disability or cause initiating the set of diseases
leading to the immediate cause of death, and to the
immediate cause of death, which was the disease,
defect or disability according to signs of which the
patient had died. Other conditions mentioned in
the death certificate were included in the original
data set as contributing causes of death. All these
causes of death were classified into  categories
according to the ninth revision of the International
Classification of Diseases, Injuries and Causes of Death
(ICD-; WHO ).
Statistical analysis
A total of   person-years was calculated for
the  men and women of the study population.
Individuals were classified by sex, quinquinneum of
their birth (e.g. – and –), IQ and
aetiology of ID. An indicator of relative mortality
differences was obtained by calculating the age-
adjusted relative mortality rates of people with ID
compared with the general population. The present
authors also calculated the absolute differences
between the age-standardized death rates. The age-
standardized cause-specific death rates were needed
to calculate the absolute mortality differences, and
the share of each cause of death in the total excess
mortality of persons with ID was derived by indi-
rect age standardization using -year age groups. In
order to compare the mortality of different diseases,
Cox’s proportional hazard models were used to
quantify the differences between groups (Cox )
using the SPSS . software package.
 Journal of Intellectual Disability Research      
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K. Patja et al. • Cause-specific mortality

Table 1 Distribution of the study population at time of death by age, sex and level of intellectual disability (ID)

Level of ID

Unknown Profound Severe Moderate Mild

Age
group
(years) Men Women Men Women Men Women Men Women Men Women Total

2–9 – – 4 3 – 1 – 1 – 1 10
10–19 – – 17 6 1 3 4 2 5 2 40
20–29 – – 19 10 3 6 10 7 11 7 73
30–39 – – 18 18 5 6 6 10 15 6 84
40–49 – 1 18 14 7 7 8 18 24 21 118
50–59 – – 15 11 19 13 23 35 38 37 191
60–69 2 2 19 14 7 16 37 54 68 56 275
70–79 1 2 6 3 11 14 29 48 57 57 228
>80 – – 1 4 5 4 12 23 19 24 92
Total 3 5 117 83 58 70 129 198 237 211 1111

Study approval
The present study was approved by the Ministry of
Social Affairs and Health, and the Ministry of Edu-
cation. The Data Protection Ombudsman approved
the data protection and linking the original material
with national databases.
relative disease mortality excess was larger for men
than women, but not thereafter. Men with ID were
at the highest risk of dying of disease in their first
 decades (Table ), but at the same time, their risk
of accident was only one tenth that of the general
population (Table ). Ageing increased the accident
risk for both sexes, particularly for women
(Table ).

Results
There was a wide distribution in age at time of
death (Table ) and causes of death (Table ). The
mean follow-up time until death was . years
(SD = .). The mean age of women and men at
death was . and . years, respectively. Overall,
mean age at death was . years for mild ID,
. years for moderate ID, . for severe ID and
. years for profound ID.
Mortality from all causes of death
Excess mortality was observed in several categories:
respiratory diseases, digestive diseases and infec-
tious diseases, but it was cut down by ageing
(Table ). There was excess disease mortality of
people with ID <  years of age compared with
the general population, but not in later years
(Table ). In age groups younger than  years, the
Cause-specific mortality
Although vascular diseases formed the largest group
of primary causes of death – a total of one-third
(Table ) – these were less common than in the
sex- and age-matched general population. The rela-
tive risk was lower for men in all groups and for
most women except those with mild or moderate
ID aged between  and  years. In the younger
age group, congestive heart failure, aortic aneurysm
and cardiomyopathy were the most common causes
of cardiac death, and were often associated with
malformations like Down’s syndrome and congeni-
tal malformations. Among the vascular diseases,
acute cardiac infarct was the cause of death in %
of cases, cerebral infarct or bleeding in %, con-
genital heart disease in % and pulmonary infarct
in % of cases. Mean age at death as a result of
cardiovascular diseases was . years.

©  Blackwell Science Ltd, Journal of Intellectual Disability Research , –
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K. Patja et al. • Cause-specific mortality

Table 2 Distribution of all causes of death (i.e. primary, immediate and contributing) in the study population (n = )

Cause of death

Primary Immediate Contributing

Main class of disease ICD-9 code n % n % n %

(I) Infectious 001–139 31 3 35 3 26 3

(II) Tumours 140 –239 124 11 102 9 22 3
(III) Endocrinological 240 –279 21 2 8 1 25 3
(IV) Haematological 280–289 1 0 1 0 6 1
(V) Disturbances of mental health 290–319 24 2 4 0 262 30
(VI) Nervous system 320–389 39 4 25 2 164 19
(VII) Vascular 390 –459 398 36 402 37 170 19
(VIII) Respiratory 460 –519 241 22 322 29 46 5
(IX) Digestive system 520–579 77 7 76 7 23 3
(X) Urogenital diseases 580–629 25 2 27 2 33 4
(XI) Gravidity. childbirth and puerperium 630–676 1 0 1 0 – –
(XII) Skin 680–709 1 0 3 0 – –
(XIII) Musculosceletal 710–739 1 0 – 0 11 1
(XIV) Congenital malformations 740–759 21 2 6 0 59 7
(XV) Perinatal 760–779 – 0 – 0 3 0
(XVI) Other symptoms 780–799 10 1 12 1 12 1
(XVII) Accidents and poisonings 800–999 80 7 69 6 17 2
Total – 1095 100 1093 100 879 100

Table 3 Risk of death from disease among people with intellectual disability (ID) by level of ID and age (adjusted risk ratios; . = similar
risk as the general population)

Age group (years)

2–19 20–39 40–59 ≥ 60

Level of ID Men Women Men Women Men Women Men Women

Mild 2.6 1.9 1.6 1.2 1.0 1.1 1.0 1.0

Moderate 1.0 1.0 2.3 1.5 1.1 1.1 1.0 1.0
Severe 2.8 1.8 2.6 1.6 1.2 1.0 1.0 1.0
Profound 3.3 1.9 2.1 1.3 1.1 1.2 1.0 1.0
All 2.6 1.7 2.2 1.4 1.0 1.1 1.0 1.0

Respiratory diseases were the second largest % had profound ID, % severe ID, % moder-
group (Table ). Pneumonia was the primary cause ate ID and % mild ID. Eleven people died of
of death in % and chronic obstructive pulmonary lung tuberculosis during the study period. The risk
disease (COPD) in %. Out of pneumonia deaths, ratio of respiratory diseases for persons with mild
©  Blackwell Science Ltd, Journal of Intellectual Disability Research , –
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K. Patja et al. • Cause-specific mortality

Table 4 Risk of accidental death among people with intellectual disability (ID) by level of ID and age (adjusted risk ratios; . = similar risk
as the general population)

Age group (years)

2–19 20–39 40–59 ≥ 60

Level of ID Men Women Men Women Men Women Men Women

Mild 0.0 0.0 0.5 0.9 1.1 0.6 1.4 2.2

Moderate 1.2 1.3 0.4 0.7 1.1 1.1 0.4 2.1
Severe 0.0 0.0 0.4 0.5 0.8 0.0 0.0 1.2
Profound 0.0 0.0 0.1 0.0 0.3 2.5 2.3 0.0
All 0.1 0.1 0.3 0.4 1.1 1.0 1.1 1.9

ID was . times higher, and for persons with pro-
found ID, it was . times higher than in the
general population. Overall, men were at higher risk
than women in younger age groups (<  years),
but at lower risk from  years of age onwards
(Table ). The mean age at death from respiratory
diseases was . years.
Cancer was the third largest group, but the rela-
tive risk of cancer was significantly lower at all
levels of ID and in all age groups (Tables  & ).
Out of all neoplasms, % were digestive, % res-
piratory and % urogenital. Out of all causes of
death, cancer accounted for % of deaths in sub-
jects with profound ID, % in moderate ID and
% in subjects with mild ID. The mean age at
death was . years. A detailed analysis of neo-
plasm prevalence and incidence is in preparation.
Diseases of the digestive system as a primary
cause of death were . times more common than
in the general population and associated with pro-
found ID and male sex (Tables  & ). Intestinal
obstruction was the primary cause of death in 
(%) cases, out of which  had profound ID, and
ulceric perforation in  (%) cases, mostly indi-
viduals with mild ID. The mean age at death was
. years, but only . years for people with pro-
found ID.
There were  neurological causes of death, out
of which the most common were epileptic seizures
(n = ) and dementia (n = ). People who died of
neurological disease were younger (mean
age = . years) than in other disease groups at all
levels of ID. The mean age at death from epilepsy
was . years and there was no significant varia-
tion by levels or sex.
Eighty people (.%) died in accidental or
violent circumstances; there was no difference in
frequency between men and women. The risk of
accident was lower for those <  years than in
the general population, even when occupational
and traffic accidents were considered (Table ).
Among the elderly, women had an increased
risk of fatal fracture compared to the general popu-
lation, while men’s increased risk of external cause
of death was caused by the higher suicide rate.
Overall, there were three homicides, seven unsolved
causes,  suicides and  accidents. Out of the
latter group, .% of accidents occurred at home,
.% in a residential home, .% in a mental
hospital and .% of accidents in an institution for
cases with ID; the place of residence was not men-
tioned in .% of cases. For accidents, the level of
ID was profound in .% of cases, moderate in
.% and mild in .% of cases. Moderate ID
and age >  years were significant risk factors
(P < . in logistic regression), as
were community settings and mental hospitals.
Fatal fractures were the most common primary
cause of death (n = ), and were caused either
by falling or being hit by a car. Drowning in a lake
was a second common cause, while intoxication and
burns were rare.

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K. Patja et al. • Cause-specific mortality

Table 5 Observed and expected deaths of men with intellectual disability with age-standardized relative mortality compared with the general
population aged from  to  years (. = similar risk as the general population)

Confidence
intervals
Age
group
(years) Cause of death Observed Expected Relative risk Lower Upper

2–19 Infectious diseases 3 1.6 1.8 0.0 11.1

Tumours 0 8.2 0.0 0.0 0.1
Vascular diseases 4 3.9 1.0 0.0 6.6
Respiratory diseases 14 2.4 5.8 4.4 15.6
Diseases of digestive system 2 0.8 2.4 0.0 4.4
Accidents and poisonings 2 16.9 0.1 0.0 0.6
Other causes 5 11.0 0.5 0.0 1.4
20–39 Infectious diseases 3 1.2 2.5 0.0 4.7
Tumours 4 15.9 0.3 0.0 0.4
Vascular diseases 15 20.7 0.7 0.5 1.8
Respiratory diseases 19 3.5 5.4 2.9 8.0
Diseases of digestive system 8 1.8 4.3 1.0 7.2
Accidents and poisonings 14 52.4 0.3 0.2 0.8
Other causes 22 27.0 0.8 0.6 1.6
40–59 Infectious diseases 4 1.8 2.2 0.0 4.1
Tumours 17 30.1 0.6 0.1 0.4
Vascular diseases 54 73.6 0.7 0.6 1.4
Respiratory diseases 32 5.8 5.5 3.5 7.5
Diseases of digestive system 9 2.7 3.3 0.7 4.0
Accidents and poisonings 17 28.5 0.6 0.4 1.3
Other causes 18 19.9 0.9 0.5 1.4
≥60 Infectious diseases 4 2.3 1.7 0.0 2.9
Tumours 39 64.7 0.6 0.4 0.7
Vascular diseases 110 144.2 0.8 0.5 0.8
Respiratory diseases 63 23.5 2.7 2.8 4.7
Diseases of digestive system 18 5.6 3.2 1.0 2.9
Accidents and poisonings 13 12.3 1.1 0.5 2.0
Other causes 23 16.7 1.4 0.4 1.0

Immediate causes of death and
contributing factors
The circulatory diseases were the dominant cause
of immediate death, followed by pneumonia. There
were  cases of pneumonia caused by a foreign
body and  instances of aspiratory pneumonia.
Psychiatric disorders were most frequently men-
tioned as a contributing disease (one-quarter of all
death certificates; Table ). Neurological diseases
were registered in % of deaths and cardiac dis-
eases equally often (Table ). Intellectual disability
was the most common cause and was mentioned in
.% of death certificates. Epilepsy contributed to
death in  cases (.%).
Obduction rate and coding of causes of death
Obduction was performed in % of cases. The
annual obduction rate varied greatly from % to
%, with an increase in the s. There was no
difference between the pattern of ID in obducted
and non-obducted people. Men were more often
obducted than women and obducted people were

©  Blackwell Science Ltd, Journal of Intellectual Disability Research , –
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K. Patja et al. • Cause-specific mortality

Table 6 Observed and expected deaths of women with intellectual disability with age-standardized relative mortality compared with the
general population aged from  to  years (. = similar risk as the general population)

Confidence
intervals
Age
group
(years) Cause of death Observed Expected Relative risk Lower Upper

2–19 Infectious diseases 2 0.6 3.2 0.0 3.2

Tumours 0 6.7 0.0 0.0 0.1
Vascular diseases 0 1.3 0.0 0.0 0.1
Respiratory diseases 6 1.4 4.3 0.3 4.7
Diseases of digestive system 1 1.2 0.8 0.0 4.1
Accidents and poisonings 1 8.3 0.1 0.0 0.2
Other causes 9 6.8 1.3 0.2 1.4
20–39 Infectious diseases 6 1.5 4.1 0.6 9.5
Tumours 2 22.4 0.1 0.0 0.3
Vascular diseases 15 12.8 1.2 0.3 1.1
Respiratory diseases 11 3.5 3.2 1.1 5.1
Diseases of digestive system 6 1.9 3.1 0.4 6.1
Accidents and poisonings 8 27.1 0.3 0.0 0.3
Other causes 22 19.8 1.1 0.5 1.2
40–59 Infectious diseases 3 2.0 1.5 0.0 3.8
Tumours 17 64.3 0.3 0.3 0.8
Vascular diseases 49 48.4 1.0 0.5 1.3
Respiratory diseases 36 5.8 6.2 4.1 8.2
Diseases of digestive system 12 3.8 3.1 1.7 7.1
Accidents and poisonings 10 19.5 0.5 0.1 0.6
Other causes 30 19.5 1.5 0.9 2.1
≥60 Infectious diseases 6 2.9 2.1 0.3 4.9
Tumours 43 71.3 0.6 0.5 0.9
Vascular diseases 150 168.3 0.9 10.8 1.2
Respiratory diseases 55 16.8 3.3 1.7 3.0
Diseases of digestive system 20 9.4 2.1 1.9 5.2
Accidents and poisonings 16 10.2 1.6 0.6 2.0
Other causes 26 31.3 0.8 10.5 2.2

younger. Cases with an external cause were all
obducted. In addition, congenital disorders, gas-
trointestinal causes and neoplasms had higher
obduction rates than other categories.
There was occasional inaccuracy in coding the
primary cause of death. The ID was coded as a
primary cause of death in  cases and psychiatric
disease in  cases (none in suicide), despite the
fact that ID, for example, is a manifestation of neu-
rological disorder rather than an independent
cause. On the other hand, epilepsy was coded as a
contributing factor in cases where the cause of
death was primarily epilepsy, such as falling or suf-
focating during the seizure.
Discussion
Finland was a stable welfare state during the
follow-up period, although there were many
changes in the care of people with ID. The s
saw the establishment of a nation-wide system of
health and social services with regional governance
and large institutions. The concept of normalization

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37
K. Patja et al. • Cause-specific mortality

Table 7 Observed and expected deaths from respiratory diseases of persons with intellectual disability with age-standardized relative mor-
tality compared with the general population aged from  to  years (. = similar risk with the general population)

Men Women
Age
group
(years) Level of ID Observed Expected Risk ratio Observed Expected Risk ratio

2–19 Mild 1 0.3 3.6 0 0.1 0.0

Moderate 0 0.0 0.0 1 0.1 10.0
Severe 1 0.1 11.1 1 0.4 2.6
Profound 12 2.0 5.9 4 0.8 5.1
20–39 Mild 2 0.8 2.4 2 0.6 3.2
Moderate 2 0.7 2.9 1 1.0 1.0
Severe 1 0.3 3.8 2 0.4 4.9
Profound 14 1.7 8.1 6 1.5 4.0
40–59 Mild 5 2.3 2.2 10 2.1 4.7
Moderate 12 1.2 9.9 14 2.0 6.9
Severe 7 1.0 7.1 5 0.8 6.2
Profound 8 1.3 6.0 7 0.8 8.4
≥60 Mild 33 12.4 2.6 16 7.1 2.2
Moderate 19 6.8 2.8 24 6.8 3.5
Severe 4 2.2 1.8 9 1.6 5.4
Profound 6 1.8 3.4 6 1.0 5.6

was set as a goal for the welfare service system
(Wolfensberger ), and from the s onwards,
the institutional population has declined rapidly.
The health care constitution renewed in 
emphasizes that discrimination on the basis of
illness or disability is forbidden at all levels of
society, which diversified the supply of services in
the community, in spite of the severe economic
depression suffered at the beginning of the s.
These changes have undoubtedly had an effect on
the mortality figures, which can be seen as one
outcome measure of the service system (Härö
).
The present study is the largest nation-wide,
population-based sample of people with ID with a
high rate of retention of subjects. The prevalence of
ID in the  study was comparable to later
studies (Balakrishnan & Wolf ; Slavica et al.
). The lengthy follow-up period, using accurate
and extensive statistics, increased the reliability of
the present study. There was comprehensive data
available on individuals after , permitting reli-
able ID classification and coding of background
variables such as associated disorders. This sample
was limited to those aged – years at the outset,
prohibiting the calculation of risk for children
under  years. The number of deaths was relatively
large, enabling the calculation of cause-specific
risks for all levels of ID as well as an analysis of
risk factors. Since the study was population
based, and the distribution of sex and age was
controlled during the analysis, the major differences
in cause-specific mortality patterns compared to the
general population cannot be explained by the
sample.
The three most common diseases primarily
causing death in both sexes of this population were,
in order, cardiac diseases, respiratory diseases and
neoplasms. In the general population, the major
killers of women and men were cardiac diseases,
neoplasms, and respiratory diseases for women and
external causes for men (Statistics in Finland ).
Interestingly, the overall tumour prevalence in the
study cohort was only half of that in the general
population (Statistics in Finland ) and this
finding calls for further investigation. The popula-
tion with ID is predisposed to different physiologi-
cal and environmental risks, which produce

©  Blackwell Science Ltd, Journal of Intellectual Disability Research , –
 Journal of Intellectual Disability Research
38
K. Patja et al. • Cause-specific mortality
disparities in mortality patterns leading to different
life expectancy and sex distribution (Patja et al.
a).
The degree of ID had a clear influence on the
risk of dying from a certain disease. As the degree
of ID progressed from profound to mild, the
disease mortality profile moved toward that of the
general population, yet some contrast persisted. The
fact that the relative risk of death caused by disease
was high until  reveals the physiological fragility
of the child and adolescent population with severe
or profound ID, and leads to the assumption of a
healthy survivor effect in the older age groups.
Interestingly, the sex difference in mortality rates
was less than in the general population, but the
men’s risk was higher than women’s than women
until adulthood.
The proportion of cardiac diseases was higher
than previously reported (Eyman et al. ;
Raitasuo et al. ). Because cardiac diseases are
common in Finland, these may be favoured in
medico-legal examinations, but the different study
population with more mildly disabled people may
also increase the number of cardiac diseases. Inter-
estingly, there was a lower occurrence of cardiac
diseases in adult age groups of both sexes com-
pared to the general population, suggesting the
different impact of both protective factors as non-
smoking and low blood pressure (van Schrojenstein
Lantman-de Valk et al. ), and predisposing
factors such as obesity (Rimmer et al. ). On
the other hand, children and adolescents with ID
have more congenital heart malformations than
normal children (Grech & Gatt ), leading to
higher mortality, although this was of lower magni-
tude in the present study than in previous reports
(Similä et al. ).
The excess of respiratory mortality, mainly
caused by pneumonia, was expectedly high and
linked with high levels of ID (Chaney et al. ).
As the risk was at least three-fold throughout life in
both sexes, ID encompasses a greater risk of respi-
ratory death than mere neurological damage, and as
in the general population, respiratory diseases accu-
mulate in old age. Gastro-oesophageal diseases
(Kuruvilla & Trewby ), dysmorphias of the oral
cavity (Gabre et al. ) and immunological
deficits (Ugazio et al. ) more commonly predis-
pose to respiratory diseases in this population.
©  Blackwell Science Ltd, Journal of Intellectual Disability Research , –
     
Tuberculosis did occur, but only in early years,
reflecting the end of tuberculosis era in the s.
Chronic obstructive pulmonary disease is connected
with smoking and occupational exposures, and
although the diagnosis of COPD has developed
rather recently, its low presence here is also
explained by lower exposure to the known risk
factors (van Schrojenstein Lantman-de Valk et al.
).
Individuals with ID suffer more than others from
constipation (Van Winckel et al. ) and chronic
regurgitation (Rogers et al. ), which increase
the risk of intestinal obstruction and peptic ulcer,
respectively. This was verified in the present study
at rates comparable to previous studies (Jancar &
Speller ). Why men in the present study were
more vulnerable to digestive diseases than women,
contrary to previous findings, remains unanswered
(Jancar & Speller ). Medication for peptic
ulcers was not in common use until the last decade
of the follow-up period, which suggests a decline in
peptic ulcers.
Accidents and other violent causes were responsi-
ble for less deaths than in the general population.
Moreover, the difference between the sexes found
in the general population (.% males versus .%
females) was not present (Statistics in Finland
). Adult males without ID often die in acci-
dents and other violent circumstances, and the
resulting difference in the mortality pattern leads to
better survival of adult males with ID (Patja et al.
a). Furthermore, the suicide rate of Finnish
men with ID is only one-third of the rate in the
general male population (Patja et al. b).
Domestic settings cause exposure to more and
greater varieties of accidents than institutional care.
People with mild and moderate ID live more often
in community, and so the level of ID also tends to
increase vulnerability. Older people are more likely
to suffer from visual impairments caused by age
(van Schrojenstein Lantman-de Valk et al. ),
predisposing to accidents. Since accidents are
avoidable in most cases, special attention should
be paid to the safety of community surroundings
and to sensory impairments which compromise
mobility.
Cause-specific mortality offers baseline informa-
tion for health promotion and preventative work.
The alarming increase in the risk of death in com-
 Journal of Intellectual Disability Research
39
K. Patja et al. • Cause-specific mortality
munity settings compared to institutions found in
some studies (Strauss & Kastner ) is more a
reflection of the normalization of cause specific
risks resulting from external causes – and lack of
prevention – than of community settings as an
independent risk factor. As people with ID move
from institutions into the community, they are
exposed to the similar environmental risks to the
general population, including shortage of health
care resources. If we intend to decrease the avoid-
able mortality in this group, then we need to focus
specially on accident risks, on preventing infections
and cardiac diseases, and on health promotion in
the community. At least in Finland, where health
care is unlikely to receive additional funding and
work loads are expanding rapidly, we are forced to
choose. Fortunately, preventative work is seen to be
profitable, and we need to include people with ID
and their unique needs in this process.
Acknowledgements
This study was supported by the Ministry of Social
Welfare and Health, the Juho Vainio Foundation,
the Finnish Paediatric Foundation, and the
Rinnekoti Foundation.
The authors would like to give special thanks to
Hanna Oksanen PhD for statistical guidance.
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