Transitions for older people with intellectual disabilities and behaviours that challenge others: A rapid scoping review

Abstract Background People with intellectual disabilities and behaviours that challenge others are living longer. This review aimed to explore what is known about the health and social care needs, experiences, service interventions and resources of and for this population as they transition to different care contexts in the UK. Method A rapid scoping review of published and unpublished literature was conducted based on collaborative working with key stakeholders and using systematic methods of data searching, extraction and analysis. Results Consistent social work support, skilled staff, suitable accommodation, creative engagement with individuals and families to plan ahead, and timely access to quality healthcare are all required to promote successful transitions as people age, and to avoid unwanted/inappropriate transitions at points of crisis. Conclusions More research is needed to assess the types of services that this population can and do access as they age, the quality of those services, and the extent to which local commissioners are planning ahead for people with intellectual disabilities and behaviours that challenge others.


| Background and rationale
Over 1 million adults with intellectual disabilities live in the United Kingdom (UK), representing over 2% of the total adult population (Mencap, 2021). In line with an overall UK ageing population (Office of National Statistics (ONS), 2021) people with intellectual disabilities are living longer. In England, an estimated 53% of the total population of people with intellectual disabilities were aged 45+ in 2020 (with almost 5% aged 85+), predicted to rise to 56% by 2040 (and 7.5% aged 85+) (Institute of Public Care (IPC), 2020).
Increased longevity is heavily implicated in the predicted rise of 30% in people with intellectual disabilities aged 50+ requiring social care services in England over the period 2012-2030 (Emerson et al., 2012). In Wales, in 2020/21, 9% of all people with intellectual disabilities registered (1231 people) were aged 65+, an increase of 54% from 2001/02, with 18% of people aged 65+ (222 people) living with their parents or other family members (StatsWales, 2022).
Data from the 2011 census showed that 37% of people with intellectual disabilities in Scotland were aged 45+ (9619 people), with 3% aged 75+ (Scottish Learning Disabilities Observatory, n.d.). The 2011 census also reported that 24% of people in Northern Ireland with intellectual disabilities were aged 45+ (9049 people), with 8% aged 65+ (Learning Disability Data and Northern Ireland Consortium, 2020).
Although the means by which the above estimates are calculated vary, using different ways to count people and at different points in time, the numbers highlight that the needs of older people with intellectual disabilities across the UK four nations (England, Wales, Scotland and Northern Ireland) require attention from policy-makers, commissioners and service providers. In addition, they are likely to underestimate the true levels of need, as many people with intellectual disabilities are not known to health or social services (Public Health England (PHE), 2016a; National Institute for Health and Care Excellence (NICE), 2018a) and the known proportion falls as people age (Emerson et al., 2012).
UK based studies have for some years found that older people with intellectual disabilities experience more health-related problems than the general population, with these issues often occurring at a younger age (De Winter et al., 2014;De Winter et al., 2016;Robertson et al., 2015;Strydom et al., 2013), including onset of conditions such as dementia (Ballard et al., 2016). A growing body of international evidence, such as the large-scale longitudinal studies IDS-TILDA in Ireland, the Healthy Ageing and Intellectual Disabilities Study in the Netherlands, and SAge-ID in Australia (de Leeuw et al., 2022;McGlinchey et al., 2019;Reppermund & Trollor, 2016) mirrors the UK experience, giving rise to discussions around 'premature ageing' (Haveman et al., 2011;Schoufor et al., 2013).
Older people with intellectual disabilities also face additional challenges associated with their circumstances of care and support. In the UK these include: family carers (typically parents) becoming unable to continue to provide care (Cairns et al., 2013;Carers Trust, 2020;Pryce et al., 2017); lack of future planning (Brennan et al., 2020;Lee & Burke, 2020;Walker & Hutchinson, 2018); and, limitations in the availability of appropriate community residential accommodation (NICE, 2018a;Taggart & Hanna-Trainor, 2017;Turner & Bernard, 2014).
Similar challenges have been identified in other national contexts, as social care staff working in supported accommodation are tasked with providing care to a growing population of older people with intellectual disabilities and complex healthcare needs (Alftberg et al., 2021;Northway et al., 2017). Lack of appropriate accommodation and insufficient numbers of suitably trained staff, particularly in the context of responding to the changing needs of people with intellectual disabilities as they age (e.g., with the onset of age related conditions like dementia; onset of frailty; the requirement for home adaptations and introduction of new equipment like hoists etc.), have been identified as two key factors working against government policies that promote the concept of 'ageing in place' (Brennan et al., 2020;Northway et al., 2017).
Some people with intellectual disabilities are known to display behaviours that challenge others. These behaviours may be a form of communication or produce sensory stimulation for the person (The Challenging Behaviour Foundation, 2021). Within the context of this article we use the phrase 'behaviours that challenge others' as a means of acknowledging their inherently relational and socially constructed nature (Mansell, 2007). As such, they are a product of: environmental factors (such as: the response of professional carers; the quality of the material environment; how well a service is organised; the quality of commissioning processes) and individual characteristics (such as: the presence of sensory disabilities or mental health issues; the onset of new conditions like dementia; events in a person's life history) (Mansell, 2007;Norfolk Safeguarding Adults Board, 2021). While policy and guidance across the UK since the 1990 s has stressed the socially constructed nature of 'challenging behaviour', it is clear that in some contexts the term continues to be used to label people (Mansell, 2007;Royal College of Psychiatrists, 2016). Such use can be driven by a need to serve agendas other than improving a person's care or outcomes, such as to enhance the legitimacy of a service, to justify service practices or to empower management decisions (Haydon-Laurelut & Nunkoosing, 2016).
Internationally, it is estimated that up to 20% of adults with intellectual disabilities display behaviours that challenge others (Bowring et al., 2019;Bowring et al., 2017;Jones et al., 2008;Lundqvist, 2013). For some, the behaviour is consistently displayed over long periods; for others it is more sporadic, depending upon their personal circumstances and on how well services meet their needs over time (Mansell, 2007).
People with intellectual disabilities who present a challenge to others comprise a very diverse group, including those with mild intellectual disabilities who have been diagnosed as mentally ill, those who enter the criminal justice system for crimes such as arson or sexual offences, or those with severe or profound intellectual disabilities who injure themselves (Mansell, 2007;NICE, 2018a). There is limited evidence concerning the epidemiology of behaviours that challenge others amongst older people with intellectual disabilities (Davies & Oliver, 2013). Although some studies indicate a decline in these behaviours with advancing age (Holden & Gitlesen, 2006;Jones et al., 2008;Murphy et al., 2005), others have found their persistence as people get older (Lundqvist, 2013;O'Dwyer et al., 2018;Taylor et al., 2011;Totsika et al., 2008).
Research suggests that behaviours that challenge others may prompt the need for older people with intellectual disabilities to move to new homes. A substantial body of evidence shows that these transitions frequently occur in unplanned and/or crisis circumstances. This evidence relates to people with intellectual disabilities living in the family home (Grey et al., 2020: McCausland et al., 2021Nankervis et al., 2011;Ryan et al., 2014;Taggart et al., 2012) and in community residential accommodation, with people with intellectual disabilities and behaviours that challenge others at particular risk of community placement breakdown (Bigby et al., 2011;Broadhurst & Mansell, 2007;Philips & Rose, 2010). In the UK, two-thirds of adults with intellectual disabilities live with their families, typically parents (NICE, 2018b). Older people with intellectual disabilities and behaviours that challenge others are likely to face particular difficulties and stresses. The death of a family member, particularly the main caregiver, can trigger complicated grieving and the need for crisis intervention (Dodd et al., 2005;MacHale & Carey, 2002), in part because parental loss is often accompanied by further losses, including the loss of home (Karavella, 2013). That many older people with intellectual disabilities remain unknown to services is likely to further exacerbate the crisis nature of transition from the family home (NICE, 2018b). To address this evidence-gap, we reviewed the literature on transition-related health and social care experiences, service interventions and resources relevant to older people with intellectual disabilities and behaviours that challenge others. In this review, we present the findings according to key themes characterising these experiences, interventions and resources. In so doing, we identify core learning for how the transitions of older people with intellectual disabilities and behaviours that challenge others can be most effectively planned and undertaken to fit with their needs and preferences.
Importantly, learning addresses how unplanned and otherwise inappropriate transitions can be avoided. The review was undertaken as part of a wider research project (based in England) evidencing the support for older people with intellectual disabilities and behaviours that challenge others, and their family carers. 1

| METHODS
Our review was intentionally inclusive and exploratory, designed to capture a broad range of evidence. We therefore undertook a scoping review, enabling the systematic synthesis of evidence from diverse sources according to its nature, features, and findings/outcomes (Peters et al., 2015). As the review constituted the early stage of a broader study, we utilised a rapid review methodology (Tricco et al., 2017). Rapid reviews are a pragmatic and robust approach to evidence generation (Langlois et al., 2019;Pluddemann et al., 2018). In order to reduce the potential for bias, we adhered to what Pluddemann et al. (2018) describe as 'additional steps' (p. 202) beyond the minimum required. As such, although our review was, necessarily, expedited, in essential areas (e.g., publication of protocol, search of multiple datasets, and inter-rater involvement at all stages) it adhered to standard procedures for systematic reviewing. Table 1 outlines our approach.
Throughout the review we consulted with members from our two expert advisory groups: a professional group, which included health and social care professionals (n = 3), policy-makers and consultants (n = 7), commissioners (n = 2), service providers (n = 3) and a patient and public involvement (PPI) adviser (n = 1); and a PPI advisory group, which included one person with intellectual disabilities and her support worker, two parent carers and one sibling carer. Advisors were all invited to contribute to these groups on the basis of their knowledge, expertise and experience in supporting older people with intellectual disabilities and behaviours that challenge others, and/or growing older themselves.
While there were more people with intellectual disabilities involved in the two groups, they agreed amongst themselves to 'play to their strengths' and focus time and energy on particular strands of project activity. Thus, one person opted to work on the review, while others focused their attention on supporting empirical work packages. Both groups contributed ideas, discussed ongoing findings, and helped to ensure clarity and relevance of analysis. Specifically, we liaised with the groups to finalise our search strategy; to consider the initial full screen returns; and to discuss our preliminary data analysis. The groups therefore contributed to analytic thinking regarding the codes and development of key themes. We adopt a wide-ranging definition of 'care contexts' for the purpose of this review, which encompasses the following environmental factors: service type (i.e., is the person living in a congregate setting, independently, or in a family home); provider type (NHS/local authority, private provider, third sector organisation, family care); relationships (who provides the care, for example, different family members; paid carers; personal assistants); place (the geographical location of care, taking particular note of the urban/rural dimension); and commissioning and funding arrangements. Our definition of care contexts also takes into account the dynamic and fluid ways in which different contextual factors interact at the micro, meso and macro levels. Our decision to focus on both transitions out of the family home as well as transitions between different service contexts was informed by findings emerging from a concurrent work package on the project and discussions with our advisory group. Both indicated that there was a population of older people with intellectual disabilities and labels of behaviours that challenge others identified as needing to transition from one form of care (e.g., supported living, residential care) into another (e.g., nursing care) due to age related health and care needs.
3. Use the learning delivered by (2), to consider the status of transitionrelated care and support for older people with intellectual disabilities and behaviours that challenge others, drawing out implications for how this care and support might be most effectively planned and undertaken to fit with their needs and preferences.

| Eligibility criteria
We included published and unpublished (grey) literature, including research articles, reports, and guidance. Within the published research we included primary (using quantitative, qualitative and mixed methods) and secondary (e.g., review) level evidence. To enhance the relevance of our review findings, we included evidence made available after 2001, to coincide with the publication of the Government's Valuing People White Paper for England and Wales (Department of Health, 2001). Valuing People included an explicit focus on the needs of older people with intellectual disabilities and on the needs of people with behaviours that challenge others. Although health and social care policy and funding is devolved in the UK, there have been calls for greater sharing of knowledge and 'lessons learned' across the four nations, given the same constraints that each face with regards to the UK structure of taxes and benefits (Bell, 2010). With this in mind, our review includes relevant material from across the UK, in order to inform our wider research project, which is located in England.
Using the population, concepts and context (PCC) framework (Peters et al., 2020), our inclusion criteria were: • Published/made available in English after 2001 • Concern older (40+) 3 adults with intellectual disabilities and behaviours that challenge others resident in the UK • Concern the health and social care needs, experiences, service interventions and resources of and for these older adults transitioning to different care contexts, for example, from family care to service care; from one context of service care to another (e.g., supported living to residential/nursing home care); and, from one context of family care (e.g., parent-led) to another (e.g., sibling-led).
We excluded discussion papers, position papers, expert opinion pieces, editorials and study protocols, as we were interested in the nature of and findings of evidence, which could be used to draw conclusions regarding our phenomena of interest.

| Information sources
The development of search strategies and database searches were undertaken with the support of a subject specialist librarian. An initial set of potential databases were reviewed using 'Healthcare Databases We generated search terms (words and phrases, including synonyms and terminology variations), combined using the Boolean operators 'and/ or' and appropriate truncation and phrase symbols to form initial search strategies, which we piloted against selected key databases. On the basis of the insights gained concerning the sensitivity and specificity of our terms, we confirmed our final search strategies to be used for each database, as well as the Google search strings, limited by file type (PDF) (see Online Appendix 1 for all database search strategies). The reference lists of included evidence identified from the database searches were hand searched. In addition, we used the expertise of the research team and project advisory group to identify other potentially relevant evidence.

| Selection of sources of evidence
After de-duplication by the specialist librarian, electronic search datasets were imported into Excel. Using titles and abstracts (where available), all records were screened by Researcher One, with Researchers Two, Three and Four also independently screening a selection. Any discrepancies T A B L E 1 Outline conduct of our rapid scoping review Guidance used re: Scoping review Guidance used re: Rapid review Specific points of impact re: Rapid approach Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist (Tricco et al., 2018).
SelecTing Approaches for Rapid Reviews (STARR) (Pandor et al., 2019) decision tool to help make broad decisions concerning the overall review process. The Oxford Centre for Evidence Based Medicine (Pluddemann et al., 2018) and the World Health Organisation (WHO) (Tricco et al., 2018) to help make decisions concerning specific methods/ techniques.
Use of limited priority databases. Limited searching for evidence, for example, no citation searching or contact made with experts beyond members of the project team. Limited searching for evidence not immediately available; if not available within a one-month period, such evidence was recorded as 'missing'. No critical appraisal undertaken.
were discussed between Researcher One and the other three researchers as appropriate, and in a majority of cases, a final decision reached, in all cases without recourse to a third researcher. In a minority of cases, a decision could not be made until additional information, unavailable in either the title or abstract, was obtained. This process enabled the exclusion of evidence that clearly did not meet the inclusion criteria and identified evidence for full text review.
All full text records were read by Researcher One, with Researchers Two, Three and Four also independently reading a selection. To reduce the potential for bias and promote transparency and consistency in decision-making, a standardised tool was used (Online Appendix 2). Discrepancies were discussed between Researcher One and the other three researchers as appropriate, and a final decision reached. Evidence excluded on the basis of full text review was recorded, including the reasons for exclusion. In cases where evidence was not immediately available, we attempted to source it using various means (e.g., contacting relevant authors). Given time constraints, if not available within a one-month period, evidence was recorded as 'missing'.

| Data extraction
A data extraction form was developed, piloted on three sources of evidence selected to ensure variation in focus and content, and a final version (Appendix 3) used to extract data from included evidence.
Data extraction was led by Researcher One; all completed forms were shared amongst the research team as a means of checking for gaps and inconsistencies.
T A B L E 2 Author/advisory group contribution to development of themes Final review also included focus on grammar, style, and overall presentation.
7th and final draft-sent to all.

| Critical appraisal of individual sources of evidence
The conduct of critical (quality) appraisal in scoping and rapid reviews is generally considered optional (Peters et al., 2020;Stevens et al., 2018;Tricco et al., 2017). For scoping reviews, the central issue is inclusion of many types of evidence (Peters et al., 2020), some of which are not amenable to quality appraisal (e.g., user resources). For rapid reviews the central issues are: lack of/limited availability of information on which to base quality assessment decisions (Tricco et al., 2017) and time available to complete the review, including in respect of chasing up missing information (Langlois et al., 2019). Given the variety of included evidence and the project time-plan, we took a pragmatic decision not to undertake critical appraisal. However, we did consider how included papers framed the concept 'behaviours that challenge others' and the extent to which the research took a critical stance towards this concept. In particular, we were alert to papers that presented a medicalised perspective on behaviours that challenge others, and considered how this may have impacted upon the findings presented.

| Synthesis of findings
Alongside primary and secondary empirical research findings, evidence included non-research case studies, and resources providing information and guidance relevant to older (40+) people with intellectual disabilities and behaviours that challenge others. Such diversity necessitated a flexible approach to bringing together the evidence in its entirety. Key characteristics of included evidence were summarised in a table of characteristics (Table 4). Using the evidence included in the table, we identified patterns and trends in the volume, focus and content of included evidence, as a basis of narrative comment in the section 4.
The findings of included evidence were integrated using a narrative approach (Popay et al., 2006;Ryan, 2013). An iterative process of reviewing the entirety of the research evidence allowed us to identify patterns in what the evidence was suggesting, however derived and expressed, which we captured in a series of themes and constituent sub-themes. The process was led by Researchers One and Two, with sustained involvement of Researchers Three, Four, Five and Six from an early stage, and involvement of the advisory groups once an initial thematic draft had been developed (Table 2).
Our aim in the analysis was to interpret, rather than merely describe, the original (author-generated) findings. Thus, we sought to generate new conceptual understanding, set out as analytical themes (as distinct, e.g., from merely collating the evidence into descriptive categories). To do so, data were analysed deductively and inductively.
Deductively, we took the focus of the review-transitions-as our point of entry into the data. Practically, this meant that the question 'What does this evidence mean for transition for older people with intellectual disabilities and behaviours that challenge others?' underpinned all interpretation. Inductively, we followed a three-stage process (Table 3), meaning that the development of our final themes was based primarily on the peer reviewed articles from our included evidence.

| Search results
Database searches yielded 261 returns, of which 223 were excluded on the basis of initial screening (using titles/abstracts). Of the remaining 38 read in full, 32 were excluded and six were identified for inclusion. A total of 37 returns were identified from the reference lists of database included articles, all of which were read in full. Of these, one article was included. A total of 40 items of evidence were identified by the research team and/or our advisory group, all of which were read in full. Of these, two were included. Therefore, a total of nine items of evidence were included in our review ( Figure 1).

Stage Analysis Outcome
Stage 1: Development of coding framework Article by article development of codes, which reflected directly the meaning and content of the author generated findings.
Equivalence of coding/ categorisation of data across the collective body of findings.
Stage 2: Development of descriptive themes/sub-themes Iterative review of all codes to identify those that clustered together in terms of their meaning to produce 'descriptive themes'. Each theme given a name that descriptively summarised its content/focus.
Equivalence of 'descriptive themes' across the collective body of findings.
Stage 3: Development of analytical themes/sub-themes Iterative review of descriptive themes, including their individual codes and associated segments of data, in terms of their meaning/relevance to the focus of the review (i.e., transitions) to develop analytical themes/sub-themes. Extended inductive process of interpretation, involving movement between the descriptive themes, their constituent codes and associated bodies of data, and developing analytical themes. Shared research team/project advisory input enhanced the reliability of the final analytical framework, as the full possibilities for analytical insight were levered.
Set of conceptually relevant analytical themes/subthemes.

| Study characteristics
Our evidence included five peer-reviewed journal articles, three reports and one resource. Two of the journal articles reported single client case studies and three reported empirical research. One report was based on empirical research, one on a rapid review of evidence and no information on the source of included evidence was provided for the third. No information was provided on the source of included evidence for the resource. Five sources of evidence referred to England, two referred to Wales, one referred to evidence published in English and no relevant information was provided for the remaining source of evidence. Table 4 summarises the characteristics of included evidence.
Our analysis generated four main themes and eight sub-themes. None provided.

Wales
There was a mixed pattern of quality of care and quality of outcome advantages between the two types of setting. In-area placements had a greater number of advantages than out-of-area placements.
3.3 | Transition over the long-term: Laying the necessary foundations We consider our inclusion of long-term factors that work for and against successful transition as valid in that, irrespective of their proximity to the point at which transition occurs, the evidence demonstrates their potential to have a tangible impact on its effective discharge.
3.3.1 | Opening up choice: Support to enable meaningful expression of needs and preferences Mats, all of the needs assessments described in her study used traditional paper-based processes.

| Promoting independence, social skills and 'preparedness'
Given that older people with intellectual disabilities who live at home  T A B L E 6 Service support to promote successful transition to independent living Service Support

Day centres
Could play a greater part in preparing people with intellectual disabilities, particularly with relevant skill development; advice and support could also be given to family carers concerning how they might enable their family member to practice and develop these skills.

Community support services
Remit could be extended to include a formal role in assisting with planning and preparing for the future. community is critical. This is especially the case regarding the use of 'out-of-area 'placements, which create a range of difficulties for people with intellectual disabilities (e.g., no longer able to maintain familial and wider social connections). In terms of the implications of this evidence for effective transition, a model of service provision that prioritises 'ageing in place' is suggested, encompassing both proactive and reactive strategies (e.g., emergency plans) (Slevin et al., 2011).
Based on the evidence included in their review, Slevin et al.
Some of the benefits of remaining in one's local area are demonstrated by the findings of Perry et al. (2013), who compared the costs and outcomes of in-and out-of-area placements for people with intellectual disabilities and behaviours that challenge others. Although both types of placement had advantages and disadvantages in terms of the outcomes measured, in-area placements were found to have smaller settings; higher staffing levels; more consistent staff training and support; greater contact with specialist providers; more common procedures for targeted assessment and response to behaviours that challenge others; less frequent use of physical restraint; more frequent reviews of medication for mental health problems or behaviours that challenge others; lower turnover of living companions; more common attendance at daytime social clubs; greater frequency of community activities; more frequent visits from friends; and, lower costs of maintaining contact for families and friends.

| Avoiding the need for unwanted/ inappropriate transition
If people with intellectual disabilities and behaviours that challenge others are to avoid being moved to unfamiliar and potentially unsuitable settings as they age, there is a need to attend to multiple issues impacting on them, their front-line professional support workers and their family carers (Slevin et al., 2011). The following sections deal with these prerequisites, as supported by the evidence included in our review. Failure in respect of any leaves people with intellectual disabilities vulnerable to unplanned and possibly inappropriate transition.

| Optimising health and social care
Despite policy requirements that needs assessments be undertaken as

Ageing in place
Older people with intellectual disabilities with dementia remain in the family home with appropriate support and adaptations as necessary. These include: individual early screening, clear diagnostic pathways, improvements to the environment, outreach services, palliative care services, speech and language therapy, respite care, carer education and training.

In place progression
The environment is developed to become increasingly specialised to ensure appropriate care within an intellectual disability setting. This requires staff education and training, waking night staff, environmental adaptations, outreach services, palliative care services, and speech and language therapy.
Referral out People with intellectual disabilities and dementia move to long-term (usually nursing) mainstream facilities, with staff supported (e.g., training) to provide appropriate care.
introduced by NHS England in 2014 across nine pilot sites to support people with complex needs to reside at home, avoiding the need for potentially long-term moves into hospitals/assessment and treatment centres. Although the vast majority of Forrester-Jones' (2019) participants were caring for a person with intellectual disabilities with additional complex needs, only one was aware of the IPC programme.
Given the known relationship between mental and physical health issues and behaviours that challenge others, the need for a proactive approach to effective healthcare of older people with intellectual disabilities and behaviours that challenge others is particularly acute. Slevin et al.
(2011) prioritise annual general practice (GP) health checks as a useful preventative strategy, as they can reveal ongoing and/or changing health needs. That older people with intellectual disabilities have been shown to under-use health services further underscores the need for proactive engagement (Slevin et al., 2011). Of particular concern is dementia. In terms of behaviours that challenge others, based on their included evidence, Slevin et al. (2011) recommend positive behavioural support (PBS) as a first-line intervention. PBS recognises behaviours that challenge others as a potential response to triggers such as physical or mental health problems, environmental factors, the result of learned behaviour, and/or an inability to communicate effectively other than engaging in such behaviour. Accordingly, behaviour support plans based on this approach should be person-centred, supportive, practical and sustainable, and relevant to the 'real world' of the person with intellectual disabilities and behaviours that challenge others. In the PBS approach, a crucial first step is to undertake a 'functional analysis' assessment of behaviours as a way of understanding their causes and how they function for the person involved. In the Forrester-Jones (2019) study, two participants identified their family member as displaying behaviours that challenges others, and others described behaviours that could be regarded as challenging. However, none recalled having been offered functional assessments or positive behaviour support plans.

| The importance of staff training
Given that PBS includes the role of the home environment (both physical infrastructure and people), Slevin et al. (2011) conclude that making relevant changes can be a powerful strategy in reducing behaviours that challenge others. As the authors note, carers (whether professional or family) need appropriate skills and methods of working, premised on relevant education and training, as well as other support, such as professional supervision, team building and stress management. Support for the claim that staff training can play a crucial role in effectively responding to behaviours that challenge others comes from Perry et al. (2011). Their study focussed on the staggered move of 18 older adults with intellectual disabilities and behaviours that challenge others from long-stay hospital to supported community living. Staff training in PBS was provided, alongside the development of person-centred plans for all residents. The fact that a reduction in behaviours that challenge others was observed from the outset of the resettlement process, when a majority of participants remained in hospital, leads the authors to prioritise staff training as the operative variable rather than resettlement per se. By the end of the intervention, a significant overall improvement in behaviours that challenge others was observed. That significant increases in family and other community activity also occurred for participants, beginning whilst still in hospital, once again suggests the importance of the training provided to staff in preparation for the move.

| Specialist community teams for people with behaviours that challenge others
This section focuses on the service infrastructure within which the inter-

T A B L E 8 Identified resources
Resources for professionals responsible for care planning and provision Access Sense (2018)-a UK national disability charity that supports people with complex communication needs-published a 'toolkit', intended for use by people with intellectual disabilities and their families when making plans for the future. It outlines key decisions that need to be made, sets out the steps to take in making these decisions and includes detailed information on the main options available, resources to support and legal rights possessed in respect of both processes. Notwithstanding its generic 'pitch', some of the content is extremely useful for people with intellectual disabilities and behaviours that challenge. This content includes details on NHS Continuing Healthcare Funding, Personal Health Budgets, statutory advocacy provision, and practical resources (templates) to be used to aid planning and decision-making. www.sense.org.uk Accessed 30th May 2021 The Housing and Support Partnership (2011)

| Front-line staff skills and attitudes
In this section we concentrate on the importance of staff skills and attitudes in supporting a successful transition. Hubert and Hollins (2010) Bissell et al. (2005) conclude that care staff have a critical role to play in observing and identifying the potential causes of behaviours that may be challenging to others (for example, in this particular case, dental pain), and responding accordingly. The authors also identify a role for specialists other than clinical psychologists and behavioural therapists -particularly that of speech and language therapists -in the assessment and response to behaviour that challenges others.

| An absence of targeted resources
Our review found no targeted resources to guide older people with intellectual disabilities and behaviours that challenge others, their families, or professionals (both front-line and planners/commissioners), in planning and decision-making. We did find some generic resources, some of which included limited relevant content. Most likely as a result of their lack of contemporaneity, we were unable to access the majority of those identified.

| DISCUSSION
We have identified a diverse range of evidence, which, collectively, suggests the same core message, namely, that transition-related care and support of older people with intellectual disabilities and behaviours that challenge others remains lacking in crucial respects. The review has also highlighted a number of factors which appear to be critical in: (i) supporting this population as they transition from one context of care to another; and (ii) avoiding unnecessary transitions, notably at points of crisis, which are now discussed.

| Implications of findings
In terms of supporting effective transition, we identified a number of systems issues that need to be addressed. In terms of avoiding unwanted/crisis transition, the review has identified a need for sustained, proactive professional involvement to underpin responsive care. Again, the need for full multi-disciplinary and multiagency input, including that from specialist community teams as appro-  Slevin et al., 2011). Timely engagement with health services will help to identify the onset of conditions that may lead to or exacerbate existing behaviours that challenge others (Bissell et al., 2005; Forrester-Jones, 2019; Slevin et al., 2011). The effectiveness of all such care, whether delivered by professional or lay carers, is premised on training and support of family carers and staff working in both community and intellectual disability specific settings Slevin et al., 2011) to understand and respond appropriately. Given the particular importance of dementia in older age, training should be provided to family and front-line professional carers in relation to both the recognition of the early symptoms, as well as the care of people with intellectual disabilities who develop dementia (Slevin et al., 2011).
More fundamentally, in terms of the principles underpinning these systems of care, evidence prioritises the need to privilege the social identity and connectedness of people with intellectual disabilities and behaviours that challenge others through, for example: person-centred support to enable them to live independent lives; honouring their relationships (for example, through locally based placements that allow people to maintain their family and social links); and, firmly embedding people in local communities (e.g., by the otherwise taken-for-granted step of providing a home in these communities). These principles foreground the values underpinning care. It was the particular attitude and supportive approach of a community residential manager that Hubert and Hollins (2010) associated with improved quality of life of people on transition to community residential living. It was also the compassion, commitment and perseverance of the clinical psychology lead that resulted in the successful transition of the older man with behaviours that challenge others (Leaning & Adderley, 2015).

| Study strengths and limitations
In terms of study limitations, as a rapid scoping review, the possibility that we have missed some relevant evidence remains. That we made strenuous efforts to read a wide body of potentially relevant evidence, the vast majority of which we eventually excluded, reduces this possibility. In terms of strengths, we adopted an enhanced rapid review process, including the use of multiple reviewers at all stages.
Focusing our search strategy on 'challenging behaviour' (and related synonyms and terminology variations) as opposed to specific conditions that may be associated with behaviours that challenge others (e.g., dementia; mental and/or physical ill health) and/or specific forms of behaviour (e.g. self-injury; violence etc.) runs the risk of having missed articles that pertained to our population of interest.
However, a trial of that alternative approach returned a vast number of returns that would have been unmanageable for the purposes of a rapid scoping review. Moreover, an initial scan of the returns showed no relevance to our research question. Therefore, we made a pragmatic decision to build a search strategy around the key terms of 'intellectual disability', 'challenging behaviour' and 'ageing'.
Our included evidence encompassed male and female participants, assessed across mild to severe/profound intellectual disability, and with a range of physical and mental health conditions. Autism was most frequently cited (n = 5 studies), followed by mental ill-health (n = 4 studies), epilepsy (n = 2 studies), genetic conditions (n = 1 study) and cerebral palsy (n = 1 study). As 'mental ill-health' was not further defined, we are unable to determine its particular presentation. Therefore, we can say that our findings are broadly relevant to the population of older people with intellectual disabilities and behaviours that challenge others, including in respect of gender, degree of intellectual disability and health status generally. Such breadth means that our findings may have less relevance to a particular population of people with intellectual disability, for example, those not addressed by our included evidence (e.g., people with dementia) and/or those whose degree of intellectual disability and/or attendant health status may prompt a need for specific care and support.
We intentionally did not adhere to a specific definition of 'behaviours that challenge others'. This enabled us to investigate how the term was understood and applied in the literature. Only one of the included sources of evidence (Slevin et al., 2011) provided a working definition, using the oft-cited Emerson reference (1995).
The authors also sought to contextualise their approach, prioritising a need to understand 'challenging behaviour' as inherently relational. The remaining sources of evidence either did not provide any indication of the type of behaviour or simply gave examples (including those set out in the Aberrant Behaviour Checklist (Aman & Singh, 1986)). In neither case was any discussion offered of the context in which this behaviour was being understood. Based on our included evidence, we suggest that our themes and recommendations relate to a broad range of behaviours that challenge others, as these are socially located.
We found very little evidence specifically focused on older people with intellectual disabilities and behaviours that challenge others in the context of transitioning to different contexts of care. We were therefore largely dependent on evidence that addressed our review question as part of a broader focus, typically either older people with intellectual disabilities or people with intellectual disabilities and behaviours that challenge others. From our included evidence, we extracted relevant content. This required close reading of many items of evidence that ended up including no relevant content whatsoever.
Our review is therefore based on a limited body of relevant evidence, reflecting a current dearth of research focusing on our particular population of interest. We are also mindful that a majority of evidence included in this review was over 10 years old at the time of writing, pre-dating a number of significant developments in the UK context, notably the impact of austerity (Malli et al., 2018), the roll out of annual health checks by primary care (PHE, 2016b) and the Transforming Care programme (NHS England et al., 2015). Although we have been able to deliver some key learning concerning current planning and implementation of transition-related care and support for older people with intellectual disabilities and behaviours that challenge others, it is clear that gaps in research remain.

| Implications for policy and practice
Our review highlights that the needs of older people with intellectual disabilities and behaviours that challenge others must be afforded greater priority within health and social care policy and commissioning practices. Wider research exploring intellectual disability and ageing (although not focused on the experiences of people with behaviours that challenge others) has highlighted the need for social care staff training to facilitate more nunaced and proactive approaches to support people as they grow older (Alftberg et al., 2021;Northway et al., 2017). The promotion of healthy ageing amongst people with intellectual disabilities relies on services and frontline staff understanding the specific health needs of this population, clearly evidenced through large-scale longitudinal research (de Leeuw et al., 2022;McCausland et al., 2016). The policy challenge lies in disseminating this knowledge effectively to practitioners, family carers and people with intellectual disabilities, while developing approaches to healthy ageing in services that are person-centred, nuanced and responsive. Involving people with intellectual disabilities and their families/advocates (where possible) is also critical to ensuring that well-planned decisions are made-decisions that take into account people's whole lives, including their relationships, homes, activities and hobbies, as well as their health needs.
Research has shown that despite policy commitments to ageing in place, progress in developing or adapting existing accommodation for people with intellectual disabilities as they age has been slow across a range of international contexts (Bigby, 2010). As this review has highlighted, commissioning and delivering suitable accommodation for people with intellectual disabilities and behaviours that challenge other is critical. It underpins family carers' ability to trust that suitable alternatives for their adult child exist beyond the family home, and it is necessary to avoid unsuitable placements in the event that a person's health deteriorates quickly (Bigby et al., 2011). Fundamentally, contemporary policy for people with intellectual disabilities has not been developed to take account of people growing older. As a consequence, systems are not designed to support comprehensive commissioning for this population, and in many cases prohibit effective, timely and inclusive discussions of future care plans (Brennan et al., 2020), with consequent distressing, avoidable, and costly crisis management. This needs to change.

| Implications for research
The themes identified also highlight a range of issues that require further research to improve the support of this population. One particularly striking finding was the absence of empirical research documenting the health and social care services that this group access as they age. From this review, it is not clear to what extent this population are enabled to age 'in place' . In addition, we were not able to decipher the settings that people transition to following a significant change in their health status, a family crisis, or as they reach end of life. This suggests to us that research is urgently needed to assess the types of services that this population can and do access as they age, the quality of those services, and the extent to which local commissioners are planning ahead for this population.