geropsych pearls


Surprised to see ADHD on a geriatric page? Most folks dx with ADHD in childhood continue to meet criteria as adults. Yes indeedy, pumpkin seedy. 

Tx comes in 2 flavors: simulants and nonstimulants.


  • Main issue is cardiac risk. Specifically a 1.8X increase in sudden death d/t ventricular arrhythmia. So if you're treating your peep for HTN, try to get them off the stimulant and on to something else.
  • Stimulants (methylphenidate, dextroamphetamine, lisdexamfetamine et al) do not require a taper or washout. Just switch. You can also stop abruptly if you need to.

Nonstimulant options:

  • Atomoxetine - non-stimulant, so less risk of ventricular arrhythmia, but can prolong the QT. Keep in mind that nonstimulants don’t provide an immediate effect like the stims do, and it will take a few weeks to get full benefit. Some pts perceive this as lack of benefit, because they don’t stay on it long enough to see the effect.
  • Bupropion - off-label, but works ok, esp if concurrent depression. 
  • Clonidine - too cognitively-blunting. Also deliriogenic, then you have a new problem. 
  • Venlafaxine, paroxetine - off-label, doesn’t work as well as bupropion, very little evidence to support
  • TCAs - off-label and cognitive side effects make them less desirable for elders
  • Modafinil - good for narcolepsy, no real benefit in ADHD

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