geropsych pearls
adhd
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.
Stimulants:
- 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