Goodman DW, Mitchell S, Rhodewalt L, Surman CBH. Drugs and Aging. Dec 2015. p1-10.
Abstract
Although previously considered a disorder of childhood, studies in the last decade have demonstrated that attention-deficit hyperactivity disorder (ADHD) continues to impair function into adulthood and responds to pharmacotherapy. Due to age-specific changes in roles and challenges, it is possible that presentation and response to intervention may differ between older and younger adults. A literature search for papers that identified older adults with ADHD, including papers describing its epidemiology, manifestation, and treatment, was the basis for this paper. There is a paucity of data on ADHD in older adults; however, small observational studies have characterized the presence, impact, and treatment of ADHD in adults over the age of 50 years, and larger epidemiologic studies have demonstrated that ADHD symptoms exist in older adulthood. Optimal criteria for diagnosis of ADHD and methods of treating ADHD in older individuals have not been systematically explored. In light of the limited data, this review discusses considerations for differential diagnosis and safe pharmacotherapy of ADHD in older adults.
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On September 30, 2015, The New York Times ran an article in the Tuesday Science section on ADHD in older adults. I was interviewed for the article and discussed a former patient age 73 who was first diagnosis with ADHD by me and successfully treated. The article is an introduction into an important clinical area for ADHD heretofore ignored. As we discovered, 60% of children will continue to have ADHD symptoms to an impairing degree into adulthood. The presumption is that ADHD in adults will simply continue throughout one’s life. However, the research is only just accumulating to support this assumption. The largest collection of research in this age group is published by my colleagues in Amsterdam and additional research from other research groups around the world.
Early this year I wrote an article for CHADD’s Attention Magazine on issues related to diagnosis and treatment of ADHD in older adults. The diagnostic issues and treatment considerations in older adults are more complex. In brief, diagnosis needs to consider medical illnesses, medications, history of head trauma, and other medical illness that worsen thinking ability. Treatment consideration are complicated by the presence of medications and medical illnesses that might limit the use of ADHD medications. Older patients and families considering an evaluation for possible ADHD should see a psychiatrist or mental health professional who has expertise and experience treating adults with ADHD.
Remember, while attentional changes occur in those of us over age 50, the cornerstone for the diagnosis of ADHD is the presence of symptoms since childhood that are relatively chronic and unchanged over one’s life and that these symptoms cause impairment in daily functioning. A comprehensive evaluation of all possible psychiatric and medical is critical for the accuracy of the diagnosis.
You might think you’re exercising good judgment by enhancing your health and wellbeing by taking herbs and supplements. While the scientific research with replicated studies is limited, the nutraceutical companies have spent billions promoting their use. Yet now, the real problem is uncovered. The New York Times recently published a story on a investigation into herbs and supplements and found several companies whose products sit on shelves at national pharmacy chains don’t contain the ingredient on the label. UGH. Feeling trick and swindled. You bet. Read the full story here.
While I don’t discourage my patients from pursuing complementary and alternative treatments, understand that regulatory oversight and scientific research is critical in determining the real utility of treatments. Without this, marketing under the guise of education becomes the detrimental order of the day.
Over the years, it has been challenging for psychiatrists to manage the risks of psychiatric medications in patients who considered childbearing, become pregnant, and chose to breastfeed. And while there is some information on many psychiatric medications, there remains little in regards to stimulant medications. Unfortunately, there is no registry for stimulant exposed pregnancy by which we can gain insight into their relative risk. The information we do have is related to animal research or people who have been active substance abusers. Very little of this research helps me in discussing evidence-based medication decisions with my patients. In my capacity as a researcher, I have had conversations about creating a stimulant pregnancy exposure registry with the pharmaceutical companies involved in ADHD but to no avail as yet.
With the proposed FDA changes in drug label for pregnancy and lactation, I hope we’ll have a better method of reviewing and evaluating relative risks and patients/families will be better informed.
The following article was distributed today, December 8, 2014 by the American Psychiatric Association, Psychiatric News Alerts.
FDA to Change Pregnancy and Lactation Labeling Information for Prescription Drugs
On Wednesday, the Food and Drug Administration (FDA) published a final rule that will set new standards for presentation of information concerning pregnancy and breastfeeding on labels of prescription drugs and biological products. The rule goes into effect June 15, 2015. “The [current] letter category system [A, B, D, and X] was overly simplistic and was misinterpreted as a grading system, which gave an oversimplified view of the product risk,” said Sandra Kweder, M.D., deputy director of the Office of New Drugs in the FDA’s Center for Drug Evaluation and Research, in a press statement. “The new labeling rule provides for explanations, based on available information, about the potential benefits and risks for the mother, the fetus, and the breastfeeding child.” The information provided under the new labeling requirements will be divided into the following categories:
Pregnancy: Containing information such as dosing and potential risks to the developing fetus and will require information about whether there is a registry that collects and maintains data on how pregnant women are affected when they use the drug.
Lactation: Containing information about using the drug while breastfeeding, such as the amount of drug in breast milk and potential effects on the breastfed child.
Females and Males of Reproductive Potential: Containing information about pregnancy testing, contraception, and infertility as it relates to the drug.
“The new system is potentially more informative and more useful than the old grading system, … [but] a great deal will depend on the content of the information that is provided under the new requirements, particularly for psychotropic medicines,” stated Nada Stotland, M.D., a professor of psychiatry at Rush University and an expert in OB-GYN psychiatry, in an interview with Psychiatric News. “If the information provided is reasonable and clear, it should help decrease the anxiety both psychiatrists and patients may feel regarding these medication decisions.” Stotland, a former APA president, emphasized that psychiatrists must continue to inform the public about multiple treatment options—including psychotherapies and social support therapies—that can safely aid in lessening symptoms of mental illnesses during pregnancy. “If left untreated—or unsuccessfully treated—mental illness can have adverse consequences for both mother and child,” she emphasized.
Sav-Rx reversed its initial denial of my patient’s Adderall XR 80 mg daily after receiving my letter of appeal. In my letter, I highlighted the stable effective dose had been prescribed for quite sometime. Their initial reason for denial was a citing that FDA approved max daily dose was 60 mg in the morning. In fact, the package insert for Adderall XR has no stated max daily dose for adults with ADHD. Fortunately for my patient, Sav-Rx reconsidered its decision. See below for my original blog describing the situation.
With an increasing number of adults being nearly diagnosed with ADHD, the expense of ADHD medications for insurance companies has escalated. While the annual prescription increase for childhood ADHD is less than 3%, the ADHD prescription market is growing at approximately 10% per year. As a result of this change, companies are under increased pressure to reduce their pharmacy expense. While this issue is certainly not limited to ADHD medication, my patients are finding the course of the medication treatment disrupted by insurance companies obstructionistic prior approval requests for long-acting stimulant medications.
Patients and their treating physicians may struggle for some time to find the most effective individualized medication dose that produces an optimal reduction in symptoms with tolerable side effects. Patients have recently found insurance companies changing their coverage of authorized medications. That means, that despite prior approval for your current medication, the new coverage change may no longer authorize the medication and/or dose. This is becoming extremely disruptive to my patients finding themselves forced to change medication because of high deductibles, leaving them paying hundreds of dollars a month for their prior effective medication.
To give you a specific example, SavRx, a prescription management service in Fremont, Nebraska, informed my patient who has been treated with Adderall XR 80 mg in the morning for the past six months that the coverage for this was no longer available to her, despite the fact that it had been approved by the previous pharmacy management company. Having submitted the documentation of effective treatment for months, SavRx is still not approving her optimal dose.
My recent experience indicates that this approach to medication authorization is increasing in frequency across several companies. I will continue to post blogs giving examples from other companies.
My suggestion to patients who encounter this issue with their treatment is to call your insurance company and complain about your specific case. The insurance companies may not be aware of what is happening and they certainly don’t want unhappy subscribers, let alone bad public press. We will soldier on.
If you’re reading this blog, you are one of the millions of people who now use the Internet to gain information on medical issues. In a recent survey of consumers, this is where people are looking for medical information.
Most accessed online resources:
53% web M.D.
22% Wikipedia
19% health magazines and websites
16% advocacy group websites
12% YouTube
10% Facebook
10% blocks
9% Pharma company websites
(results from third annual national consumer survey by Makovsky Health and Kelton, 2014)
I would like to take this opportunity to direct your attention to the attitude magazine website that has a large number of webinars from noted academic and professional experts in ADHD. For many with ADHD it’s often easier to watch a video on a specific ADHD topic then to read a book. While many with ADHD can sit and read for extended periods of time, it always struck me as odd that clinicians referred patients to books knowing their ability to sustain attention would be limited, especially in the evening when it medication affect us dwindled.
Explore the webinars on this site as a can be extremely helpful. On this blog site, I will continue to direct my patients in readers to reliable sources of information and clinical insights from my practice not available elsewhere.
Anticipating over 300 attendees, the 13th Annual ADHD Conference for parents, teachers, professionals and adults with ADHD on Saturday, February 22, 2014 from 8:00am to 1:00pm will feature several expert speakers. West Chester University is just outside Philadelphia. Below is the program of speakers and topics.
Marie Paxon, program coordinator, invited me to present on the science of diagnosis and treatment of ADHD in adolescents and adults. If you reside in the area, please consider attending because it is a great way to learn a great deal about ADHD quickly and network with people with ADHD and those who offer guidance and treatment. See you there.
ADHD and the Brain: Knowledge Matters Speakers
Marilyn B. Benoit, M.D. is a child and adolescent psychiatrist. She is senior vice president of Clinical and Professional Affairs and chief clinical officer at Devereux. She is a past president of the American Academy of Child and Adolescent Psychiatry. Dr. Benoit has served on the faculties of Howard and George Washington Universities and is a clinical associate professor of psychiatry at Georgetown University Medical Center, from which she received the Vicennial Silver Medal of Honor for 20 years of distinguished service.
David W. Goodman, M.D. is assistant professor of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine. He is also director of the Adult Attention Deficit Disorder Center of Maryland in Lutherville and medical director of Suburban Psychiatric Associates, LLC. Dr. Goodman is the author of The Black Book of ADHD.
Marjorie Johnson, LCSW, PCC is a licensed clinical social worker and certified coach who provides leadership and career coaching, training, and counseling. She specializes in helping students and professionals with ADHD. Ms. Johnson serves on Chester County/Main Line CHADD’s Professional Advisory Board and is a professional member of ADDA (Attention Deficit Disorder Association.). She is past president of the International Coaching Federation-Philadelphia chapter and was named the 2011 Small Business Person of the Year by the Exton Chamber of Commerce (PA).
Jesse D. Matthews, Psy.D. is a licensed psychologist and has worked with individuals with ADHD for a number of years. He is in private practice at The Center for Psychological Services in Paoli and Ardmore and also works at Holcomb Behavioral Health Systems, a community mental health organization. He evaluates adolescents for substance abuse at the Chester County Youth Center in West Chester and does substance abuse evaluations and treatment in an outpatient program in Kennett Square. Dr. Matthews is an adjunct professor at Immaculata University. Previously, Dr. Matthews worked for six years as a counselor at Hill Top Preparatory School, and he facilitated the Chester County/Main Line CHADD teen ADHD support group for two years.
Joan M. Polka, Ph.D. is a psychologist in the Counseling Center at West Chester University assigned full time to the Act 101 portion of the Academic Development Program (a developmental education opportunity for underprepared first-time college students). She is also co-chair of Chester County/Main Line CHADD’s Adult Program and was the 2011 CHADD Educator of the Year.
Martin Patwell, Ed.D. is director of the Office of Special Services for Students with Disabilities at West Chester University. He has also been the director of evaluation clinic at Landmark School. He has presented “Trends and Issues in Disabilities in Higher Education” at Jiangxi University, Nanchung, China. He is also a consultant to The College Board, Inc.
Preeti Singh, M.S. is the associate director of the Twardowski Career Development Center at West Chester University.
Sharon Watson, M.S. is assistant director of West Chester University’s Office of Services for Students with Disabilities. She has over 20 years of experience working with students with learning differences, mental health, and physical disabilities.
8:30 a.m. Welcome
Chester County/Main Line CHADD and West Chester University
West Chester University
Earl F. Sykes Student Union
110 West Rosedale Avenue
West Chester, PA 19383
8:45 –9:15 a.m.
ADHD Across the Lifespan
Marilyn Benoit, M.D.
Research has proven that ADHD does not end with childhood. Over the course of a lifetime, the scenarios change, but the struggles might not. What does ADHD look like at each stage of life and what is the impact? This fast-paced-but-thorough presentation will help attendees learn more about this complex disorder and will provide a summary of current treatment and management options. Don’t miss this valuable session to gain a better understanding of childhood, teen, and adult ADHD.
9:15 –10:30 a.m.
ADHD and the Brain – What You Need to Know About Treatment and Management
David W. Goodman, M.D.
Those with ADHD express frustration with the disorder’s symptoms: trouble focusing, procrastination, forgetfulness, and difficulty filtering out distractions. Some people have a slower processing speed and others struggle with impulsivity. To make things even more complex, many people with ADHD will have a co-occurring condition like learning disabilities, anxiety, depression, or autism. The good news is that treatment is available, and there are strategies to counteract these challenges. Dr. Goodman will provide an overview of medications and pro-social treatments for ADHD and discuss common co-occurring conditions in this valuable presentation. Children and adults report that they receive unhelpful advice like “try harder,” “start applying yourself,” and “pull yourself up by your bootstraps.” Attend this session to learn about evidence-based treatments for ADHD and how they make a difference.
10:45 –11:30 a.m.
ADHD and Social Interactions
Jesse Matthews, Psy.D.
Social interactions can consist of anything from a casual conversation with an acquaintance to daily communication with loved ones. This can present challenges for both children and adults with ADHD. Those with ADHD may feel isolated and disconnected from others. They may find that executive function challenges can cause them to misinterpret social cues, which are usually unspoken or vague. The invisible challenges of impulsivity, forgetfulness, and an inability to regulate emotions can have a negative effect on forming and maintaining friendships. Fortunately, new information and strategies are available through the field of social learning and social cognition. Attend this session to learn more about this exciting topic and how to apply it to everyday life.
• Facilitated activity: Mindfulness Meditation and ADHD
Marjorie Johnson, LCSW
Mindfulness meditation is a way to calm the mind and relax the body while increasing the ability to sustain attention and manage distractibility. Hear about compelling research and daily applications of mindfulness meditation. Practice it to experience the deep relaxation it generates.
11:45 a.m. –1:00 p.m.
Becoming Successful in College and Early Career
ADHD and Career Success
Preeti Singh
Career development is a life-long process, involving decision making, self-awareness, exploration, preparation, and experience. What tools are available to help students successfully navigate this territory? This brief presentation will provide an overview of resources and strategies.
WCU Student Panel
Sharon Watson, facilitator
Current students at West Chester University who have “been there, done that” tell it like it is. Their transitions, challenges, and routes to where they are today provide a look at what real students face in college.
• Facilitated activity: ADD and Loving It?!
This video blends humor, hope, and science to dispel the myths about adult ADHD. Comedian Patrick McKenna seeks a diagnosis for adult ADHD and learns the facts from an impressive array of experts. Funny, moving, and transformative, this fascinating documentary will hold you spellbound!
My discussion with Dale Archer, M.D. (psychiatrist, best-selling author) on WYPR September 27, 2014 about ADHD, over- diagnosis, and over-prescribed medications was lively. While Dr. Archer advocates “medication as a last resort” and “the goal of treatment is to get off medication” after learning new skills, I offered the research on medication benefit and a quality of life measure to evaluate medication utility. Certainly, treatment of ADHD at all ages incorporates behavioral therapy, organization skills, couple/family/individual therapies, and academic/occupational accommodations, in addition to medication, when indicated.
For those of you interested, the radio broadcast is available and runs 35 minutes. I invite you to listen and decide for yourself the merits of each position. Ultimately, this information best serves those who have ADHD and their families.
I have been invited as an expert on ADHD to participate in an interview on the Mid-day with Dan Rodricks show on WYPR on January 27 1-2pm. This is a live panel discussion that will include Dale Archer M.D., a psychiatrist and writer, to discuss the use of medication and treatment options for ADHD. The discussion is moderated by Dan Rodricks who is a distinguished journalist in Baltimore with a regular feature in the Baltimore Sun newspaper.
Dr. Archer wrote an article online for Forbes on January 6, 2014 on his perspective of ADHD and the overuse of medication and the over-marketing of ADHD. His article highlights and echoes the sentiments of Alan Schwatz in his New York Times article “The Selling of Attention Deficit Disorder” published December 15, 2013.
This one-hour program will give me the opportunity to highlight the national and international scientific literature and research on ADHD. I hope to highlight the well documented negative consequences over the course of one’s life with untreated ADHD as reflected in several international prospective studies following ADHD children into young adulthood.
This program promises to be a lively discussion and offers listeners the opportunity to call in with questions. I encourage you to mark your calendar. I believe the program can be accessed online. If you listen, please leave me your comments for feedback.
