Managing attention deficit in
adults in your office
Nick Kates MB.BS FRCPC MCFP(hon)
Chair, Dept. of Psychiatry, McMaster University Cross Appointment, Dept. of Family Medicine, McMaster University Quality Improvement Advisor, Hamilton Family Health Team
No funding or support from Industry for any aspect of this presentation or my work
Except my lifelong commitment to
Self-referred - concerned about his mood Recent life stresses Inconsistent work and relationship history Met criteria for ADD + PHQ score was 14 Was also depressed – poor response to Buproprion Seen a year later – mood was brighter and wanted to start a stimulant Positive response to Methylphenidate Referral for assessment of Bipolar Affective Disorder Mood swings consistent with cyclothymia Consistent history of problems with attention, distractibility, academic underachievement Two diagnoses eventually established Some overall improvement with Lithium Reluctant to start Ritalin 6 - 9 % of all children 25-78% continue to have problems as adults 4-5% of all adults Could be third most prevalent psychiatric disorder ? 50 – 60 adults in an average family practice Democratic Male : female 2:1 ◦ Self-perception Changing prevalence with age
70 adults in your practice
20% of mothers, 25-30% of fathers have ADHD
20-45% co-morbid depression (genetic link)
25% have alcohol and drug problems
0-27% Bipolar affective disorders (one way co-morbidity)
10-40% have anxiety disorders
Significant increases in incarceration rates
Increased likelihood of being in an MVA
Prenatal ◦ Drug use ◦ Alcohol ◦ Tobacco use ◦ Bleeding ◦ Prematurity ◦ Stress
No evidence re diet
Postnatal ◦ Head trauma ◦ Brain hypoxia ◦ Lead poisoning ◦ Streptococcal Bacterial Infection
Triggers auto-immune antibody attack of basal ganglia
No evidence re diet
No credible social theory
Prefrontal Cortex - 4 functions ◦ Working memory ◦ Self-regulation of affect / arousal ◦ Internalisation of speech ◦ Reconstitution - Behavioural analysis
◦ Self regulation ◦ Future directed ◦ self-control of emotions
Dopaminergic and noradrenergic pathways
Prevalence continues to decrease with age
Adults more likely to “act in” than “act out”
Sometimes can be adaptive
Some individuals present when structure of home / school is removed
Behaviour Description Anticipatory avoidance Magnifying difficulty of impending tasks and doubts of being able to complete task
Procrastination Deadline-associated stress can help focus
Pseudo efficiency Sense of productivity by completing several easy tasks while avoiding high-priority tasks
Juggling Taking on new projects without completing those already started Key Symptoms
Difficulty sustaining Difficulty sustaining attention in attention for homework, meetings, at work, home chores, etc. responsibilities Loses things Disorganized, poor time Appears to be not listening management Trouble with follow through Inefficient, procrastinate Easily distracted Trouble with follow through Daydreams Poor memory, forgetful Distracted Loses things Avoids tasks with mental effort Can’t stay in seat, Can’t sit through squirming, fidgeting, meetings (checking always on the go email, scribbling notes) Can’t wait turn, blurts out Impatient (hates answers waiting in lines), Can’t work or play quietly, runs, climbs excessively interrupts others Drives fast, likes active Intrudes and interrupts others jobs, always on the go Talks excessively Inner restlessness Restless Impatient Can’t wait turn, Doesn’t matter about blurts out answers consequences Intrudes and Makes inappropriate interrupts others comments (“no Quits school, gets mental filter”) into trouble with the Relationship and law marital difficulties Rushes into things Spends money Takes risks beyond means Accident prone Frequent job/career Impatient/interrupts changes Criteria ◦ Inattention ◦ Impulsive / hyperactivity ◦ Both 5 or more symptoms (was 6) Greater than 6 months Persistent and Maladaptive At least two domains
◦ Before the age of 12 (was 7)
Avoiding tasks or jobs that require concentration Difficulty initiating tasks Difficulty organizing details required for a task Difficulty recalling details required for a task Poor time management, losing track of time Indecision and doubt Hesitation of execution Difficulty persevering or completing and following through on tasks Delayed stop and transition of concentration from one task to another
Chooses highly active, stimulating jobs Avoids situations with low physical activity or sedentary work May choose to work long hours or two jobs Seeks constant activity Easily bored Impatient Intolerant and frustrated, easily irritated Impulsive, snap decisions and irresponsible behaviors Loses temper easily, angers quickly A tendency to act first and think after Present along a spectrum
Symptoms improve with age
◦ ? Maturational process
◦ Learning new skills
◦ Developing adaptive compensatory mechanisms
Presence doesn’t always require treatment
Treatment decisions based upon extent to which it interferes with daily activities Screening
Diagnosis based on behaviours only
Symptoms along a spectrum
Incidental finding
Previous history often undocumented
“Vogue” diagnosis – increasing self-detection
Not diagnostic Self-Reports Point out areas for interventions May identify co-morbid problems ◦ ASRS ◦ Barkley Screener ◦ Weiss Functional Impairment Scale
Assessment Concentration
Lack of organisation
Forgetful
School / work performance
Underachieving
Relationship instability / conflict
Family history
Poor self-esteem
Patients presenting with:
Major Mood and Anxiety D/O (including poor response to treatment)
Drug abuse or drug dependence
Poor school performance as a child (not reaching potential)
Frequent job changes or moving often
Frequent driving infractions
Higher number of accidents than average population Have you ever been diagnosed with ADHD? Do you have a family of ADHD (siblings, children, parents or extended family)? Did you have any difficulty in school? Did you daydream or have difficulty payment attention? Did you get your homework done on time? Were you disruptive?
Anything positive – move to Step 2
Do you currently have substantial difficulties with forgetfulness, attention, impulsivity or restlessness that are interfering with your relationships or your success at work?
Anything positive – move to Step 3
Complete ASRS and Complete Diagnostic Interview
Symptoms
Course / Time Frame
School / work performance - underachieving
Other mental health issues / diagnoses
Family functioning
Relationship history
Legal history
Drug use
Family history
History from family
Family members can bring a different perspective Management Education
Structure
Behavioural management
Maintaining self-esteem
Family interventions
Cognitive Behavioural Therapy
Medication Information about the prevalence
Information about the symptoms
Reading materials
Driven to Distraction Edward Hallowell and John Ratey
Delivered from Distraction Edward Hallowell and John Ratey
You mean I’m not lazy, crazy or stupid Kate Kelly and Peggy Ramundo
Rating Scale www.med.nyu.edu/psych/assets/adhdscreen18.pdf Information www.caddac.ca www.chaddcanada.org www.adhdcanada.ca http://www.caddra.ca/ www.ADHDandYou.ca www.associationpanda.qc.ca http://www.attentiondeficit-info.com/home.php
Daily list of tasks - keep it manageable Keep an appointment book / planner Keep notepads in accessible places Use a personal dictaphone or cell phone to write things down Post key messages in visible places ie car Develop a filing system - file everything immediately Ask a friend / family member to remind you of important events / appointments Memory aids Learn to tolerate Organizational aids mood swings Task fragmentation Nutrition Prioritization Sleep hygiene Favour routines Physical activity / Reinforce success exercise Time management Reduce screen time, skills alcohol, drugs Set personal / attainable goals
Reward yourself when these have been attained
If don’t work out take a time out to review the situation
Develop daily routines
Use the structural approaches
Stress management
Maintain a sense of humour Behaviour Description Anticipatory avoidance Magnifying difficulty of impending tasks and doubts of being able to complete task
Procrastination Deadline-associated stress can help focus
Pseudo efficiency Sense of productivity by completing several easy tasks while avoiding high-priority tasks
Juggling Taking on new projects without completing those already started ◦ Building self-esteem ◦ Correcting behaviours during your visit ◦ Identify masquerading (cover-up) skills
◦ Goal focused - SPEAR Stop Pull-back Evaluate Act Re-evaluate
recognise achievements
find strengths
avoid failures
avoid criticism
cognitive approaches
empowerment Help with assessment
Identify other issues
Explain and answer any questions
Reading material
Engage as a “coach”
Support Medication Stimulants ◦ Methylphenidate ◦ Concerta ◦ Biphentin ◦ Dextroamphetamine ◦ Adderall ◦ Vyvanse Atomoxetine Guanfacine Anti-depressants Buproprion Venlafaxine Desipramine
◦ Short acting (2-4 hours)
◦ Up to 80 mgm. / day ◦ Up to 3 divided doses
◦ Can be combined with long-acting
◦ Side-effects Sleep Appetite Rebound Tics
◦ Short acting (3-4 hours) ◦ Slow release (spansules) 5 and 10 mgm
◦ Up to 40 mgm. / day (twice the potency of MPH) ◦ Divided doses ◦ Can be combined with long-acting
◦ Side-effects Sleep Appetite Rebound
Start with a test dose Can use fixed schedule Can use selectively (as needed)
Can be used in combination with anti- depressants Can be used in combination with long-acting
Potential for abuse (resale) 40-120 mgm
Can take up to 2-3 weeks to work
Sleep problems
Fatigue
Upset stomach
Dizziness
Liver damage
Suicidal thoughts 1-7 mgm, once daily
Can take up to 2 weeks to work
Not a stimulant
Selective alpha 2A-adrenergic receptor agonist.
Reinforces receptors in the brain
Can be used in conjunction with a stimulant
Swallowed not crushed
Stop gradually Product Admin Availability Starting Dose Titration Max Dose
Methylphenidate Tablet in the 18, 27, 36, 54 18 mg/day PRN adjusted 72 mg/day hydrochloride morning mg (morning) weekly extended-release (Concerta)
Methylphenidate Capsule, in the 10, 15, 20, 30, 10 mg OD 10 mg weekly up 1 mg/kg/day Not hydrochloride morning, Can be 40, 50, 60, 80 (morning) *up to to max exceeding 80 controlled release sprinkled on food mg 0.25/mg/kg mg/day (Biphentin)
Mixed salts Capsule in the 5, 10, 15, 20, 25, 10 mg OC 5-10 mg weekly 30 mg/day* amphetamine am. Can sprinkle 30 mg (morning) up to 20 mg extended-release on applesauce (Adderall XR)
Lisdexamfetamin Capsule in the 10, 20, 30, 40, 30 mg 10-20 mg/day at 70 mg/day e-dimesylate morning. Can 50, 60 mg weekly intervals (Vyvanse) dissolve in water
Atomoxetine Capsule once a 10, 18, 25, 40, 40 mg/day (total Up to 60 mg/day 100 mg/day (Strattera) day or BID 60, 60 100 mg dose) after 7-14 days, Up to 80 mg/day after another 7- 14 days
Guanfacine Tablet once a day 1, 2, 3, 4 mg 1 mg Increase weekly 7 mg in adults, 4 (Intuniv) by 1 mg Can be in children, 4 in used to augment combination a stimulant Sleep
Appetite
Less rebound
Increased arousal / irritibility
Weight loss
Slight increase in blood pressure and heart rate but not of stroke or MI
Reviews – Meta-analyses suggest Faraone 2010
◦ Long-acting no different from short-acting
◦ Amphetamine derivatives slightly more effective than methylphenidates
◦ Stimulants more effective than anti-depressants
Dopamine / Noradrenaline
Buproprion Venlafaxine
TCAs ◦ Desipramine ◦ Imipramine
SRIS ◦ No evidence of any benefits
Reviews – Meta-analyses suggest Buproprion effective (Verbeeck 2009)
Venlefaxine effective (Treuer 2011)
Desipramine effective (Maidment 2003)
Buproprion more effective than venlefaxine (Habel 2009)
High prevalence
Can present in many different ways
No diagnostic test / use screening tools
Provide information about the problem
Help provide structure
Variety of medication options