Adult ADHD. Jennifer A. Ganem, MS, APRN

Transcription

1 Adult ADHD Jennifer A. Ganem, MS, APRN 22nd Annual Northeast Regional Nurse Practitioner Conference May 6-8, 2015

2 DISCLOSURES There has been no commercial support or sponsorship for this program. The planners and presenters have declared that no conflicts of interest exist. The program co-sponsors do not endorse any products in conjunction with any educational activity.

3 ACCREDITATION Boston College Connell School of Nursing Continuing Education Program is accredited as a provider of continuing nursing education by the American Nurses Association Massachusetts, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation.

4 SESSION OBJECTIVES Describe the assessment of ADHD. Discuss strategies to manage ADHD including medication management. 22nd Annual Northeast Regional Nurse Practitioner Conference May 6-8, 2015

5 ADULT ADHD Jennifer A. Ganem MS, APRN Londonderry Square 50 Nashua Road Londonderry, NH Phone: (603) Fax: (603)

6 Potential Conflicts of Interest I was on the following Speaker Bureaus: Shire Pharmaceuticals, Inc Forest Pharmaceuticals, Inc Novartis Pharmaceuticals Corporation AstraZeneca Pharmaceuticals I presented a poster funded by Shire Development LLC at the American Academy of Nurse Practitioners National Conference (June 2012)

7 Objectives Describe the assessment of ADHD Discuss strategies to manage ADHD including medication management

8 The Statistics Population surveys suggest ADHD exists in most cultures in about 5% of children and 2.5% of adults. 1 About 60 percent of children with ADHD in the United States become adults with ADHD. 2, 3

9 Attention-Deficit/Hyperactivity Disorder 1 ADHD: Combined Presentation (314.01) 6 or more Inattentive symptoms and 6 or more Hyperactive and Impulsive symptoms which have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level ADHD: Predominately Inattentive Presentation (314.00) 6 or more Inattentive symptoms that have persisted BUT DO NOT HAVE 6 or more of the Hyperactive-Impulsive symptoms ADHD: Predominately Hyperactive-Impulsive Presentation (314.01) 6 or more Hyperactive and Impulsive symptoms that have persisted BUT DO NOT HAVE 6 or more of the Inattentive symptoms

10 ADHD: Inattentive Symptoms 1 Fails to give close attention to details or makes careless mistakes in schoolwork Has difficulty sustaining attention in play activities Doesn t seem to listen when spoken to directly Doesn t follow through on instructions and fails to finish schoolwork or chores Has difficulty organizing tasks and activities Avoids, dislikes or is reluctant to engage in tasks that require sustained mental effort Loses things necessary for tasks or activities Easily distracted by extraneous stimuli Forgetful in daily activities

11 ADHD: Hyperactive Symptoms 1 Fidgets with hands or feet or squirms in the chair Leaves seat in classroom or in other situations in which seating is expected Runs about or climbs excessively in inappropriate situations (in adolescents, may be limited to feeling restless) Difficulty playing or engaging in leisure activities quietly On the go or often acts as if driven by a motor Talks excessively

12 ADHD: Impulsive Symptoms 1 Blurts out answers before questions have been completed Has difficulty waiting turn Interrupts or intrudes on others

13 And 1 Several inattentive or hyperactive-impulsive symptoms were present prior to the age of 12 Several inattentive or hyperactive-impulsive symptoms are present in two of more settings (home, school, work; with friends or relatives) There is clear evidence that the symptoms interfere with, or reduce the quality of, social, academic, or occupational functioning The symptoms don t appear exclusively during the course of schizophrenia or another psychotic disorder and are not better explained by another mental disorder

14 ADHD Indicators: Clinical Pearls Does the patient seem distracted by extraneous stimuli like cell phones or the music playing in the background? Does the patient finish your sentences? Does the patient talk about having no filter or saying things without thinking? Does the patient overspend or is the patient good at managing money and promptly paying bills? How many speeding tickets has the patient had? MVAs?

15 Clinical Pearls (continued) How many projects have been started at home but have not been finished? Can the patient make a decision easily or does the patient suffer from analysis paralysis? Was the patient late for the appointment? Is the patient often tardy for work or other things? How often does the patient change jobs or been terminated due to poor organization or not completing tasks in a timely manner?

16 Clinical Pearls (continued) Does the patient hyper-focus, sometimes on the wrong thing, and lose track of time? How many relationships have ended due to the patient s difficulties? Does the patient have a sibling, parent, and/or child with ADHD? (The rate at which the disorder is inherited is about 75% - similar to the rate at which height is inherited.)

17 Assessment Scales The Adult ADHD Self-Report Scale (ASRS) is an 18 item scale. It can be accessed at: ASRSv1-1.pdf Many translations of the ASRS can be accessed at: The World Health Organization endorses the use of an ASRS screener which has a 6 item scale

18 Assessment Scales (continued) There is also an online rating scale which can be accessed at: Once completed, the patient receives an assessment, such as: Your score on Part A was 6 out of a possible 6. Your score on Part B was 12 out of a possible 12. Scores in this range are indicative symptoms highly consistent with ADHD in adults. While there is no numerical cut off for scores on Part B, higher numbers are more consistent with ADHD in adults.

19 Educational/ Workplace Accommodations Coaching Community Support ADHD Behavioral Intervention Medication

20 Community Support CHADD Support Groups Local Regional National Virtual Parent Support Groups Hospitals/ Behavioral Health Center

21 Workplace Accommodations An ADHD diagnosis, in and of itself, does not entitle an employee to services and/or accommodations The individual must disclose his/her documented diagnosis, and show that the ADHD substantially limits a major life activity in this case, the person s job In order to seek protection under the Americans with Disabilities Act (ADA), the individual must show that s/he are otherwise qualified to perform the job, and s/he must work for a company with at least 15 employees

22 Educational Accommodations Section 504 of the Rehabilitation Act of 1973 Disability must "substantially limit" the child s ability to learn requiring the need for specialized services or accommodations All determinations of substantial limitation must be made without regard to the ameliorative effects of mitigating measures This means that the question of whether a substantial limitation exists must be determine before any intervention for that limitation is implemented "Mitigating measures" includes such things as medication, assistive technology, learned behavioral modifications, psychotherapy, and/or reasonable accommodations Parent Information Center provides workshops on the special education process and have trained advocates for a nominal fee

23 Coaches assist ADHDers with Coaching identifying their personal strengths and weaknesses developing concrete strategies to manage their symptoms in all areas of life Coaches are supportive and hold ADHDers accountable Coaching can be done in-person, via the phone and/or virtually Coaching can be individual, couples and/or group Resources to locate an ADHD Coach:

24 Behavioral Interventions Therapy to help patients learn to manage symptoms of comorbid mental health disorders, such as depression, anxiety, oppositional behavior, tic disorders, OCD Can be individual, family and/or group

25 Medication Jennifer A. Ganem MS, APRN - May 2015

26 Factors to Consider Desired length of symptom reduction Current BMI Family history of success/failure with ADHD medication Comorbid conditions Potential for Diversion (The term diversion means the transfer of medication from the person to whom it is prescribed to a person for whom it is not prescribed.)

27 Your Biggest Fear Jennifer A. Ganem MS, APRN - May 2015

28 Medication Diversion and Abuse According to one study, 11% of the patients reported they sold their short acting stimulant medication and another 22% had misused it in. 4 In a study of college students, 34% reported they took a stimulant that was not prescribed to them. Most use occurred in periods of high academic stress. 5 Most common manner of stimulant abuse is crushing pills and snorting. 6 There is evidence that sustained-release and longer acting preparations have decreased abuse potential. 6,7,8

29 Street Prices for Stimulants in the Northeast Adderall 10mg tablet $5-10 Adderall 20mg tablet $10 Ritalin 10mg tablet $5-10 Vyvanse 20-60mg $2-$5 Concerta 54mg $5 Streetrx.com

30 What Can You Do? Ask about the patient s current and past use of nicotine, alcohol, marijuana, ecstasy, hallucinogens, cocaine, heroine, ketamine Ask if the patient has ever used someone else s prescribed medication If the patient is actively using substances other than nicotine, you may want to consider a referral to a mental health provider who specializes in ADHD and substance use. Otherwise

31 Prescribe Only Long-acting Stimulants! How long is the average adult awake? hours? The short acting stimulants don t provide that kind of coverage unless it s taken multiple times a day and research shows that ADHDers forget to take their medication! You can also make it standard practice to only prescribe non-stimulants for patients with a history of substance use

32 Also Tell The Patient To lock all (stimulant) medication Explain that children, babysitters, and/or visitors may steal stimulant medication

33 And That stimulant medication should not be carried in a purse or left in a car. If patient must carry a small amount of medication, instruct them to keep it in a labeled prescription bottle.

34 AND You WILL NOT issue another prescription under any circumstances and document this conversation - even if you decide to do a contract!

35 What Might be Best A Contract I, agree that Jennifer A. Ganem MS, APRN will be the only provider prescribing, a stimulant medication for managing ADHD. I agree that I will obtain all of my prescriptions for this medication at one pharmacy. The exception would be an emergency situation or in the unlikely event that I run out of medication. Should such an occasion occur, I will inform Ms. Ganem as soon as possible. I understand the importance of taking the medication at the dose and frequency prescribed by Ms. Ganem. I agree not to increase the dose of the medication without first discussing it with her. I understand that expected prescription refill dates will be used to promote optimal use of this medication. I understand that Ms. Ganem may require random drug testing as a matter of routine monitoring.

36 The Contract (continued) I will attend all reasonable appointments, treatments and consultations as requested by Ms. Ganem, and I will pursue other ADHD consultations/management strategies as necessary. I understand that I should check with Ms. Ganem, my PCP, or pharmacist before taking other medications including over-the-counter and herbal products. I agree to be responsible for the secure storage of my medication at all times. I understand the importance of not informing others about my stimulant therapy. I agree not to give or sell my prescribed medication to any other person.

37 The Contract (continued) I acknowledge that Ms. Ganem is not obligated to replace any medication shortfall. I consent to open communication between Ms. Ganem, my PCP and any other health care professionals involved in my ADHD management, such as pharmacists, ADHD coaches, emergency departments, etc. I understand that if I break this agreement, Ms. Ganem reserves the right to stop prescribing stimulant medications for me. Patient Signature Witness Signature Date Date

38 WARNING: ABUSE AND DEPENDENCE CNS stimulants, including ----, other methylphenidatecontaining products, and amphetamines, have a high potential for abuse and dependence. Assess the risk of abuse prior to prescribing, and monitor for signs of abuse and dependence while on therapy.

39 The gold standard Urine Drug Testing Very helpful when you suspect split diversion Visit 1: You prescribe (short acting stimulant) once daily Visit 2: You increase the dose to BID dosing. Visit 3: Patient says it s still not lasting long enough, you increase the dose to TID, but you want to make sure the patients drug level increases accordingly.

40 The gold standard Urine Drug Testing Very helpful when you suspect split diversion Visit 1: You prescribe (short acting stimulant) once daily Visit 2: You increase the dose to BID dosing. Visit 3: Patient says it s still not lasting long enough, you increase the dose to TID, but you want to make sure the patients drug level increases accordingly.

41 Advantages of Oral Fluid Drug Testing Easy-to-use, non invasive collection method Expanded test menu Provides an option for individuals with a shy bladder Specimen alteration or substitution less likely due to conveniently observed collection Preserves patient dignity when observed specimen collection is required Solution for an office that may not have an accessible restroom

42 Long Acting ADHD Medications amphetamine methylphenidate atomoxetine lisdexamphetamine guanfacine XR Mixed amphetamine salts methylphenidate CR methylphenidate CD methylphenidate LA methylphenidate transdermal methylphenidate XR liquid desmethylphenidate XR

43 How the Long-Acting Stimulants Differ: 1. Mechanism of Action: Methylphenidate is believed to be primarily a dopamine reuptake inhibitor with some mild norepinephrine reuptake inhibition. Amphetamine is believed to be a dopamine reuptake inhibitor and a strong norepinephrine reuptake inhibitor. It s also thought to block the dopamine pump - increasing dopamine secretion. 2. How they are released 3. The duration of efficacy

44 2015 Also Both methylphenidate and amphetamine have been shown to have similar side effect profile and response rates of 70-75% 9 If there is a trial of each type of stimulant, the response rate increases to 75-90% 10

45 methylphenidate CR (Concerta) Delivers methylphenidate using an immediate-release coating and a delayed-release osmotic mechanism 22% immediate, 78% delayed release Designed for 12-hour effect Available dosages: 18mg, 27mg, 36mg, 54mg Approved up to 72mg/day (Adolescents and adults commonly need daily doses of 1-1.5mg/kg) To be effective the tablet can not be broken, crushed or chewed Approved 6-65yo

46 methylphenidate CD (Metadate) Biphasic delivery of methylphenidate using immediate and delayed-release beads within a capsule 30% immediate, 70% delayed Designed for 8-hour effect Available dosages: 10mg, 20mg, 30mg, 40mg, 50mg, 60mg Capsules can be opened and contents mixed with applesauce Approved 6-15yo

47 methylphenidate LA (Ritalin LA) Biphasic delivery of methylphenidate using immediate and delayed-release beads within a capsule 50% immediate release, 50% delayed Designed for 8-hour effect Available dosages: 10mg, 20mg, 30mg, 40mg Approved 6-12yo

48 methylphenidate transdermal (Daytrana) Continuous delivery of methylphenidate through DOT Matrix transdermal patch Efficacy from 2 hours* through 12 hours Approved for a 9 hour wear time (12 hour duration) Available dosages: 10mg, 15mg, 20mg, 30mg Approved 6-12yo * first time point measured in studies

49 methylphenidate XR liquid (Quillivant XR) Liquid form of extended release methylphenidate (25mg/5ml) 20% immediate release, 80% delayed release 12 hour duration with peak plasma concentration at 5 hours Starting dose is 20mg (4ml) given orally once daily in the morning with or without food. Dosage can be increased 10-20mg per day to a maximum dose of 60mg daily. Approved 6 and up, but age 65+ have not been studied

50 dexmethylphenidate XR (Focalin XR) Delivers dexmethylphenidate (active enantiomer of racemic methylphenidate) using immediate and delayed-release beads within a capsule 50% immediate release, 50% delayed Efficacy from 1/2 hour through hours Available dosages: 5mg, 10mg, 15mg, 20mg, 30mg Capsules can be opened and contents mixed with applesauce Approved 6yo-adult

51 Mixed amphetamine salts (Adderall XR) Delivers mixed salts of amphetamine using immediate and delayed-release beads within a capsule 50% immediate release, 50% delayed release Designed for 12-hour effect Available dosages: 5mg, 10mg, 15mg, 20mg, 25mg, 30mg Approved 6yo-adult

52 lisdexamphetamine (Vyvanse) It s a pro-drug, meaning it doesn t become active until various processes occur in the body It s the most consistently released stimulant from person to person 13 to 14-hour effect Available dosages: 10mg, 20mg, 30mg, 40mg, 50mg, 60mg, and 70mg Capsules can be opened and contents mixed with 4 ounces of water Approved 6yo-adults

53 atomoxetine (Strattera) Non-stimulant medication (NE reuptake inhibitor) Designed for 24-hour effect Available dosages: 10mg, 18mg, 25mg, 40mg, 60mg, 80mg Recommended starting dose is 0.3mg/kg/day, which is titrated over 1-3 weeks to a dosage of 1.8mg/kg/day or 80mg Approved 6yo-adults

54 guanfacine XR (Intuniv) Non-stimulant medication (long-acting* alpha-2 agonist) Once daily dosing with 24-hour effect Starting dose is 1mg with dosage increases of 1mg per week Recommended dose 1mg-7mg ( mg/kg target weight based dose range) Available dosages: 1mg, 2mg, 3mg, 4mg To be effective as a long-acting agent, the tablet can not be broken, crushed or chewed. Approved 6yo-18yo * The short-acting agent (guanfacine/tenex) is NOT interchangeable Jennifer A. Ganem MS, APRN - May 2015

55 Stimulants: Common Side Effects headache, lack of appetite, insomnia, mood instability*, stomach pain, increased BP/pulse, exacerbation of tics With Daytrana only irritant contact dermatitis* Side effects typically decrease with continued use. * = Exceptions. If the patient has these side effects, stop the medication ASAP! atomoxetine: headache, lack of appetite, sedation, mood instability*, stomach pain, increased BP/pulse, exacerbation of tics guanfacine XR: NO impact on appetite headache, sedation, lack of appetite, decreased BP/pulse

56 Follow up Visits Ask when the patient is taking the medication Screen for medication misuse, abuse, or diversion Reinforce to take the medication exactly as prescribed Do not change the dose or timing To call the office for an appointment if the medication doesn t seem to be working as it should or if experiencing adverse effects

57 Follow up Visits Obtain a self-report of medication efficacy Can use the ASRS again 0-10 scale 0 = able to pay attention 10 = unable to pay attention Ask about common adverse effects Lack of appetite Abdominal symptoms Headaches Sleep disturbance

58 Managing Decreased Appetite Maximize the hungry times of day by having additional (healthy) food Yogurt smoothies at night Have small protein-based snacks throughout the day Nuts Peanut butter crackers Cheese sticks Greek yogurt

59 Managing Insomnia Good Sleep Hygiene Use the bed only for sleeping so that the bed is positively associated with sleeping This means no reading, eating, watching TV, etc Set and maintain a regular sleep schedule and keep as close to it as possible on weekends Do not take naps during the day Get exposure to sunlight in the morning

60 Managing Insomnia Good Sleep Hygiene (continued) Get exposure to sunlight in the morning Get some daytime exercise and avoid exercise 2 hours before bedtime Reduce the use of computers and television within two hours of bedtime, because it can alter natural body rhythms If doing either, wearing amber lensed safety glasses for a couple of hours before bedtime will help block the blue light emissions. This allows the brain to produce melatonin. 11

61 Managing Insomnia Good Sleep Hygiene (continued) Keep the bedroom at a comfortable temperature; keep it dark and free of distractions Mute the cell phone or better yet keep it out of the room! Use a sound machine or fan for white noise Reduce stress and/or try relaxation techniques before bed Take a hot bath or have decaffeinated tea as a drop in body temperature helps increase drowsiness

62 Managing Insomnia Good Sleep Hygiene (continued) Move the clock so there s no clock-watching Use nightlights in the bathrooms and hallways Avoid caffeine after 2pm Avoid alcohol before bed

63 References 1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association. 2. Faraone, S.V., Biederman, J., & Mick, E. (2006). The age-dependent decline of attention-deficit hyperactivity disorder: A meta-analysis of follow-up studies. Psychological Medicine. 36: Kessler, R.C., Adler, L., Barkley, R., Biederman, J., Conners, C.K., Demler, O., Faraone S.V., Zaslavsky AM.(2006). The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry.163: Wilens, T. E., Gignac, M., Swezey, A., Monuteaux, M. C., & Biederman J. (2006). Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications. Journal of the American Academy of Child and Adolescent Psychiatry, 45(4), doi: /01.chi b3 5. DeSantis, A.D., Webb, E.M., & Noar, S.M.(2008). Illicit use of prescription ADHD medications on a college campus: a multimethodological approach. Journal of American College Health. 57(3): doi: /JACH Bright, G.M. (2008). Abuse of medications employed for the treatment of ADHD: results from a large-scale community survey. Medscape Journal of Medicine. 10(5): Kollins, S.H, Rush, C.R., Pazzaglia. P.J., & Ali, J.A. (1998). Comparison of acute behavioral effects of sustainedrelease and immediate-release methylphenidate. Experimental and Clinical Psychopharmacology. 6(4): Mao, A.R, Babcock, T., & Brams, M. (2011). ADHD in adults: current treatment trends with consideration of abuse potential of medications. Journal of Psychiatriatric Practice. 17(4): Steele, M,, Jensen, P.S., & Quinn, D.M. (2006). Remission versus response as the goal of therapy in ADHD: a new standard for the field? Clinical Therapeutics. 28(11): DOI: Pliszka. S.R. (2003). Non-stimulant treatment of attention-deficit/hyperactivity disorder. CNS Spectrums. 8(4): PMID: Burkhart, K., & Phelps, J. R. (2009). Amber lenses to block blue light and improve sleep: a randomized trial. Chronobiology International, 26(8): doi: /

64 Some Adult ADHDers Richard Branson - business magnate/investor Glenn Beck - political commentator Jim Carrey - comedian/actor Ryan Gosling - actor Woody Harrelson - actor Dean Kamen - inventor (also had dyslexia) Greg LeMond - cyclist Adam Levine - singer/songwriter Howie Mandel - comedian/actor Ty Pennington actor Michael Phelps Olympian