ADHD Across the Lifespan
Because ADHD is a chronic disorder that requires lifelong monitoring and treatment, PCPs must recognize its presentation across the lifespan and target treatment appropriately.
Although DSM-5 diagnostic criteria apply to preschool-aged children, evaluation and treatment are challenging. First-line treatment for children 4 to 6 years of age is behavioral parent training and classroom interventions. If behavioral interventions do not promote significant improvement, methylphenidate may be prescribed for children with severe symptoms.13 Preschoolers with ADHD are less likely to be ready for school than children without ADHD, underscoring the need for early identification and treatment.29
Special considerations associated with this age group are related to the neurodevelopmental delay and impulsivity that come with ADHD. With academic promotion to high school or college, there are increasing demands for time management, longer-range planning toward future goals, and organization of multiple tasks. Therefore, functional difficulties related to executive functioning that may not have been apparent earlier become apparent, leading to a previously missed diagnosis of ADHD. The complexity of learning to drive may pose serious challenges to patients with ADHD, who are at higher risk for traffic accidents. In addition, adolescents often begin to experience issues with substance abuse and diversion of stimulant medications.25
The following established clinic practices should be implemented in the management of adolescents and adults with ADHD. Initial stimulant prescriptions should be delayed until a diagnosis is established. If prescribed, patients must agree to implementation of a Schedule II patient agreement, regular appointments, not asking for prescriptions outside of regular appointments, periodic urine drug screens (UDS), and stated actions for positive UDS for illicit drugs. In addition, before prescribing a stimulant, the PCP should check the prescription monitoring program for any red flags. These precautions can improve care and manage provider risk related to long-term prescriptions for CNS stimulants in adolescents and adults.30 The use of nonstimulants or extended-release stimulants is preferred when substance use or misuse is a concern.16
Adults with ADHD present differently than their younger counterparts and, therefore, may go undiagnosed. A recent review of the literature supports the importance of emotional dysregulation as a significant element of adult ADHD that is not reflected in the DSM-5 criteria.31 To improve identification of ADHD, some clinicians may wish to include neuropsychological tests; however, because of the inconsistent cognitive deficits of ADHD, no distinct psychometric test or profile for ADHD exists.32
The PCP must review the screening items carefully with the patient during a diagnostic interview to clarify and expand on selected answers. Further inquiry related to impairment in functioning, such as time management difficulties, erratic work/academic performance, anger control issues, family or marital problems, difficulty managing finances, frequent accidents related to recklessness or inattention, or frequent loss of cell phones or keys, may provide important information to clarify the overall diagnostic picture.
A thorough substance use history, including stimulant, energy drink, caffeine, and cigarette use, may present the possibility of the individual treating their symptoms to enhance attention or to manage psychiatric comorbidities. Implementation of substance use monitoring strategies is indicated if substance use or medication diversion/misuse is suspected. An adult treatment algorithm is being developed by the American Psychiatric Association.
The lack of age-appropriate diagnostic criteria and the complexity of differential diagnosis (mild cognitive impairment, increased polypharmacy, sleep disturbances, chronic pain, and physical conditions) make an ADHD diagnosis difficult in older patients.
In a systematic review, Torgersen et al found that the prevalence of ADHD symptoms declines to 1% to 2.8% in adults older than 50 years.33 However, there is reason to believe that ADHD symptoms persist into late adulthood in a large number of patients. Older adults are likely to have comorbid mental health disorders that require treatment, including depression (36%-54%) and anxiety (26%-42%), as well as mild cognitive impairment.33 Fischer et al found that approximately 50% of memory clinics in the United States reported seeing ADHD patients; 20% of clinics reported screening regularly for ADHD.34 However, they concluded that ADHD in older adults may not have been considered to be a premorbid condition affecting cognitive functioning.34
In general, older adults have a reduced capacity to metabolize drugs and have an increased sensitivity to medication-associated side effects. In addition, there are increased concerns about polypharmacy and drug-drug interactions in this population. Despite a lack of controlled studies, a “start low, go slow” titration approach is recommended when using central nervous system stimulants. Patients reported improvements in variables of attention, such as being more organized, more focused, and being able to understand written text better. In addition to stimulants as first-line treatment, psychological treatments using metacognitive therapy and cognitive behavioral therapy have shown promise.34
When to Refer
It is the role of the PCP to manage mild to moderate ADHD with co-occurring anxiety and depression. When medical or psychiatric comorbidities contribute to the complexity of treatment and uncertainty of diagnosis, it may be time to refer the patient to psychiatric clinicians or therapists. Referral also is recommended for patients who fail to respond to algorithm-recommended treatments, as well as for those in whom drug-seeking behavior is suspected or there is a patient/family reluctance to accept the diagnosis and/or treatment.25
Carol Kottwitz, DNP, PMHNP, PMHCNS, is a psychiatric nurse practitioner and owner of CK Therapeutics LLC, and assistant professor in the School of Nursing and Human Physiology at Gonzaga University in Spokane, Washington.
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