podcast for family medicine

Depression and Anxiety in Geriatric Patients

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On this week’s episode of the podcast, I am joined by Dr. Carolina Osorio, a geriatric psychiatrist (and one of my favorite people). After she finished her psychiatry residency, she also went on to finish a fellowship in geriatric psychiatry to take care of her favorite people. Dr. Osorio runs a special program that treats elderly people with depression and anxiety.


Mental health in the elderly

Sylvia Yu (MS3), David Puder, M.D.

As many people age, their health declines, and their needs increase. At the same time, we can experience loss of spouses because of aging, loss of friends and fear of death. We can lose eyesight, hearing, and subsequently, our drivers licenses and autonomy. It can be an incredibly stressful and lonely time.

At this time in history, like no other time before, we are experiencing a wave of baby boomers that will put a new strain on our already waning mental health facilities. Baby boomers are also more likely to stigmatize using mental health services.

Dr. Osario noticed these problems and she took steps to create a program that is helping her local aging population in a way that makes them feel comfortable.

If you are a primary care physician, psychiatrist, or a family member that is a caretaker for the elderly, this article will have takeaways from Dr. Osorio’s program that can help clarify how we can best help the aging population.  

When Dr. Osorio was a resident, she noticed that in mixed-age groups, older adults didn’t get the treatment that they needed. A general outpatient partial program wasn’t benefiting them, and sometimes it would make them worse because older adults tend to become parents to their younger peers in their group. She noticed that the older adults ended up taking care of their younger counterparts and not getting the individualized help they needed.

She started building a program to help the elderly in the way that they needed to be helped—through diet, exercise, therapy, medication management and stress reduction.

Medically, older adults have comorbidities, or more than one medical issue that needs to be treated. Because of this, having a geriatric therapist, group therapy session, or a geriatric mental health program can keep them happier, healthier and independent for longer.

If you run an outpatient group for the elderly, if you’re suggesting one for your patient, or if you are looking for one for an elderly friend or relative, here are a few things to consider:

  • Small groups - It takes longer to express their stories, to receive feedback, and to cognitively process information. Because of this, there should be no more than 8 participants in any one session.

  • Medication support/management/consultation - Often, elderly people are on too many medications, and this could be slowing them down physically, causing mental decline, and speeding up the aging process. We will make suggestions below on how medications can be managed.

  • Evidence-based therapies - A good outpatient elderly care program will also include evidence-based therapies (Bartels, 2003) to help the patients cope with their depression and anxiety, such as cognitive behavioral therapy (CBT), problem solving (Malhouff, 2007), reminiscence therapy (Elias, 2015), nutrition education, and medication education. Below, we will go into these therapies and why they are helpful.

Medications for aging adults

Benzodiazepines

Unfortunately, many elderly patients are prescribed benzodiazepines—drugs used to treat anxiety. Many primary care doctors have busy schedules with short appointment times. When the patient has hypertension, diabetes and osteoporosis, mental health can take a back seat to managing the more urgent health issues. The primary care doctor will usually just prescribe a benzodiazepine to deal with the anxiety issues.

There are several problems with giving benzodiazepines to the elderly. With time, the body gets used to the benzodiazepine, and the doctor starts to increase the dose. Then, the patient typically becomes even more depressed, more lethargic. This, in turn, increases other health issues.

That is why special consideration should be given when prescribing “benzos” to the elderly. It is also why Dr. Osorio’s goal in her outpatient program is to taper them off of their benzodiazepine medications. She says many of the patients she sees have been on them for 20-30 years.

Tapering a patient off of a benzo should be done very, very slowly in order to avoid delirium or worsening of anxiety.  

For example, if the patient is on 4mg of Xanax a day, Dr. Osario will convert them to Klonopin. Because of the half-life of the medication, the patient will have fewer symptoms of withdrawal when they start coming off of it. Then, she would reduce the dosage to 3mg of Klonopin over the next six months to a year.

Anticholinergic medications

As we age, our brain changes and there are parts of the brain that are going to have synapses that decrease. Acetylcholine actually decreases with age. But, if you add a medication that is anticholinergic, you are putting a bigger burden into that normal process. Then, there can be bad side effects such as confusion and dementia.

Because of that, Dr. Osorio says she will typically taper off or replace any medication with an anticholinergic burden. For example, the antidepressant Paroxetine is a no-go drug in the elderly population because it is very anticholinergic. The tricyclic antidepressants are also very anticholinergic. Nortriptyline, however, is one that Dr. Osorio would prescribe because it has much less of the anticholinergic burden at lower doses.

(I will put a list up on my website in my resource library of the different medications that are anticholinergic. Along with “Beers list,” medications that are contraindicated in older adults.)

Lithium

Physicians don't often think about lithium. Lithium is brain-protective (Forlenza, 2014). It has many functions that are very healthy and it actually produces neurogenesis in some patients. Consider, if you have a patient on an SSRI that isn’t responding how you’d like, adding a tiny dose of lithium (usually about 150-300mg).


Medication management for the elderly

Psychiatrists must work very closely with the patient’s primary care doctors. There are primary care doctors who also have a fellowship in geriatrics, but most do not have the specialized training needed to maximize mental health and minimize side effects. Sometimes it is helpful to have a conversation on behalf of the patient and guide them in certain medications. Every doctor should think about the whole body in general, and working with a primary care doctor can help psychiatrists do that.

A lot of older adults start feeling better when you start decreasing their meds. This indicates they were just depressed and did not have Major Depressive Disorder that required a heavy load of medications to manage it. It also shows that the depression was a side effect of medications. That, really, is the first thing you want to think about when you have a new patient and you see a very large list of medications that they are taking—are the symptoms because of the medication or is the medication helping alleviate symptoms? Should they be taking every single medication on the list?

There are a couple of studies that have talked about serotonin in older, depressed patients and how that can delay the progression of mild cognitive impairment of Alzheimer’s (Smith, 2017). One study showed that SSRIs are the best medications for it—Wellbutrin, SNRIs, tricyclics. There is actually another study done with older adults who had mild cognitive impairment and a history of depression (Bartels, 2018). Those who were taking SSRIs delayed progression of mild cognitive impairment by three years. But, in those patients who were put on another type of antidepressant, the progression was faster.

However, it is important to note that putting an elderly patient on an SSRI does not deal with the root of the issue. Therapy in conjunction with medication has been shown to be more powerful and sometimes eliminate the need for medication. If the patient is lonely, eating poorly, and has no life activities to look forward to, changing those factors can decrease the need for medication. Always consider therapy in addition to any psychiatric medication.

No matter what you prescribe, the patients have to take the medication for it to be helpful. Make sure to write down the medication, dosage, and times in clear language. Help the elderly patient understand what to take and when. When necessary, get helpful family members involved to remind the patient as well.

Therapy for the elderly

Another component of aging healthfully is receiving therapy. The cognitive load of aging alone, including the sum total of traumatic experiences, is often enough to require therapy to help with life transitions.

There are many forms of therapy available that can help the elderly experience a fuller life, deal with trauma safely, manage their depression and anxiety, and even stay mentally sharper for longer.


Problem solving therapy for the elderly

Problem-solving therapy is a way of teaching the elderly how to find ways to solve the particular problems that are unique to them. These problems cause anxiety and depression, so teaching them how to think about them, how to solve problems themselves, can give them a sense of autonomy and control. Sometimes, in therapy, you cannot solve the actual problem, per se, but the process of working through it together gives them different options that they can utilize if their anxiety starts to spike when they are alone.

For example, one elderly lady Dr. Osorio works with struggles with terrible anxiety. She recently broke her arm. She couldn’t clean her home, and her family would come over to help. She felt like a burden to them and was very anxious about this. During problem solving therapy, they  made a list of all of the things that needed to be done around the house, and then they marked the three things she could do, even with her broken arm, to help. She felt better knowing she could help her family while they were helping her. Even though we couldn’t fix the problem, we made it manageable, and gave her some autonomy back.


Reminiscence therapy for the elderly

In reminiscence therapy, you focus on reminiscing about good things. For example, Dr. Osorio will bring her elderly patients a picture of a turkey. She will ask them what it reminds them of. Everyone starts talking about Thanksgiving with their families. They discuss memories, smells, and they walk through the senses of what it was like for them at a happy time. This alone starts to fire up positive emotions in their brains and can change their moods instantly.

The cool thing about reminiscence therapy is that it even works with patients who have dementia, because their long-term memory is pretty solid. They can dip into their past and they immediately start brightening up. Their whole countenance changes.

It is a simple therapy to use, and it can be very helpful when dealing with depressed patients. They often feel alone, but when they begin to talk about the good times and share memories, it connects them to others in their group, and helps them make positive social connections.

Cognitive behavioral therapy for the elderly

There are also behavioral activations we can implement to help the elderly. The elderly patient typically has a hard time with scheduling routines. As their therapist, it can be helpful to get them to schedule a solid routine they can stick with because we have to break the cycle of depression and anxiety. For example, if you're depressed, you want to be in bed, you stay in bed, you get more depressed. This is damaging to an elderly person because it is much harder to get them to start scheduling and moving around again once they slow down. Activating their schedule can be a first step in keeping them independent for longer.

For elderly cognitive behavioral therapy, first, we do education on this process and then start helping them find ways in which they can break that lethargic routine. We want to help them choose an activity that they want to do so that it’s easier to break that cycle. Maybe that is going every Sunday to visit their grandkids. Maybe they can join a card game club, join a church, a quilting group, a storytelling group or take a community educational class. That one simple thing can break their cycle of depression, ease loneliness, and keep them engaged for longer.  

Aging and brain health

The evidence for maintaining brain health while aging says there are several things we can do to stay healthy: physical activity, socialization, nutrition and stress management.

Physical exercise

Dr. Osorio’s favorite exercise to recommend for the elderly is tai chi. Tai chi decreases the risks of falls in older adults (Lomas-Vega, 2017). There are even insurances that are starting to pay for tai chi for older adults because it is cheaper than fixing a broken hip. It’s a very easy, very smooth exercise.

For the wheelchair-bound, she recommends chair exercises. A physical therapist can help the patient move their arms, their torso, their necks. Maybe some of them can lift their legs from the knee up. Even if they can’t, they can still get a good exercise in and get some positive movement going.

When the elderly patient is doing really well in exercise they can start to add weights. Weights are very important because when they use weights their muscles are contracting and they’re positively impacting those bones. This is a good way to decrease osteoporosis. Even with the elderly, muscles can get stronger and their strength can increase. Studies even show that exercise in the elderly pretty much halts the dementia progression.


Socialization

Socialization is also very important. One study showed that the higher risk factor for morbidity and mortality was related to isolation (Holt-Lunstad, 2015). Isolation is actually toxic for our brains. If someone is home alone, they will usually die faster.

Being with friends and family and maintaining a social life helps the brain because it uses visuospatial skills, social skills and cognition. A simple conversation, a regular visit with a loved one or a new person can help an elderly person maintain positive brain health.

Human connection is necessary throughout all of life, and to have close, connected friends makes a huge difference. As part of her program, Dr. Osorio notices if they're having issues making friends, and she helps them create some behavioral activation to get them to places where there is a potential of making friends.


Nutrition

As far as nutrition goes, we have to take into account that the elderly population is pretty diverse. There are 60 year olds who are very fragile because of many health problems and there are 90 year olds who are pretty healthy.

Dr. Osorio personally recommends the Mediterranean diet. The Mediterranean diet is a diet that consists of grains, fish, olive oil, avocado, fruits and vegetables. The Mediterranean diet offers omega-3 fatty acids in the fish, high poly and monounsaturated fats in the olive oil and in the nuts.  There is also a lower amount of sugar then the average American diet. If elderly patients are struggling with making the big change in their diets, it’s best to merely suggest they don’t consume processed foods.

The Mediterranean diet has been associated with a reduced risk of developing mild cognitive impairment (MCI) or progressing to Alzheimer disease from MCI (Scarmeas, 2009). This year it was the number one diet recommended by the medical field.


Stress management

Stress reduction also adds to positive brain health. Mindfulness and visualization are both helpful practices to reduce stress. Stress reduction is not a one-time fix all. It is something that has to be practiced every single day in order to work.

Ask the patient to download a meditation app if they are technologically savvy, or even join a meditation group for seniors to increase their socialization. If neither of those works, getting them to quietly rest and close their eyes for even five minutes with the intention of relaxing, not just to nap or sleep, can have positive benefits.

Conclusion

If you work with the elderly, or know someone who is elderly, if they struggle with mental health issues such as anxiety and depression, or have comorbidity with other health issues, consider suggesting an outpatient group therapy for the elderly. It can be extremely helpful when paired with nutrition, exercise, and a cohesive plan with their primary care physician.

Other episodes I HIGHLY recommend if you are interested in treating elderly people:

Sensorium: Total Brain Function Optimization Part 1

Psychiatric Approach to Delirium with Dr. Timothy Lee

Questions, comments, thoughts? Please comment on the picture that corresponds to this post on my instagram: @Dr.DavidPuder

How to treat violent and aggressive patients

Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic

On this week’s episode of the podcast, I interview Dr. Michael Cummings. Dr. Cummings works at a state psychiatric hospital for the criminally insane, so he has extensive experience in treating patients for aggression and violence.

The different types of aggression

The words “aggression” and “violence” are sometimes used synonymously, but in reality, aggression can be physical or non-physical, and directed either against others or oneself. Violence is more of a use of force with an intent to inflict damage.

One study looked at the principle types of aggression and violence that occur in psychiatric patients, and broke it down into three categories:

  • Impulsive violence (the most common category)

  • Predatory violence (purposeful and planned violence)

  • Psychotically-driven violence (least common)

Within 5 state hospitals, 88 chronically or persistently violent patients with 839 assaults, the rate of impulsive violence was 54%, and predatory violence was 29%. Psychotically driven patients logged 17% of total violence (Meyers, M. Cummings et al., 2013). Studies show psychotically driven violence decreases the longer the patients are in care and medicated.

Predatory Violence

Predatory violence is what people typically think of when they think of psychopathy, or someone with antisocial personality disorder. It is violence with a purpose, and that purpose is usually to gain something. They typically show a lack of fear and very little autonomic arousal even when they are being violent.  The amygdala and the temporal lobe is underactive and the communication between them has a weak signal. People with predatory violence also have lower affective empathy.

Some of the early research done by Adrian Reign measured blood pressure, galvanic skin response and heart rate when showing neutral, frightening or peaceful pictures to children. Of those who lacked effective response or autonomic response to those pictures, 75% percent of those individuals became violent criminals by age 18. Interestingly, 25% of them became prosocial and entered jobs as police officers, bomb disposal experts, and so forth.

True psychopaths are a very tiny part of the population. About 2% of women score significantly on the psychopathy checklist. About 2-4% of men have elevated scores on the psychopathy checklist. Not all of those individuals, however, are violent, and many persons who are psychopathic are more interested in profit. Some become the crime bosses (not actually doing the violence themselves) and others end up in politics.

Impulsive violence

Impulsive violence or aggression is actually the most common, and in many ways the most complex, form of violence that occurs in a variety of mental illnesses, including:

  • psychosis

  • mood disorders

  • personality disorders

  • anxiety disorders

  • PTSD

It is essentially an imbalance in impulse generation and a failure of the prefrontal cortex to evaluate the impulse and weigh the consequences. All of us generate a variety of impulses, some good and some bad, including impulses driven by our irritability and anger.

In predatory aggression there is increased medial prefrontal cortex activity whereas in reactive aggression there is decreased activity.

What can cause impulsive violence to be an issue:

  • Traumatic brain injury

  • Some of the dementias including frontotemporal dementias

  • Anoxic brain injury

  • Intellectual disability

  • Personality disorders

  • Drugs

  • Drug detox

Psychotic aggression

Psychotically driven aggression is most often a result of delusional ideation or the belief the person holds that they are in some way being persecuted and being taken advantage of. Psychotic or mentally ill people do have an increased rate of violence compared to the general population. The mentally ill are responsible for around 5% violent crimes, meaning non mentally ill people are responsible for 95%.

Psychotic Delusions leading to violence

Ones study looking specifically at the first episodes of psychosis found that in about 458 patients, anger was associated with certain types of delusions that led to the violence (Coid, 2013).

The underpinnings of delusion-driven violence usually stems from when people have delusional beliefs that are persecutory in nature. When they believe that someone is out to get them, it removes inhibitions against acting out violently, because that person’s view is they are protecting themselves. Typically, this violence comes from the belief they are being spied on or persecuted.

Persecutory delusions associated with a command hallucination is a particularly potent precursor to violent behavior. If your delusion tells you your neighbor is the devil, and your command auditory hallucination is that God is telling you to “kill him and save the world from destruction”  it can lead to a very bad outcome.

IQ and aggression

There is also an association between the IQ and aggression (Huesmann, 1987).

A recent study in state hospitals looked at what correlated with persisting violence, and across all of the types of violent behavior, cognitive deficits (particularly impairments and executive functioning) were associated with elevated rates of violence.

Men are more violent than women

Men are likely more violent than women because they have historically been the hunters, which involves violence. Women were gatherers more often than not, and consequently, men have a standing evolutionary tendency toward more frequent use of violence. Women can be violent, but if you look at the rates of violence between men and women, men are clearly more violent.

The purpose of aggression  

You could say the healthiest outcome for our aggressive and violent impulses is when we use our innate ability to be aggressive to engage in things like a healthy competition. Or even to provide motivation and drive to achieve.

In the beginning, humanity formed tribes, and aggression allowed someone to climb up the dominance hierarchy within the tribe. It also allowed them to protect themselves from other tribes. It was basic for survival.

If we look at animal psychology, there is a lot we can learn about the aggression and dominance hierarchy, like how apes interact with each other, or form alliances. As a way of creating alliances, often an alpha ape will groom other males.  The violence comes out when the clans come against each other. When one ape is wandering from its clan, two apes from another clan may attack one single ape viciously.

In other circumstances, if a dominant ape is taken away from his clan for a couple of days and brought back into the clan, a couple of other apes may have formed a new alliance against the prior leader and attack him.

As human beings, we are also like this. Many of our social interactions and group structures have the same kinds of alliances and effects of absence can play out similarly. Of course as humans, we do have higher verbal centers, and philosophy or spirituality, that allows an individual to be less violent and to transcend their base instincts.

Aggression and autism

People with intellectual challenges most often exhibit impulsive violence, particularly those on the autistic spectrum. The person may have a greater difficulty processing or understanding their own emotions if there are significant intellectual deficits. They may also have elements of not being able to judge a response or to moderate a response. The general pathophysiology of the autistic spectrum disorder suggests that the connections between neurons and the autistic brain is not what it should be, and they are not differentiated so that information processing can be fragmented.

Treatment of aggression

Psychotic aggression treatment

Treating with an antipsychotic medication is helpful and decreases violent episodes. In one study, clozapine helped psychotic aggressive patients with executive dysfunction more, compared to using haldol or olanzapine (Krakowski, 2011).   

Psychopathic aggression treatment

A predatory-violent individual needs to be contained in prison if there is a demonstrated past of persistent violence.

There is evidence that by enhancing intellectual empathy, psychopaths will be less violent. There is also interesting research that by giving oxytocin, the hormone that increases affiliation and collaboration, may have a moderating effect on some psychopathic individuals.

However, in terms of psychopharmacology, we don’t have any specific medications to control that behavior. Some medications, such as clozapine, can affect the underlying issues behind psychotic behavior and thereby reduce it, but there is no direct treatment for psychopathic violence pharmacologically.   

Impulsive aggression treatment

Dr. Cummings discussed the use of Mood stabilizers helping in persons with borderline personality disorder, SSRIs and trazodone helping in dementing illness in the elderly and alpha 2 agonists in people with things like autism or TBI. Alpha 2 agonists (clonidine) can fool the brain stem into thinking enough norepinephrine has been released, then less norepinephrine is secreted, making the brain stem calm down.

Essentially, in an emotional disorder, if you change the affective (limbic) tone, you can decrease the likelihood of emotionally reactive aggression, for example, by using mood stabilizers lithium and divalproex.  

Using an antipsychotic, and not just a mood stabilizer, doesn’t show any benefit for traumatic brain injury patients. Antipsychotics have been used for people with autism spectrum disorder, and some evidence shows that drugs like risperidone can be helpful to control outburst issues. If there is evidence of sexual aggression (or aggression occurring at women after puberty), using an GnRH agonist—antiandrogen treatment—can sometimes be necessary).

Psychotherapy for aggression

There have been a number of anger management therapies that have been used over time. Therapists can help people be aware of their anger and manage their impulses, or push their anger and aggression toward a more prosocial response.

For people with borderline personality disorder, dialectical behavioral therapy, mentalization based therapy or transference therapy are important. For schizophrenic patients, a good therapeutic alliance is important to create medication compliance. I have touched on how to process anger in my microexpression series and will have future episodes focusing more on the psychotherapy approaches to anger.  

Overall in therapy, we must assume that our patients will lie to us sometimes because they are afraid, and double check to insure they are following our prescribed protocol. We must also work hard to build trust and a therapeutic alliance.

Final Thoughts

Violence and aggression deserve much more attention as a specialty than we have given it in the past. It is a major burden for family members and friends.

Please submit any questions you have and we will submit them to Dr. Cummings and to answer.

(In the podcast details about specific medications are discussed for psychiatrists who are interested in advanced psychopharmacology.)

Further reading:

Link to Ideal blood levels are found in Resource Library

“California State Hospital Violence Assessment and Treatment (Cal-VAT) guidelines”




ADHD: Diagnosis, Symptoms & Treatment

Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic

In this week’s episode of the podcast, I interview Dr. Michael Cummings about psychopharmacology for Attention Deficit/Hyperactivity Disorder (ADHD). We talk about the symptoms, the treatments, and the typical myths about the disorder.

What is ADHD?

ADHD is a brain neurotransmitter disorder that affects a person’s ability to concentrate, their social interactivity, and their impulsivity.

Diagnosing ADHD

People who truly have ADHD typically experience inattentive and hyper symptoms across all areas of their life. For example, if they are in a job that requires periods of attention to complete or organize a project, it will be inherently more difficult for people with ADHD.

One of the things that’s important in diagnosing people (particularly younger people) is their collateral history. People around the person with suspected ADHD are often more aware of the person’s deficits than the person themselves. When they reach adulthood, the problems might be made more obvious when they integrate into normal society and notice they struggle with symptoms of ADHD (compared to other people).

Although not required for diagnosis, PhD level psychologists can do psychological testing, along with ADD/ADHD testing and IQ testing, to get a full idea of the patient’s symptoms. It helps confirm the diagnosis because these tests are widely used among the entire population, which provides a large sample mean to compare with. It’s also helpful to get a benchmark of performance before beginning treatment and then follow it up with later testing to see how effective the treatment has been.

Myths about ADHD

If a child is hyper, he or she has ADHD.

ADHD diagnosis has, at times, been a fad in the public, leading to many misdiagnoses and overmedicating, especially in children. Children are inherently hyperactive and less attentive than adults are. Doctors who are performing diagnostic tests must really pay attention to the criteria in children to make sure that the magnitude of the problems truly cause stress and social dysfunction before they try to diagnose or medicate a child.

For example, the LA times published an article that ⅓ of the children in Orange County suffered from ADHD. Real studies show that prevalence in children is around 6-8%, in adolescence about 2.8%, and in adults about 2.5% of the population.

ADHD disappears with the onset of puberty.

Attentional deficits sometimes remains into adulthood, while hyperactivity may disappear as a child matures.

We are giving people methamphetamines as medication.

Methamphetamines and amphetamines are completely different drugs on a molecular level. The methyl group paired with amphetamines increases its absorption and effect on the brain. The amphetamines that are used to treat ADHD are essentially variants of dextroamphetamines.

There are even versions that are difficult to abuse, such as with vyvanse, where lysine (the amino acid) is bound to the amphetamine. The lysine make the amphetamines unabsorbable unless it’s in the GI tract. It cannot be inhaled or injected and still be effective. Similarly, some of the slow-release versions are encapsulated in pills that won’t release the drug easily, except very slowly in the GI tract, making it difficult to divert or abuse those formulations.

Dopamine stimulants are the only treatments for ADHD.

There are other drugs that are useful for ADHD symptoms. They are (for the most part) drugs that increase brain norepinephrine. They can be used for people who don’t tolerate increases in dopamine, or for other reasons cannot be treated with dopaminergic agents.

The most common side effect from amphetamines are increased anxiety, insomnia, increased sweating, hypertension, heart rate and blood pressure. These are things that can be overcome by titrating the drug more gradually, or being very attentive to the overall dosing of the drug.

Amphetamines are likely the first line of treatment, unless a person has anorexia, is still growing, or still has strong family genetics with a history of addictions.

What are true warning signs of child ADHD?

When the child is struggling socially, has attention deficit, is struggling academically, and the problems are noted by the educators and parents alike, it may be time to seek out a diagnosis. Most teachers get pretty good at recognizing the one or two children in the class that are most impulsive, most hyperactive, and less attentive, so it can be helpful to ask them first if they’ve noticed something disruptive about the child.

Often, boys with ADHD are easier to spot, because they tend to act out more. Girls tend to more often fall into the inattentive subtype, but may not be hyperactive or disruptive. They may not do as well academically, though intelligent, and that is a cue that they should be tested for the inattentive subtype. The problem is that unlike many disorders that have clear markers, attention—and the ability to modulate attention—always varies.

One of the characteristics of people with ADHD is that they tend to be impulsive, often acting without thinking through the consequences of their behavior, which can lead them in some cases to do things that will get them in trouble in school or in their social group. It can become a self-reinforcing phenomenon. If a child is often in trouble and begins to take on the “troublemaker” attitude, the behavior can continue as part of their identity. There is even an association between ADHD and the development of conduct disorder and/or antisocial personality disorder.

ADHD in adults

Sometimes I treat young adults who were high functioning enough in high school to be able to get by academically, but they noticed a major difference in college when the coursework became more difficult. They’d procrastinate as long as they could, and only get things finished at the last minute when adrenaline kicked in and stimulated their brain to do the work.

ADHD has been recognized as a failure of the reticular activating system to adequately stimulate the portions of the brain stem (the cortex and basal ganglia) in a way that it works for non-ADHD people. It can feel a little like the brain is drowsy all of the time.

Another characteristic of ADHD is that patients tend to be more able to concentrate on subjects they are interested in. For example, medical students who prefer higher-risk, fast paced environments tend to not need their medication when they are in emergency room rotations. When they are in a subject matter that is not as interesting to them, they might need to take their medication to function at a higher level and retain the information. I try to help my ADHD patients increase the meaning in what they are doing on a daily basis as a form of treatment.

People with ADHD have a higher rate of injury than the general population. There are many circumstances in which not paying attention to your environment is dangerous.

One study shows that there is even a correlation between car accidents and ADHD. Driving requires attention and responses, and if people are prone to do impulsive things, but are not prone to pay attention, it can increase their rate of accidents.

There is a noted decrease in risk of drug abuse when someone is treated appropriately with dopaminergic drugs, than there is if someone with ADHD is untreated. One of the things that occurs in people who don’t receive appropriate treatment and education (but they have ADHD) is that the first time a person takes a stimulant medication, maybe experimenting in college, illegally borrowing some for a test from a friend, they will report it as being the “first time they ever felt normal.” It can be a powerful lure to revisit the experience of feeling more normal, and being able to pay attention (I am in saying this, not recommending you ever share your ADHD medications, but nevertheless it is commonly reported to me on history as how they found out they might need treatment.)

Without guidance and education, it can be a pathway to drug abuse rather than an appropriate treatment. Proper treatment can greatly enhance quality of life.

Treating ADHD

I once had a patient in the emergency room that told me she put a little bit of methamphetamines in her coffee every morning. She wasn’t getting high off of it, but I did wonder if she was self-treating something she had naturally noticed was a problem for her—inattention.

People with ADHD should also be receiving a broad spectrum of psychosocial treatment and therapy, not just medication. If a child is under the age of 6, he or she should be given behavioral therapy as a first line treatment. The initial approach of diagnosis should be made carefully. If the person does have ADHD, the first treatment should be psychosocial interventions, afterwards, if that does not work, they can try medication.

The main category for pharmacological treatment of ADHD are dopaminergic stimulants. These drugs essentially serve to stimulate the production of dopamine (amphetamines) or to block its reuptake (with drugs like methylphenidate). Amphetamines increase and release proper neurotransmitters and block reuptake, while methylphenidate is more purely just a reuptake inhibitor for dopamine.

Medications that contain amphetamines will stimulate motor activity in healthy people, while it will actually return a hyperactive person to a calmer state as the dopamine regulates in their brain.

For those who don't respond to dopamine increasing drugs, the other approach has been to increase norepinephrine with drugs like atomoxetine or some of the noradrenergic antidepressants, thereby increasing the person’s alertness. About 70% of people respond to dopaminergic agents, and 30% don’t respond, or can’t tolerate the increase in dopamine because of either insomnia or increased restlessness.

Sometimes people with ADHD can also have comorbid anxiety. One professor explained that there is a survival advantage of both having ADHD and being willing to do high-fear tasks, but they also can have comorbidity with anxiety that keeps them from taking too high of risks and killing themselves.

Often, when a patient comes to see Dr. Cummings that has both ADHD and anxiety, his first line of defense is to try and increase serotonin through SSRIs, along with the drug they are taking for ADHD. Some could take an antidepressant as well. Most children and adolescents with ADHD do best with a dopaminergic agent, although those are also problematic in some people.

Exercise also has a positive effect on ADHD, specifically anaerobic exercise. It can aid several neurotransmitters, including norepinephrine and dopamine.

Issues with ADHD medication

Sometimes children who are on ADHD medication can experience a loss of proper growth hormone, causing different issues. If someone chronically takes a stimulant, they will be about an inch or an inch and a half shorter than if they did not take a dopamine stimulant. If that’s a problem for them will depend on the inherent genetic makeup of the person. If the child comes from a family of very tall people, it might not be a problem to lose an inch or two. If the family is short, losing an inch or two might be more of an issue socially and culturally.

Also, anorexia can be an issue, because dopaminergic medications can decrease appetite. It occurs to some extent in everyone who takes a dopaminergic drug, definitely enough to cause widespread clinical concern. However, there are approaches, such as taking drug holidays from the medication, that can help regulate the decreased appetite. Whether someone should take a drug holiday, or break from taking their medication, will depend on how disruptive the person will become when they are not on a stimulant. If it will cost the person social interactions and friendships, it is usually better to keep them on the medication.

Other abuses of ADHD drugs are very similar to the abuse or appropriate use of any molecule. The person who is using a stimulant appropriately is using it to improve their functionality—they are using it to pay attention and have a normal life. The person who is abusing a stimulant is taking it for the purpose of getting high. They are seeking the euphoric effects of the stimulants rather than positive life change. Someone who is trying to get a “speed run” will take a gram of medication, while someone who is trying to medicate for ADHD will take 20,30, or 50mg of methylphenidate in order to maintain their ability to concentrate.  

The true identification of abuse of amphetamine medication is a person’s deterioration in their ability to function in a balanced manor. Not sleeping for days because of stimulants, even if someone is able to get A’s on tests, is not improving their functionality and may hurt them long term.

In conclusion

As a whole, doctors need to be more careful when diagnosing ADHD. There is a tendency to over-diagnose, leading to over-medicating. Even if you receive a diagnosis, there are also several cognitive behavioral therapies that have been developed to help people deal with the psychosocial components of having ADHD. These can be self-administered through computers. There are also mindfulness practices to help the person monitor themselves so they are better at social interactions. Exercise should also be optimized. Repeat psychological tests can help guide effective treatment. Patients who have had ADHD untreated for years might have subsequent low self esteem. Approaching the uniqueness of the patient and their presentation will help the patient thrive!



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Psychiatric Approach to Delirium with Dr. Timothy Lee

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This week on the podcast, I am joined by Dr. Timothy Lee, the Loma Linda residency program director and the head of medical consult and liaison services. One of his specialities is delirium, so this week we will be discussing both hypoactive and hyperactive delirium.  

What is delirium?

Delirium is an acute change in a person’s sensorium (the perception of one’s environment or understanding of one’s situation). It can include confusion about their orientation, cognition or mental thinking.

With hyperactive delirium, a patient can become aggressive, violent and agitated with those around them. A patient experiencing delirium can have hallucinations and hear things, they can become paranoid, and they are overall confused. A family, or non-psychiatric medical staff, might be concerned that the patient is experiencing something like schizophrenia.

Hyperactive delirium symptoms in patients:

  • Waxing and waning—it comes and goes

  • Issues with concentration

  • Pulling out medical lines

  • Yelling profanities

  • Throwing things

  • Agitated

  • Responding to things in the room that aren’t there

  • Not acting like themselves

Hypoactive delirium is much more common than hyperactive delirium (based on research studies), but it is often missed because the presentation is much less dramatic. People with hypoactive delirium are confused and disoriented, but they do not express their confusion verbally or physically.

Hypoactive delirium symptoms:

  • Slower movement

  • Softer speech

  • Slower responses

  • Withdrawn

  • Not eating as much

Often, nurses and physicians can miss the fact that the patient has the typical confusion that denotes delirium because the patient is quieter, so it doesn’t come to the attention of the medical team or psychiatrist consult service.

Delirium can even be confused for depression. One Mayo Clinic study showed that when consulting a doctor about their depression, 67% of the time, the patient ended up having delirium.

Why does delirium happen?

Often we see it happen, even to relatively healthy people, in physically stressful situations—post surgery, during an acute illness, or even just being stuck in the hospital for a few days. This does not mean it is indicative of a sudden onset of a long term mental illness, such as schizophrenia.

To consider what can cause delirium, I like to think systematically from the top of the body and work my way down. This is by no means exhaustive, but it can be helpful.

Many things can cause delirium. I like to think about starting at the top of the body and going down, as a way to not miss the cause. Here are a few we would consider as we go down the body:

  • Stroke—check strength in both arms and legs, have the patient smile

  • Hypertensive emergency

  • Infection or meningitis

  • Physical trauma—concussion, head injury with initial loss of consciousness, then after regaining consciousness they can have delirium

  • Brain bleeding

  • Medications that affect the brain, such as ones that produce anticholinergic side effects. (They suppress acetylcholine, causing brain imbalances and confusion. Anti-allergy medicines, pain medications, and some psychiatric medications are anticholinergic.)

  • Circulatory issues

  • Thyroid imbalances or parathyroid hormones

  • Cancer

  • Heart attack

  • Traumatic injury to the heart

  • Aspiration pneumonia

  • Lung infection

  • Lung cancer

  • Viral pneumonia

  • Pancreatic inflammation

  • Urinary tract infections in women

  • Liver cirrhosis

  • Hepatitis

  • Gallbladder inflammation

  • Low bilirubin

  • Hepatic encephalopathy

How do we identify delirium in a patient?

Asking certain questions to the patient and/or medical team and family can help us understand if the patient is experiencing delirium. Often, a patient experiencing delirium will still know where they are, what they are doing, and who they are. The main test to really determine if it’s delirium is the “clock drawing” where we ask the patient to draw a clock with the hands showing 11:10.

Here are some questions and tasks we ask the patient to answer and perform to test for delirium:

  • Does the person know who they are?

  • Does the person know where they are?

  • In what detail does the person understand where they are?

  • Does the person know the date?

  • Can they orient to the situation? Do they know why they are there and the circumstances that led to them being in the hospital?

  • We might ask the patient to repeat back a few words for us.

  • We will ask them later if they remember the three words we asked previously.

  • We test for concentration, like asking the days of the week in reverse order.

  • We try to assess their visual and spatial ability.

  • We might ask them to draw a clock to look for spacing, impairments, or difficulties.  

Some tests that are common to determine delirium are:

  • The Mini Mental Status Exam (MMSE)

  • The Montreal Cognitive Assessment

How to help

It is important, if the patient has loved ones with them, to educate the family about delirium, because both hypoactive and hyperactive delirium can be terrifying to watch.

When it comes to giving medications, it’s important to follow a few rules, Dr. Lee says. Giving medications with anticholinergic side effects can make the patient more agitated. When prescribing meds, be careful not to switch from a hyperactive delirium presentation to a hypoactive delirium presentation by just sedating the patient but maintaining confusion. Medications like benzodiazepine, barbiturates, sedatives and pain medications (beyond what is needed for pain) can all cause worsening of delirium.

If the confusion is from an infection, an antibiotic should eventually help the cause of the delirium, however it may take a few days for the confusion to improve after the cause is eliminated.  At times antipsychotic medications are used to help the delirium and reduce the time needed to stay in the hospital.

Even after the cause of the delirium is gone, and the delirium seems to have improved very quickly, a person may still have lingering cognitive issues. It’s important to be conservative in terms of how quickly you taper them off of the antipsychotic medication used to treat the delirium.





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