Evidence-Based Reviews

Psychostimulants for older adults

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Certain agents may improve apathy, ADHD, depression, and other conditions


 

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Psychostimulants are recognized for their role in managing attention-deficit/hyperactivity disorder (ADHD), but also have found a treatment niche in conditions such as apathy, fatigue, and depression.1 Psychostimulants—methylphenidate, amphetamines, and their respective isomers—are known to promote wakefulness, increase energy, and help improve attention. Although these medications can provide much-needed relief to many older patients, clinicians need to be mindful of possible side effects and safety concerns when prescribing psychostimulants for geriatric patients.

Most psychostimulant research has evaluated children and younger adults; however, geriatric patients (age >65) deserve special consideration. Although these patients’ changing physiology often presents treatment challenges and may predispose individuals to adverse events, emerging evidence suggests that psychostimulants are valuable in treating motivational and attentional symptoms that do not respond to other treatments. Older adults’ diminished treatment response to antidepressants, fatigue, and comorbid medical illness make stimulants an attractive treatment option. However, there is a paucity of research addressing psychostimulant use in geriatric patients. Moreover, psychostimulants should be used in older patients only after carefully considering potential side effects and general medical safety.

This article will focus on clinical scenarios in late life—such as apathy, ADHD, and depression in medically ill patients—when treatment with psychostimulants may be useful. Psychostimulants are FDA-approved primarily for use in ADHD and other uses are considered off-label. We will highlight research in this population and use case vignettes as examples to present a sensible approach to treating geriatric patients with psychostimulants (Table).

Table

Using psychostimulants in older adults

CategoryComment(s)
Clinical utilityApathy, ADHD, fatigue, depression in medically ill patients
Starting dosageMethylphenidate: 10 mg/d (typical dose is 20 mg/d)
Consider a 5 mg/d starting dosage for frail patients
Give the second dose mid-afternoon to avoid insomnia Dextroamphetamine: 10 mg/d (typical dose is 20 mg/d)
Consider a 5 mg/d starting dosage for frail patients
Give the second dose mid-afternoon to avoid insomnia
Comorbid medical conditions that warrant concernCardiac or glaucoma history
Possible drug-drug interactionsMAOIs: Serotonin syndrome, hypertensive crisis
TCAs: Increased antidepressant levels
Warfarin: Increased warfarin levels
Safety monitoringHeart rate, blood pressure, weight
ADHD: attention-deficit/hyperactivity disorder; MAOIs: monoamine oxidase inhibitors; TCAs: tricyclic antidepressants

Stimulants and apathy

Apathy is a loss of motivation, interest, or initiative that is not attributable to cognitive impairment, diminished consciousness, or emotional suffering.2 Considered a distinct entity from depression, apathy is common late in life, particularly in persons with dementia of the Alzheimer’s type (DAT); 70% to 90% of patients may experience apathy at some stage of dementia.3 Apathy is linked to impairment in activities of daily living and needing more assistance from caregivers, which increases caregiver burden. Treating apathetic symptoms may improve quality of life for the patient and caregivers. For a case study of an older patient with apathy treated with a psychostimulant, see Box 1.

Apathy has been treated successfully with a variety of stimulant medications. In an open-label study, patients with DAT who received methylphenidate, 10 to 20 mg/d, showed significant improvement in Apathy Evaluation Scale (AES) scores.4 Similarly, Herrmann et al5 also demonstrated improvements in AES scores in DAT patients taking methylphenidate, 20 mg/d, compared with placebo. Although methylphenidate appears to have the strongest evidence for treating apathy, dextroamphetamine also has been shown to produce modest improvements in apathy scale measures.6 A double-blind, placebo-controlled crossover study showed that dextroamphetamine, 20 mg/d, significantly improved scores on neuropsychiatric inventory scales that were driven by apathy subscales.6 However, this trial was small (N = 8).

Preliminary evidence indicates that psychostimulants may improve apathetic symptoms in patients with dementia. In Mr. A’s case (Box 1), he experienced apathy symptoms that affected his quality of life and that of those around him. He showed a clear lack of interest and motivation and indifference. This scenario is common among geriatric patients and may be misinterpreted as depression. Although the overlap may be considerable, screening for apathy may help determine a treatment course with psychostimulants instead of antidepressants, thus avoiding unnecessary medication trials.

Box 1

Case 1: A dementia patient who loses interest in life

Mr. A, age 76, has dementia of the Alzheimer’s type. His family brings him to a psychiatrist because Mr. A exhibits a generalized loss of interest. His history reveals a gradual onset of memory problems with steady decline. Current deficits include problems with forgetfulness, misplacing items, increasing difficulty with names, occasional repetitiveness, and mild word finding difficulty. His family complains that Mr. A does not take care of himself, sits all day long, is not interested in his favorite TV shows, is indifferent to his physical health, is not interested in catching up with friends, and has been doing very little from day to day. He does not seek food but cleans his plate when served. His family became concerned when Mr. A showed no excitement in going to his grandson’s baseball game, which he had previously enjoyed. Mr. A denies any concerns and scores a 3 out of 15 on the Geriatric Depression Scale. Mr. A’s family rated him 4 on the same scale.

On the Apathy Evaluation Scale (AES), he scores 46 (moderate severity). We start methylphenidate, 5 mg administered in the morning and early evening (5 pm). Subsequent conversations 2 weeks later with Mr. A’s family revealed Mr. A’s interest levels have improved and reported no side effects. We increase methylphenidate to 10 mg twice a day. Mr. A has remarkably improved hygiene 1 month later and is more engaged in the interview. He scored a 32 (mild severity) on the AES and the family notes that he is interested in watching his grandson play baseball. During this treatment, we did not change Mr. A’s other medications—donepezil, 10 mg/d, and bupropion, 150 mg/d.

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