Kembara Xtra - Medicine - Adult Attention Deficit Hyperactivity Disorder
BASICS Adult Attention Deficit Hyperactivity Disorder (ADHD) is a pattern of behaviors that includes impulsivity, hyperactivity, and/or lack of attention. It is prevalent in a variety of contexts that harm social, intellectual, or occupational performance. Adult ADHD often starts in childhood; 30-60% of individuals who were diagnosed with ADHD as children will still fulfill criteria as adults. Complications of adult ADHD include career, financial, and interpersonal difficulties as well as an increased risk for car accidents and suicide. DESCRIPTION Hyperactivity/overactivity, impulsivity, and trouble focusing are symptoms. Executive function deficits and emotional instability are frequent characteristics. The three basic kinds of ADHD are (i) combined, (ii) inattentive predominant, and (iii) hyperactivity-impulsivity predominate. The inattentive and hyperactive varieties are next most prevalent, then the combination type. EPIDEMIOLOGY Prevalence 4.4-5.2% of adults between the ages of 18 and 44 suffer with ADHD. Men are more likely than women to have ADHD. This can be the result of women being undervalued. Women are more likely to be undetected or have the wrong diagnosis and are less likely to be referred for testing. PATHOPHYSIOLOGY AND ETIOLOGY Genetics ADHD appears to have a genetic component, and given that it has a heritability of about 0.8, genetic influences are likely to account for roughly 65% of phenotypic variation. First-degree relatives of people with ADHD have a 4–5 times higher chance of developing the disorder than the general population. RISK ELEMENTS According to studies, children of moms who smoked or had obesity or diabetes during pregnancy are more likely to have ADHD. The risk is also higher for people who were exposed to lead as children. Whether these relationships are causative is unknown. Other factors that raise the risk include preterm birth, extremely low birth weight, significant neglect, abuse, or social deprivation, as well as specific infections that can occur during pregnancy, delivery, and the early years of life. ● Pregnancy obesity, gestational diabetes, high blood pressure (BP), childhood seizures, childhood brain damage, and other neurodevelopmental disorders like autism spectrum disorder and learning difficulties are additional risk factors for ADHD. COMMONLY ASSOCIATED CONDITIONS include substance use and abuse disorders, mood and anxiety disorders, intellectual disabilities, tic disorders, delayed sleep-wake phase disorder, and obsessive-compulsive disorder (OCD). The patient's history and the patient's present level of functioning in at least two separate contexts (such as at work and at home) are used to make the diagnosis. It's crucial to compile the patient's academic and childhood history. HISTORY Poor focus, disorganization, failure to finish projects, poor performance at work, and problems controlling anger are some of the frequently reported symptoms of ADHD. DSM-5 requirements consist of (1): - At least five signs of impulsivity, hyperactivity, or inattention - A number of symptoms must appear before to the age of 12 (if not recognized in childhood, this is proven by a review of past instances of childhood symptoms). - Two or more environments (such as home, work, etc.) must exhibit the same symptoms. - There must be convincing evidence that the symptoms affect or degrade social, intellectual, or occupational functioning. - The presence of symptoms must last longer than six months. Previous use of drugs or chemicals, such as anticonvulsants, steroids, antihistamines, nicotine, or caffeine, that have negative effects on attention and mimic symptoms of ADHD. Thyroid diseases, head trauma or injuries, liver disease, and seizure disorders in the past Ask about family history of ADHD as well as other psychiatric and neurologic issues. Ask about cardiovascular illness, neurodevelopmental diseases such as autism spectrum disorder, tic disorders, and learning impairments. MEDICAL ANALYSIS A physical examination is essential to excluding other medical issues. Focus on thyroid and neurological tests; seek for results that point to drug misuse. Record your baseline weight and blood pressure, and keep an eye on yourself if you start receiving medical attention. DISTINCTIVE DIAGNOSIS Hyperthyroidism/hypothyroidism, sleep loss, sleep apnea, phenylketonuria, OCD, lead toxicity, and drug misuse DETECTION & INTERPRETATION OF DIAGNOSIS Adult ADHD screening techniques include the Childhood Symptom Scale and the Wender Utah Rating Scale, which are retrospective measures. The Adult ADHD Rating Scale IV, Adult ADHD Self-Report Scale Symptom Checklist, and the Conners Adult ADHD Rating Scale are some of the most widely used symptom scales today (1). These scales can be finished in 5 to 20 minutes. Although improvements in imaging technology have shown anatomical and functional abnormalities in the brains of people with and without ADHD, there is no proof that these findings have any clinical value (1). Initial examinations (lab, imaging) ECG with concerns for heart illness in the patient or family history Thyroid-stimulating hormone (TSH) To rule out concurrent substance addiction disorder, a urine toxicology test was performed. Tests in the Future & Special Considerations Consider polysomnography in patients with sleep disorder symptoms to rule out sleep apnea. Liver function test monitoring (with atomoxetine) While a history of childhood behaviors is useful, adult patients frequently have difficulty recalling childhood symptoms. To help with the development of an accurate diagnosis and the identification of high-risk behaviors, find out whether there is a family history of ADHD, family and personal substance misuse, and tic disorders. Precautions should be taken to avoid using stimulants during pregnancy due to the significant risk of preterm birth and poor fetal weight. The patient should be fully informed of the risks and advantages of the proposed course of therapy, and ideally so should her spouse. Avoid using stimulants in adult individuals with a history of heart disease. ALERT Adult ADHD can coexist with other illnesses such mood disorders, generalized anxiety disorders, and substance misuse; treating both the ADHD and comorbid conditions will improve the patient's prognosis. There is growing evidence that stimulants and nonstimulants used in children are also useful in adults, despite the fact that most research and drug trials have been conducted in children. ALERT It is advised to perform pill counts, check urine for drugs, observe behavior, and search prescription databases because stimulant medications can lead to dependency, substance misuse, and diversion. Amphetamine abuse can result in fatal cardiovascular side effects and sudden death. UNSPECIFED MEASURES Stimulants are the primary and most effective treatment for ADHD when substance addiction is absent. There are numerous formulations of stimulants, and patients may need to test out various dosages, formulations, and drugs before experiencing the best possible improvement in symptoms and functioning. Nonstimulants are helpful when there is a risk of abuse, there are coexisting disorders, or the patient does not respond well to stimulants. MEDICATION – To minimize negative effects, medications should be gradually increased to their effective level. Although stimulants are more effective than antidepressants or nonstimulants, adverse effects can lead to a 30% prescription discontinuation rate. Stimulants can be divided into those connected to amphetamine and those connected to methylphenidate. Both groups contain both fast-acting and slow-acting medications. Recent data indicate that long-acting drug users have higher rates of adherence and persistence. Bupropion, an antidepressant that has been investigated for treating ADHD, has been found to have a moderate impact in comparison to stimulants. First Line Stimulants: lisdexamfetamine (Vyvanse), dexmethylphenidate (Focalin), dextroamphetamine/amphetamine (Adderall), dextroamphetamine (Dexedrine), and methylphenidate (Concerta, Ritalin). There are short-acting, intermediate-acting, long-acting, and patch formulations of methylphenidate compounds. – Patients who are new to stimulants may benefit from using Ritalin LA. Another option for people up to the age of 65 is Concerta ER, which can be begun at a dose of 20 mg per day and increased in dosage by 10 mg increments each week depending on how well symptoms are controlled. 18 mg/day as a starting dose, increased by 18 mg per week until symptoms improve. Maximum daily dose is 72 mg, and it also contains an oral osmotic release to reduce misuse risk. - Dextroamphetamine is frequently utilized; it has a half-life of 4 to 6 hours. The recommended starting dose is 5 mg BID, and the maximum daily dose is 20 mg BID. - Adderall is a 75%/25% combination of dextroamphetamine and amphetamine that is also available in extended-release form. Initial doses for short-acting medications can be as low as 5 mg BID or 20 mg daily, and they can be increased by 5 mg or 10 mg per week, respectively, up to a daily total of 40 to 60 mg. - Lisdexamfetamine (Vyvanse) is an extended-release stimulant that must be metabolized into dextroamphetamine to become active. – In addition to increased anxiety and irritability, stimulants frequently cause hypertension (HTN), tachycardia, sleeplessness, weight loss, stomach trouble, and increasing tics. Nonstimulants: Atomoxetine (Strattera) has been demonstrated to be more effective than a placebo in treating adults with ADHD (6)[B]. It has a lower risk for misuse than stimulants, making it a better option than other drugs for individuals who have a history of substance abuse. It can be administered as a single dose or divided dose. Up to 4 weeks may pass before an impact begins. When ADHD is also present with anxiety, mood disorders, or tics, atomoxetine may be especially helpful. There are a few isolated incidences of liver injury linked to these drugs. Keep an eye out for increased suicidal thoughts. Antidepressants are most effective for people who are at high risk or who have a history of substance addiction disorders. Adults with ADHD symptoms respond well to bupropion (Wellbutrin), particularly if they also have concomitant depression (5)[A]. – ADHD has also been demonstrated to benefit from the use of tricyclic antidepressants such desipramine and nortriptyline (1). - 2-Agonists (guanfacine, clonidine) have been shown to be successful in treating children and adolescents, but their effectiveness, safety, and tolerability in adults have not been thoroughly investigated (7)[C]. These might be combined with disorders of disruptive conduct or concomitant tics. - Patients who are resistant to stimulants alone have seen favorable results when they combine stimulants with a nonstimulant drug like atomoxetine, guanfacine, or clonidine. QUESTIONS FOR REFERENCE Referrals for diagnosis and treatment may be required for patients with coexisting diseases. When managing pregnant women with ADHD, take into account referring them to an obstetrician skilled in high-risk pregnancies. ADVANCED THERAPIES In addition to medication, cognitive-behavioral therapy (CBT) can be helpful in helping patients manage their symptoms. When medication does not fully improve executive dysfunction (EDF)-related impairments, CBT can help. Adding memantine as a supplement to extended-release methylphenidate was linked to better executive performance in adults with ADHD and EDFs, indicating a need for more study. ALTERNATIVE & COMPLEMENTARY MEDICINE There is conflicting evidence that adding fatty acid supplements to medicine may help treat ADHD, while eliminating artificial food coloring has only a marginally positive effect on symptoms. With the help of rewards, this demographic can be motivated to behave in a particular way. Behavioral therapy has been shown to improve parenting skills among this population. Schools that prioritize learning, reduce punishment, and foster a good learning environment see a considerable boost in classroom performance. CONTINUAL CARE To prevent treatment pauses, the transition from pediatric to adult care must be carefully organized. SUCCESSIVE RECOMMENDATIONS Close monitoring of the drug when the dosage is adjusted and side effects are looked for. Repeat screening checklists as necessary to determine the effectiveness of interventions. Support behavioral change, which is a crucial component of long-term management (e.g., self-initiated through CBT).
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