6/2/2011. At the end of the presentation you will be able to: What is Adult Attention Deficit Hyperactivity Disorder?

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Beatrix Hampton
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1 At the end of the presentation you will be able to: Adult Attention Deficit Hyperactive Disorder (ADHD) Concern for our patients wellbeing. 1. Describe the most common behaviors and problems associated with Adult ADHD. 2. List other conditions that can coexist with Adult ADHD. 3. Describe the treatments, including home remedies and self-help modalities for adults who have ADHD. 4. Describe ways that nurses can intervene successfully to help adults with ADHD. What is Adult Attention Deficit Hyperactivity Disorder? It is the same as childhood ADHD. All adults with ADHD had it as a child. 1/3 continue to have symptoms that are less severe into adulthood 1/3 continued to have significant symptoms as adults What are the characteristics of adult ADHD? Hyperactivity, impulsiveness & inattention Unstable relationships Poor work or school performance Low self-esteem How prevalent is Adult ADHD? 4% of the US adult population or 8 million adults have ADHD. Equally divided between men and women. Why should nurses be concerned about Adult ADHD? Assist with proper diagnosis Guide patients towards a full and satisfying life 1

Ramifications of Adult ADHD Overlap of ADHD and bipolar disorders. 2 to 3 times more likely to become substance abusers. 3 times more likely to develop degenerative dementia.

Challenged by daily tasks. Can t follow directions or remember information. Can t concentrate or stick to time limits. On edge.

2 Ramifications of Adult ADHD Overlap of ADHD and bipolar disorders. 2 to 3 times more likely to become substance abusers. 3 times more likely to develop degenerative dementia. Often suffer from depression. Less likely to finish high school on time. How can you tell if an adult has ADHD? Can t get organized or keep appointments. Can t stick to a job. Challenged by daily tasks. Can t follow directions or remember information. Can t concentrate or stick to time limits. On edge. Disinhibition a troublesome problem Disregard for social conventions Can t monitor their behavior Impulsive and aggressive Other Common Behaviors and Problems Chronic lateness Forgetfulness & procrastination Poor organization skills Low frustration tolerance Chronic boredom Difficulty concentrating Hypersexual Adult ADHD Rarely Exists Alone Learning disabilities Anxiety disorders Substance dependency and abuse Mood disorders Personality disorders What Might a Colleague Notice in an Adult with ADHD? 2

3 Janice the Struggling RN Janice struggles to pay attention. Quiet and cooperative most of the time but she often appears to be daydreaming. Smart but has trouble keeping her mind on complicated tasks she knows how to do. "What's wrong with me?" Henry the Project Guy Henry loves puttering around in his shop which is piled high with wood. Has dozens of unfinished carpentry projects and more ideas for new ones. Every day Henry faces frustration because he cannot complete a task. Faye is at a Loss Fayel was fired from her job because she lost inventory and carelessly filled out forms. Afraid that she might be losing her mind. Seen psychotherapists and tried several medications, but none ever helped her concentrate. Susan, LPN, Can t Concentrate Susan Horn LPN is not able to concentrate during in-services. Her Supervisor notices that she is interested in projects that she believes are essential to her work. Became excited about a new medication delivery system - had difficulty focusing on the details. Jack, NA - The Risk Taker Jack Jones, NA constantly talks about bungee jumping, and various extreme sports. Sustained a few broken bones, he continues to participate in dangerous activities. Interrupts during staff meetings. Can t pay attention to other staff members when they are expressing their opinions. Ineffective Nurse Manager Kathy Smith has difficulty listening to her staff when they come to her with their concerns. Can t take the steps needed for resolution of their difficulties. Often provides quick fixes which cause additional challenges. 3

4 What isn t ADHD? Transient symptoms that may occur when the person is under stress. Personalities with certain characteristics common with ADHD. What causes ADHD? Genetics tends to run in families Smoking, drinking alcohol or using drugs during pregnancy Exposure to polychlorinated biphenyls (PCBs) during pregnancy Preschool children exposed to lead How Is Adult ADHD Diagnosed? History of ADHD in childhood Physical exam EEG, CT, or MRI Psychoeducational testing What you Might Find when Taking a Patient s History Poor educational performance with disciplinary problems Changing employers frequently Poor work performance Driving violations, use illegal substances, and smoke cigarettes Marital problems and multiple marriages Conditions to Rule Out Anxiety disorders Mood disorders Adjustment disorders Learning and language deficits Psychotic disorders Other rule outs or co-existings Alcohol or drug abuse Untoward effects of medications Seizure disorder Sleep apnea Hearing or vision problems Thyroid disorder Lead poisoning Hypoglycemia 4

Making a Diagnosis Assessing Your Patients Diagnostic and Statistical Manual diagnostic criteria The DSM states that for a diagnosis the person needs: 6 (or more)symptoms of inattention OR 6 (or

5 Making a Diagnosis Assessing Your Patients Diagnostic and Statistical Manual diagnostic criteria The DSM states that for a diagnosis the person needs: 6 (or more)symptoms of inattention OR 6 (or more) symptoms hyperactivity or impulsivity that have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level. 6 or more symptoms of inattention Inattention to details - makes careless mistakes Difficulty sustaining attention Doesn t listen Doesn t follow instructions - fails to finish work Difficulty organizing tasks and activities Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort Loses things Easily distracted Forgetful 6 or more symptoms of hyperactivity or impulsivity Fidgets or squirms Leaves the room Restless Difficulty engaging in leisure activities quietly On the go" - acts as if "driven by a motor" Talks excessively Blurts out Difficulty awaiting turn Interrupts or intrudes on others Treatments for ADHD Medications Medications Used to Treat Adult ADHD Same medications given in children. Therapy Best treatment is a combination of medications and therapy. About 2/3 of adults with ADHD show significant improvement. 5

6 Psychostimulants Methylphenidate (Ritalin, Concerta, Daytrana, Metadate) Amphetamine-dextroamphetamine (Adderall) Dextroamphetamine (Dexedrine) Lisdexamfetamine (Vyvanse) Dexmethylphenidate (Focalin) Side Effects of Psychostimulants Most common: insomnia, anorexia, nausea, weight loss, headache, rapid pulse, abdominal pain and mood swings. Less common: involuntary muscle movements (tics) of the face or body. Rare: seizures, hypertension, delusions or liver problems. Issues to Consider with Stimulant Medication Therapy Short acting wear off quickly. Are controlled substances. Methylphenidate (Daytrana) long-acting patch delivers medication for about 9 hours, but can take up to 3 hours to start working. Some people can t take stimulants. Alternative Medication Therapy Atomoxetine (Stratterra) Antidepressants such as bupropion (Wellbutrin)or venlafaxine (Effexor) Atomoxetine (Stratterra) First medication to receive an FDA indication for treatment of ADHD in adults. No abuse potential & no need for a special prescription. Works more slowly than stimulants. May take several weeks before it takes full effect. Side effects: nausea, anorexia, insomnia, slightly increased BP and pulse, decreased sex drive, sweating, and painful urination. Antidepressants: as bupropion (Wellbutrin) and venlafaxine (Effexor) May take several weeks before they take full effect. Bupropion side effects: headache, nausea, dry mouth, insomnia, sweating, anxiety and constipation - may subside as the body adjusts. Rarely: seizures. Venlafaxine side effects: nausea, loose bowel movements, headache and insomnia - may subside as the body adjusts. High doses of venlafaxine can increase blood pressure. 6

FDA requirements for all ADHD medications Makers develop Patient Medication Guides Explain risks of the medications.

Also recommends that any treatment plan for ADHD include an initial health history, including family history, and examination for existing cardiovascular and psychiatric problems.

There is about a 1 in 1,000 chance for medication-related psychiatric problems, without a history of psychiatric problem in the past.

Behavioral Treatments for Adult ADHD Cognitive & behavioral therapy Relaxation training & stress management Behavioral coaching & job coaching Both is better than one alone Medications are very

7 FDA requirements for all ADHD medications Makers develop Patient Medication Guides Explain risks of the medications. Must alert patients that the medications may lead to possible cardiovascular or psychiatric problems. Also recommends that any treatment plan for ADHD include an initial health history, including family history, and examination for existing cardiovascular and psychiatric problems. Why these requirements? Some patients with existing heart conditions may have a slightly higher risk of strokes, heart attacks, and/or sudden death. There is about a 1 in 1,000 chance for medication-related psychiatric problems, without a history of psychiatric problem in the past. These include: auditory and visual hallucinations, suspiciousness, and mania. Behavioral Treatments for Adult ADHD Cognitive & behavioral therapy Relaxation training & stress management Behavioral coaching & job coaching Both is better than one alone Medications are very effective in 'turning down the volume' on ADHD symptoms, but they do not teach people skills a skills-based approach can help patients learn how to cope with their attention problems and better manage their disorder. Family education & therapy Support - Always a Good Thing Helpful to attend support groups with other adults who share like experiences. Information and coping strategies are often shared. Online as well as in person in certain communities. Nurses Can Teach Take medications as directed. Control impulsive behavior. Minimize distractions. Find constructive outlets for excess energy. Ask for help. Life can be fun. Practical hints. Encourage support group attendance. Talk to their colleagues and supervisors. 7

8 Encourage Patients to Consider Alternative Treatments Yoga Eliminate certain foods sugar and caffeine, common allergens such as wheat, milk and eggs, and artificial food colorings and additives Dietary supplements Neurofeedback training Teach Patients How to Organize Themselves Make lists. Use a daily planner, PDA or appointment book. Leave notes or use sticky pads. Set an alarm clock Carry a notebook. Set up systems to file & organize information. Break down tasks into small steps. Ask for help. Follow a consistent routine. Nurses Can Help with Provider Appointments List issues that caused them difficulty. List all symptoms they are having. Write down personal information - major stresses or recent life changes. List all medications including any vitamins or supplements. Make a list of questions to ask the health care provider. What questions might they want to ask? What are other possible causes for my symptoms? What tests do I need? What's the best treatment? What are the alternatives? What happens if I do nothing? How do I manage (other condition) and ADHD together? Should I see a specialist? Are there generic alternative to the medicine? Do you have brochures? What Web sites do you recommend? What question might they be asked? First memories of problems? Symptoms - continuous or occasional? Which bother you most? Which cause you problems? Any social problems or trouble in school? How is work performance? Any problems with sleep? What makes the symptoms worse? Better? How much caffeine, alcohol or street drugs do you use? Nurses can keep up on research related to ADHD National Institutes of Mental Health (NIMH) sponsor research in genetics, brain imaging, and behavioral, leading to a better understanding of ADHD. ons/attention-deficit-hyperactivitydisorder/complete-index.shtml. 8

9 Resources National Institute of Neurological Disorders and Stroke. Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) Attention Deficit Disorder Association (ADDA) American Psychiatric Association American Psychological Association MedicineNet.com emedicinehealth.com ADHD Online Community Find a Therapist on WebMD Find a Doctor on WebMD About.com Test your knowledge Take a! ADHD Quiz: Test Your Medical IQ about ADHD@ /quiz.htm. Think you have ADHD - take a quick screening. Quick (6 item) Adult ADHD Screening htm. A 24 question Screening Quiz for Adult Attention Deficit Hyperactivity Disorder 9

Could I Have Attention-Deficit/ Hyperactivity Disorder (ADHD)?

Could I Have Attention-Deficit/ Hyperactivity Disorder (ADHD)? Finding an Answer to ADHD as an Adult Do you feel that you have struggled throughout your life with poor concentration, inattention, impulsivity,