Psychostimulants for Older Adult: Certain Agents May Improve Apathy, ADHD, Depression, and Other Conditions

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. [ILLUSTRATION OMITTED] 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). 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 irnprove 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 (page 26). 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 sub-scales. (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, page 26), 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. …