Transcript 03 PPT ADHD__FM__SubstAbuse 2016x

Managing
ADHD
Fibromyalgia
Alcohol & Substance Abuse
in Primary Care
NURS 870
Spring 2016
ADHD
3 types:
Predominantly inattentive (more in girls)
Predominantly hyperactive-impulsive (more in boys)
Combined
Attention Deficit Hyperactivity
Disorder (ADHD)
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ADHD is a problem with inattentiveness, over-activity, impulsivity, or
a combination. For these problems to be diagnosed as ADHD, they
must be out of the normal range for a child's age and development.
ADHD is the most commonly diagnosed behavioral disorder of
childhood. It affects about 3 - 5% of school aged children. ADHD is
diagnosed much more often in boys than in girls.
ADHD may run in families, but it is not clear exactly what causes it.
Whatever the cause may be, it seems to be set in motion early in life
as the brain is developing. Imaging studies suggest that the brains of
children with ADHD are different from those of other children.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/
Retrieved Jan 3, 2012
ADHD: American Academy of Pediatrics (AAP)
Definition
• The diagnosis is based on very specific symptoms,
which must be present in more than one setting.
• Children should have at least 6 attention symptoms
or 6 hyperactivity/impulsivity symptoms, with some
symptoms present before age 7.
• The symptoms must be present for at least 6
months, seen in two or more settings, and not
caused by another problem.
• The symptoms must be severe enough to cause
significant difficulties in many settings, including
home, school, and in relationships with peers.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/
Retrieved Jan 3, 2012
Adult ADHD
• ADHD afflicts approximately 3% to 5% of school-age
children and an estimated 60% of those will maintain
the disorder into adulthood.
• Prevalence rates for ADHD in adults are not as well
determined as rates for children, but fall in the 1% to
5% range.
• ADHD affects males at higher rate than females in
childhood, but this ratio seems to even out by
adulthood.
ADHD Symptoms
Class
Specific Symptoms
Inattention
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Hyperactivity
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Often fidgets with hands or feet or squirms
Often leaves seat in classroom or elsewhere
Often runs about or climbs excessively
Has difficulty playing quietly
Often on the go, acting as if driven by a motor
Often talks excessively
Impulsivity
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Often blurts out answers before questions are completed
Often has difficulty awaiting turn
Often interrupts or intrudes on others
Does not pay attention to details
Has difficulty sustaining attention at school
Does not seem to listen when spoken to
Does not follow through on instructions or finish tasks
Has difficulty organizing tasks and activities
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
Often loses things
Is easily distracted
Is forgetful
Adult ADHD: Problematic Features
The following behaviors and
problems may stem directly from
ADHD or may be the result of related
adjustment difficulties:
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Chronic lateness and
forgetfulness.
Anxiety
Low self-esteem.
Employment problems.
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Difficulty controlling anger.
Impulsiveness.
Substance abuse or addiction.
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Poor organization skills.
Procrastination.
Low frustration tolerance.
Chronic boredom.
Difficulty concentrating when
reading.
Mood swings.
Depression.
Relationship problems.
Adult ADHD: Scholastic, Occupational & Social
problems
School-Related Impairments
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Had a history of poorer educational performance and were underachievers.
Had more frequent school disciplinary actions.
Had to repeat a grade.
Dropped out of school more often.
Work-Related Impairments
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Change employers frequently and perform poorly.
Have had fewer occupational achievements, independent of psychiatric status.
Social-Related Impairments
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Have a lower socioeconomic status.
Have driving violations such as: be cited for speeding; have their licenses suspended; be involved in more
crashes; rate themselves and others as using poorer driving habits.
Use illegal substances more frequently.
Smoke cigarettes.
Self-report psychological maladjustment more often.
http://www.webmd.com/add-adhd/guide/adhd-adults
Retrieved Jan 5, 2012
ADHD: Medication Options
Stimulants (amphetamines) are the most commonly used ADHD
drugs. Although these drugs are called stimulants, they actually
have a calming effect on people with ADHD.
I.
Stimulants
I. Amphetamine-dextroamphetamine (Adderall)
II. Dexmethlyphenidate (Focalin)
III. Dextroamphetamine (Dexedrine, Dextrostat)
IV. Lisdexamfetamine (Vyvanse)
V. Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)
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A nonstimulant drug called amoxetine (Strattera) may work as
well as stimulants, and may be less likely to be misused.
III. An antidepressant called bupropion (Wellbutrin) can also treat
the symptoms of ADHD, and is an option for patients with coexisting anxiety.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002518/
Retrieved Jan 3, 2012
ADHD: Medication Issues
1. Risk for diversion
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Patients must sign narcotic agreements
Adderall is number one most abused drug on college campuses
Many college students abuse ADHD meds to fuel all night study
sessions
Just say YES to study drugs?
• http://www.cnn.com/2014/04/17/health/adderall-collegestudents/
ADHD: Medication Issues
2. Possible troublesome side effects:
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anxiety, jitteriness, palpitations, sweating, insomnia, loss of
appetite
No easy “quick fix”
Some ADHD patients never find a med that works for them
ADHD Careers
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Captivated by Change: Police Officers and Firefighters
Thrive in High-Intensity Environments: Doctors and Nurses
Talk Success: Salespeople
Express Creativity: Artists and Entertainers
Physical Work: Members of the Military
Be Independent: Entrepreneurs
Work Outside the Office: Commission Salespeople
Seek Variety: Mechanics
Hands-On Work: Construction Workers
Clear Deadlines: Delivery Truck Driver
Fibromyalgia
a centrally mediated disorder of pain sensitivity
FM: Signs & Symptoms
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Stiffness and pain frequently begin gradually and diffusely and have
an achy quality.
Symptoms can be exacerbated by environmental or emotional
stress, poor sleep, trauma, or exposure to dampness or cold or by a
physician who implies that the disorder is “all in the head.”
Patients tend to be stressed, tense, anxious, fatigued, ambitious, and
sometimes depressed.
Many patients also have irritable bowel syndrome symptoms,
interstitial cystitis, or migraine or tension headaches.
Pain may worsen with fatigue, muscle strain, or overuse. Specific,
discrete areas of muscle (tender points) may be tender when
palpated.
FM: Diagnosis
Consider FM in patients presenting with:
• Generalized pain and tenderness, especially if
disproportionate to physical findings
• Negative laboratory results despite widespread
symptoms
• Fatigue as the predominant symptom
FM: Diagnosis
Consider diagnostic tests to rule out other medical causes
for FM symptoms:
• ESR or C-reactive protein
• CK
• Hypothyroidism
• Others based on presenting chief complaint
FM: Diagnosis
Diagnosis is based on the following:
• Pain elicited by palpation of
specific tender points: A specific
number of tender points (≥ 11 of
18) is no longer required for
diagnosis but may indicate more
recalcitrant pain. Digital palpation
should be done with a force of
about 4 kg. A positive result
requires that palpation be painful.
• A history of widespread pain for
at least 3 mo: Pain is considered
widespread when patients have
pain in the left and right side of
the body, above and below the
waist, and in the axial skeleton
(cervical spine, anterior chest or
thoracic spine, or low back)
FM: Treatment
Stretching and aerobic exercise, local heat, and massage
(& stress management!)
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Stretching exercises, aerobic exercises, sufficient sound sleep, local
applications of heat, and gentle massage may provide relief. Overall
stress management (eg, deep breathing exercises, meditation,
psychologic support, counseling if necessary) is important.
Exercises to gently stretch the affected muscles should be done daily;
stretches should be held for about 30 sec and repeated about 5 times.
Aerobic exercise (eg, fast walking, swimming, exercise bicycle) can
lessen symptoms.
FM: Treatment
Tricyclic Antidepressants to Improve Sleep
• Amitriptyline 10-50 mg po QHS
• Trazodone 50-150 mg po QHS
• Cyclobenzaprine 10-40 mg po QHS
FM: Treatment
Nonopiod Analgesics for Pain
• Avoid narcotics as they are not helpful for FM pain
• Try Acetaminophen, NSAIDS, tramadol
• Try gabapentin, pregabalin, milnacipran
• Duloxetine or other SNRIs are helpful
ETOH & Substance Abuse
Screening in primary care
ETOH Screening
http://pubs.niaaa.nih.gov/publications/aa65/AA65.htm
Clinicians under strict time constraints may have time to ask a
patient only one screening question about his or her alcohol
consumption. One study (6) has shown that a positive response
to the question “On any single occasion during the past 3 months,
have you had more than 5 drinks containing alcohol?” accurately
identifies patients who meet either NIAAA’s criteria for at-risk
drinking or the criteria for alcohol abuse or dependence specified
in the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM–IV) (7).
Screen patients annually and as indicated by presenting
complaints.
ETOH Screening
http://pubs.niaaa.nih.gov/publications/aa65/AA65.htm
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may have time to ask a
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Drug Addiction Screening
https://ncadd.org/learn-about-drugs/drug-abuse-self-test
The Drug Abuse Screening Test (DAST):
1.
Have you used drugs other than those required for medicinal reasons?
Yes No
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Have you abused prescription drugs?
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Do you abuse more than one drug at a time?
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Can you get through the week without using drugs?
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Are you always able to stop using drugs when you want to?
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Have you had "blackouts" or "flashbacks" as a result of drug use? Yes No
7.
Do you ever feel bad or guilty about your drug use? Yes No
8.
Does your spouse (or parents) ever complain about your involvement with drugs?
Yes No
9.
Has drug abuse created problems between you and your spouse or your parents?
Yes No
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Have you lost friends because of your use of drugs?Yes No
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Have you neglected your family because of your use of drugs?
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Have you been in trouble at work because of drug abuse? Yes No
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Have you lost a job because of drug abuse? Yes No
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Have you gotten into fights when under the influence of drugs?
Yes No
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Have you engaged in illegal activities in order to obtain drugs?
Yes No
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Have you been arrested for possession of illegal drugs?
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Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
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Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding,
etc.)? Yes No
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Have you gone to anyone for help for a drug problem?
Yes No
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Have you been involved in a treatment program specifically related to drug use? Yes No
Drug Addiction Screening
https://ncadd.org/learn-about-drugs/drug-abuse-self-test
Total your score – the total presented above reflects the severity of problems or
consequences related to your drug abuse. An interpretation of your score should be
based on the following guidelines:
0:
No problem
1-5:
Low level of problems related to drug abuse
6-10:
Moderate level of problems related to drug abuse
11-15:
Substantial level of problems related to drug abuse
16-20:
Severe level of problems related to drug abuse