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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) • • • 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 • • • • • • • • • Hyperactivity • • • • • • 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 • • • 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: • • • • • • • Chronic lateness and forgetfulness. Anxiety Low self-esteem. Employment problems. • • • • • Difficulty controlling anger. Impulsiveness. Substance abuse or addiction. • • • 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 • • • • 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 • • Change employers frequently and perform poorly. Have had fewer occupational achievements, independent of psychiatric status. Social-Related Impairments • • • • • 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) II. 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 • • • 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: • • • 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 • • • • • • • • • • 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 • • • • • 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!) • • 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 • Clinicians under strict time constraints may have time to ask a CAGE patient only one screening question about his or her alcohol One study (6)cut has shown thatdrinking? a positive C consumption. Have you ever felt you should down on your A response Have people you by“On criticizing your drinking? to annoyed the question any single occasion during the G past Have3you ever felt bad you or guilty months, have hadabout moreyour thandrinking? 5 drinks containing E Eye opener: Have you ever had a drink first thing in the morning to alcohol?” accurately identifies patients who meet either steady your nerves or to get rid of a hangover? NIAAA’s criteria for at-risk drinking or the criteria for alcohol The CAGE identify alcohol problems over the lifetime.and Two positive abuse orcan dependence specified in the Diagnostic Statistical responses areMental considered a positive test and indicate further (7). Manual of Disorders, Fourth Edition (DSM–IV) assessment is warranted. 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 2. Have you abused prescription drugs? 3. Do you abuse more than one drug at a time? 4. Can you get through the week without using drugs? 5. Are you always able to stop using drugs when you want to? 6. 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 10. Have you lost friends because of your use of drugs?Yes No 11. Have you neglected your family because of your use of drugs? 12. Have you been in trouble at work because of drug abuse? Yes No 13. Have you lost a job because of drug abuse? Yes No 14. Have you gotten into fights when under the influence of drugs? Yes No 15. Have you engaged in illegal activities in order to obtain drugs? Yes No 16. Have you been arrested for possession of illegal drugs? 17. 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 18. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding, etc.)? Yes No 19. Have you gone to anyone for help for a drug problem? Yes No 20. 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