Any one have advice on what types of patients would benefit from ritalin use? Any specific thing to look for before starting ritalin that might predict outcome or is it one of those, "this patient isn't initiating much and not very alert, lets give ritalin a try" kind of thing...
also, do any of you do routine neuroendocrine screening in your brain injured patients when they are still inpatients?
Ritalin: Methylphenidate & related stimulants have effects that can/are regularly seen in non-brain injured individuals, hence the widespread use/abuse/controversy in ADHD, college students, etc. For my patients with brain injury, however, I most frequently use it in patients with hypoarousal and/or impaired initiation. It also has demonstrated benefit in improving attention for some patients. You shouldn't have to wait long to see a therapeutic effect, a decided advantage when titrating dose. When compared with other classes of drugs used to enhance cognitive function, stimulants such as ritalin tend to have a higher "hit rate" (proportion of patients reporting/observed with favorable response.)
Neuroendocrine screening: A trendy, albeit controversial topic. Lots of articles on this issue in the last few years, particularly with increased attention regarding growth hormone. Ghigo et al. (Brain Inj 2005; 19: 711-24) recommend systematic screening of "all patients with moderate-to-severe TBI at risk of developing pituitary deficits." The controversy revolves around the fact that while neuroendocrine abnormalities do occur, and are more prevalent in individuals with poorer outcomes, few data exist to connect the poorer outcomes to the neuroendocrine abnormalities. In other words, if provocative testing can find 20% of severe TBI pts with abnormalities of growth hormone release, there is far less evidence to suggest that GH administration will improve global outcome (or any outcome, other than lean body mass perhaps). I used to routinely screen for these, but it is such a low-yield practice that I now employ it only in pts with clinical history suggestive of problems-->e.g. interrupted menses, hyponatremia, etc., or in SAH secondary to ACoA aneurysm rupture.
