methylphenidates/stimulants in geriatric depression, as an adjunct medication

[annoyedpsychiatrist]

Any general thoughts on this? I treat a large pool of geri patients, id say >50% are geri or close to it. A lot of men tend to not do so well with age, become severely depressed, lay in bed all day and have zero motivation. Had one guy in his late 60s who had been on adderall 40 xr BID (no misuse on his part, just an idiot prescriber) and he did not do well when he went off. Eventually we decided on a low dose of vyvanse and hes the best hes ever been. Im noticing males tend to do worse (just my observation) than females with age. Im thinking a low dose of methylphenidate for my more tougher cases where I need them to get out of bed and engage. Had one guy with diabetes stop eating, stay in bed all day, and start to physically decompensate. Wanted him to do ECT but people still fear the stigma behind it. A

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[wolfvgang22]

I think it's ironic you are on the one hand calling someone an idiot prescriber for inappropriate stimulant prescribing, stopped the medication with a poor result, and then immediately asking if it's ok to prescribe stimulants off label. I also think that stimulants definitely have some effectiveness for depression in this population as dysonrichard801 pointed out, but the medicolegal climate makes prescribing stimulants off label a more risky legal proposition even if the benefits outweigh the risks for the patient medically.

 

[calvnandhobbs68]

I think it's ironic you are on the one hand calling someone an idiot prescriber for inappropriate stimulant prescribing, stopped the medication with a poor result, and then immediately asking if it's ok to prescribe stimulants off label. I also think that stimulants definitely have some effectiveness for depression in this population as dysonrichard801 pointed out, but the medicolegal climate makes prescribing stimulants off label a more risky legal proposition even if the benefits outweigh the risks for the patient medically.

I think OP is referring more to the dose and administration rather than a general distaste for stimulants. I can think of basically no cases where someone needs to be on Adderall XR 40mg BID.

 

[WisNeuro]

They are really going hard with their chatGPT/AI experiments, aren't they?

 

[annoyedpsychiatrist]

I think it's ironic you are on the one hand calling someone an idiot prescriber for inappropriate stimulant prescribing, stopped the medication with a poor result, and then immediately asking if it's ok to prescribe stimulants off label. I also think that stimulants definitely have some effectiveness for depression in this population as dysonrichard801 pointed out, but the medicolegal climate makes prescribing stimulants off label a more risky legal proposition even if the benefits outweigh the risks for the patient medically.

i think its ironic that you are assuming that im calling stimulants inappropriate, yet im asking for general opinions? Also youre assuming that I stopped the medication, but i never did this. He was off for two months due to the adderrall shortage before he even saw me. Yes i think putting someone on adderall xr 40mg bid in their late 60s (when he was titrated up on adderall xr) is generally not a good idea.

Yes i think there is more stigma attached to it, though i tend to make my older patients get cardiac clearance if they have risk factors/if i have concerns.

 

[clausewitz2]

I have definitely had a couple of inpatient Geris go from full-on Diogenes syndrome, hasn't showered in a year, lays in bed all day, seeking no medical care for bleeding tumors on face kind of depressed to literally dancing to music and playing practical jokes on staff after staring methylphenidate. When it works it definitely works.

 

[TexasPhysician]

I have a couple of geri patients with significant benefit on low dose stimulants. I don’t commonly try it, but it has a role after enough treatment failures. I have yet to need to go above Ritalin LA 20 in anyone.

 

[tr]

I don't treat geri patients now but I do recall from training that the geropsych people did use stimulants a fair amount. I recall them leaning more on Provigil/Nuvigil vs full on amphetamine when possible though. Guessing there might be less of a bp issue with those.

 

[wolfvgang22]

i think its ironic that you are assuming that im calling stimulants inappropriate, yet im asking for general opinions? Also youre assuming that I stopped the medication, but i never did this. He was off for two months due to the adderrall shortage before he even saw me. Yes i think putting someone on adderall xr 40mg bid in their late 60s (when he was titrated up on adderall xr) is generally not a good idea.

Yes i think there is more stigma attached to it, though i tend to make my older patients get cardiac clearance if they have risk factors/if i have concerns.

Fair enough. I was feeling a bit cynical, my apologies.

 

[Shikima]

I don't treat geri patients now but I do recall from training that the geropsych people did use stimulants a fair amount. I recall them leaning more on Provigil/Nuvigil vs full on amphetamine when possible though. Guessing there might be less of a bp issue with those.

I'd hypothesize that there might be a corollary sleep disorder resulting in sleepiness/fatigue requiring stimulants which is being interpreted as depression.

 

[annoyedpsychiatrist]

That is another challenge in itself, the disruption of sleep in the elderly and lack of safe and highly effective ways to treat it. CBTi requires motivated individuals willing to come off their ambien -_-

 

[WisNeuro]

That is another challenge in itself, the disruption of sleep in the elderly and lack of safe and highly effective ways to treat it. CBTi requires motivated individuals willing to come off their ambien -_-

People unwilling to put up with temporary discomfort and/or inconvenience to obtain a long-term health benefits are the poster children for healthcare in the US.

 

[docksan]

I've had a few a patients do very well on Ritalin or Vyvanse, with any refractory cases leaving me wondering to what extent personality is playing a role. Typically they don't require high doses but the effect size is quite modest.

 

[SpinDktr]

I do only geriatric psychiatry currently. I have tried stimulants many times, and always been disappointed in results. I would estimate over 100 prescriptions written for various stimulants and when those don't work switch stimulant class and still don't work. When there is benefit it is very minimal and very temporary; always no longer than a month. Have gotten over using them entirely at this point. I see a lot more catatonia honestly; my geri unit typically has about 25% of the patients with mild to moderate catatonic symptoms.

 

[jbomba]

Have a non geri patient with TRD. Has had great improvement after endocrine started phentermine. Wondering if going with low dose Ritalin might make sense after the phentermine ends.

 

[smalltownpsych]

I have found that even really depressed old guys without hx of mental health are fairly easy to treat with good talk therapy just so long as I don’t focus on their “feelings“ and difficulty with expressing those directly. Many of them are struggling with redefining themselves in this final stage of life and their declining abilities and their role in the world as they shift from being productive and feeling good about that. Not saying meds aren’t helpful but sometimes these guys are forced into a tough choice from their perspective: meds they don’t want to rely on vs. touchy-feely crap therapy.

 

[Candidate2017]

Any general thoughts on this? I treat a large pool of geri patients, id say >50% are geri or close to it. A lot of men tend to not do so well with age, become severely depressed, lay in bed all day and have zero motivation.

I have found that even really depressed old guys without hx of mental health are fairly easy to treat with good talk therapy just so long as I don’t focus on their “feelings“ and difficulty with expressing those directly. Many of them are struggling with redefining themselves in this final stage of life and their declining abilities and their role in the world as they shift from being productive and feeling good about that.

Unless it's severe depression, sometimes we just need to have empathy and validate what elderly male patients are going through. They're probably not enjoying having an enlarged prostrate, with typical illnesses like DM/COPD/HTN, arthritis/bad knees and joints, etc. On top of that, the finish line is approaching, and if they don't have good relationships with spouse and children or come to terms with how they spent their life and regrets and failures, then they will have zero motivation.

Female patients seem to do much better in terms of aging. That's probably because they experience it earlier and more acutely from peri and menopause in their 40s and 50s, as well as being more successful with social connections and having halfway decent relationships with their children and grandchildren. Females value connections, while males value accomplishments. While the average female will build biological connections by the time death appears on the horizon, the average male won't accomplish much.

 

[sloh]

Unless it's severe depression, sometimes we just need to have empathy and validate what elderly male patients are going through. They're probably not enjoying having an enlarged prostrate, with typical illnesses like DM/COPD/HTN, arthritis/bad knees and joints, etc. On top of that, the finish line is approaching, and if they don't have good relationships with spouse and children or come to terms with how they spent their life and regrets and failures, then they will have zero motivation.

Female patients seem to do much better in terms of aging. That's probably because they experience it earlier and more acutely from peri and menopause in their 40s and 50s, as well as being more successful with social connections and having halfway decent relationships with their children and grandchildren. Females value connections, while males value accomplishments. While the average female will build biological connections by the time death appears on the horizon, the average male won't accomplish much.

Not having meaningful goals with something to aim at, and not actually making progress towards those goals, is so damaging to the male psyche.

 

[annoyedpsychiatrist]

most of the geri depression cases i get are the more severe ones where they get pretty bad apathy/lack of motivation. Stop eating/bathing/going out and refuse to get out of bed, almost a reverting back to childhood type ordeal.

 

[smalltownpsych]

most of the geri depression cases i get are the more severe ones where they get pretty bad apathy/lack of motivation. Stop eating/bathing/going out and refuse to get out of bed, almost a reverting back to childhood type ordeal.

Yes, and I have worked with these folks and found that psychosocial intervention is still the key. Not saying that throwing a little speed or other medications their way won’t help with that, but if they don’t get the intensive level of intervention needed, doesn’t matter what medication they get. In general, I think we underestimate what is needed to get the moderate to severe cases back to functioning. Once a week psychotherapy and a medication works great for people that can bounce back to their fairly recent previous high level of function. Heck, many of those people have spontaneous remission while waiting to see us. Unfortunately, the treatment trials are typically done with these people, such as college students with no comorbidities, so our system and thought processes are organized around that model.

 

[annoyedpsychiatrist]

Yes, and I have worked with these folks and found that psychosocial intervention is still the key. Not saying that throwing a little speed or other medications their way won’t help with that, but if they don’t get the intensive level of intervention needed, doesn’t matter what medication they get. In general, I think we underestimate what is needed to get the moderate to severe cases back to functioning. Once a week psychotherapy and a medication works great for people that can bounce back to their fairly recent previous high level of function. Heck, many of those people have spontaneous remission while waiting to see us. Unfortunately, the treatment trials are typically done with these people, such as college students with no comorbidities, so our system and thought processes are organized around that model.

Getting some people into once a week therapy can be harder than it sounds, depending on insurance/availability. A lot of the ones around here are smart, and are doing cash only therapy practices

 

[TexasPhysician]

I do only geriatric psychiatry currently. I have tried stimulants many times, and always been disappointed in results. I would estimate over 100 prescriptions written for various stimulants and when those don't work switch stimulant class and still don't work. When there is benefit it is very minimal and very temporary; always no longer than a month. Have gotten over using them entirely at this point. I see a lot more catatonia honestly; my geri unit typically has about 25% of the patients with mild to moderate catatonic symptoms.

My Geri population is not inpatient or catatonic level, so that’s a big difference.

I am surprised that you’ve tried it 100x with minimal to no benefit. I’m not sure I’ve tried anything 30+ times with minimal benefit and kept doing it. What is leading you to keep trying? Is the data really supportive and your population is an anomaly?

 

[smalltownpsych]

Getting some people into once a week therapy can be harder than it sounds, depending on insurance/availability. A lot of the ones around here are smart, and are doing cash only therapy practices

Exactly. Also, most outpatient therapists don’t even offer more intensive services for more severe cases or have experience with these individuals.

 

[whopper]

In fact, a 2016 meta-analysis found that stimulants like methylphenidate were effective in treating depression in elderly patients, with no significant increase in adverse events compared to placebo. Another study in 2018 also found that methylphenidate was effective in reducing depressive symptoms in elderly patients with chronic obstructive pulmonary disease (COPD).

Can you present the data's source? I'm not doubting this study but question the duration. I could very confidently do a cocaine study for depressed people for 3 days and I'm sure a majority will feel better on cocaine. Of course long-term cocaine use will cause more problems than it's value as an antidepressant.

How long were these people followed? If it's anything less than 3 months I wouldn't put much weight to the study.

 

[Sushirolls]

Never saw results in past when I had more Geri, even in residency.
No longer bother now.
Other options to recommend, and definitely talk about ECT.
OSA workups are almost routine for me.
I try lithium adjunct before stimulants.

 

[SpinDktr]

My Geri population is not inpatient or catatonic level, so that’s a big difference.

I am surprised that you’ve tried it 100x with minimal to no benefit. I’m not sure I’ve tried anything 30+ times with minimal benefit and kept doing it. What is leading you to keep trying? Is the data really supportive and your population is an anomaly?

I'll get families that really want to try it for my hospitalized patients, or higher functioning patients that say they really benefitted from Ritalin or something 30-40 years ago and ask for it; as long as there aren't red flags, I've been pretty game to try it when nothing else has seemed to work. Or a new study comes out and says try stimulants in this geri population or for this particular issue....

It's funny tho, time goes by quickly. I'd probably say that my prescribing of stimulants has been gradually decreasing over the last 10-12 years, to the point that over the last 2 years I have just decided not to even go there. But figure an average of 10 prescriptions per year over 10 years.... adds up to 100. I kind of pulled the number from that line of thinking.

 

[whopper]

A side topic but when I ran a geri-unit I too also had way higher frequencies of catatonic patients then I'd ever seen before. I'm talking seeing it on the order of less than yearly in regular adult inpatient but in the geri-unit seeing it about at least monthly. I talked to George Grossberg, a highly respected geri-psychiatrist about it. He responded he hadn't seen it in the data but did say this was the EXACT type of thing that gets a psychiatrist the opportunity to consider reviewing this for a publication. Such a study wouldn't be hard. Screen everyone coming for catatonia for a period of a few months and then publish the findings.

 

[Shikima]

I have found that even really depressed old guys without hx of mental health are fairly easy to treat with good talk therapy just so long as I don’t focus on their “feelings“ and difficulty with expressing those directly. Many of them are struggling with redefining themselves in this final stage of life and their declining abilities and their role in the world as they shift from being productive and feeling good about that. Not saying meds aren’t helpful but sometimes these guys are forced into a tough choice from their perspective: meds they don’t want to rely on vs. touchy-feely crap therapy.

What was the common thread of treatment before the advent of modern medicine? Getting on the couch 1-3x/week. Of course, I'm not including those populations which includes IDD, formal thought disorders, manic-depression, etc.

 

[liquidshadow22]

interestingly i had an older woman tell me this was the only medication that helped with her physical pain from arthritis and was receiving from a friend a low dose XR of adderall. I do see some studies to support that it can be used to treat pain which was surprising but also to some degree I think makes sense that it could help...

 

[medhead1990]

Hopefully no de-railing the conversation but I was going to make a post and thought this was recent enough and relevant enough i might as well just hop in on the coat tails.
In training I only ever say augmentation with ritalin in geri cases or once in a pt (50s so not quite geri) who had really bad cancer and had pretty much given up. I saw more success than failure, and was under the impression this truly was only done in geri setting. I was doing some board studying the other day and had some material that seemed to present ritalin augmentation as somewhat normal choice that can/should be considered right along side SGA's. From the above sounds like most people either don't do this or have had lack luster results with it but wanted to bring it up again and see if anyone has more thoughts on it. I must admit because of all the metabolic stuff with SGA's is a huge turn off for me, and the idea that a little Ritalin to help with energy/motivation and hopefully get them to follow through with behavioral activation type ( Ie. exercise) stuff does sound appealing. That being said i fully recognize if i became the town doc who gave everyone with TRD, Rx-cocaine I would likely become very popular with patients and the DEA.

 

[comp1]

Stimulants make the vast majority of people feel better, depressed or not. I've definitely seen it done and it's probably standard of care for like 3rd or 4th line. I also concur with the above poster that the medicolegal side makes this murky. Controlled substances always are. I mean most people are going to die of a heart issue with or without stimulants, right? And there's at least some argument to be made that your stimulant prescription was somehow involved with that when they eventually do.

 

[mistafab]

Hopefully no de-railing the conversation but I was going to make a post and thought this was recent enough and relevant enough i might as well just hop in on the coat tails.
In training I only ever say augmentation with ritalin in geri cases or once in a pt (50s so not quite geri) who had really bad cancer and had pretty much given up. I saw more success than failure, and was under the impression this truly was only done in geri setting. I was doing some board studying the other day and had some material that seemed to present ritalin augmentation as somewhat normal choice that can/should be considered right along side SGA's. From the above sounds like most people either don't do this or have had lack luster results with it but wanted to bring it up again and see if anyone has more thoughts on it. I must admit because of all the metabolic stuff with SGA's is a huge turn off for me, and the idea that a little Ritalin to help with energy/motivation and hopefully get them to follow through with behavioral activation type ( Ie. exercise) stuff does sound appealing. That being said i fully recognize if i became the town doc who gave everyone with TRD, Rx-cocaine I would likely become very popular with patients and the DEA.

When looking at the data for stims in a large adult TRD data set, response was abysmal at 1/10, remission didn’t happen. If I’ve already done 2nd line (switch or augment), I’d rather reach for TCA or MAOI next than give someone a stim.

If those real depression treatments don’t work, then you need to stop the med pathway and go interventional anyway.

I am speaking only to adult TRD, not Geri.

 

[whopper]

BP, HTN, and addiction risks. The BP and HTN are especially worrisome in the elderly.

IF the patient significantly improves and does so even long term makes me wonder if they had undiagnosed ADHD. I've seen several patients with ADHD and several comorbid problems such as depression, anxiety, OCD, and with only a stimulant all the other problems are significantly improved even long term and for years. E.g. patient has panic attacks literally daily and the day after stimulant use starts they're gone even with a low dosage stimulant. Only seems to happen if the person has ADHD with the comorbid problems leading me to suspect all the other stuff like depression and anxiety was secondary to untreated ADHD.

 

[whopper]

Wanted to add, people in the geriatric block these days might've had undiagnosed ADHD for decades. When I was in residency about 20 years ago, it was an era where ADHD was massively overdiagnosed. Someone has bad grades? "They must have ADHD," but the people age 60+ were in an era where almost no one was diagnosed with it even if they had it.

If, however, you then want to diagnose and treat these undiagnosed people, starting someone in an older age with ADHD is worrisome. Stimulants to an older person could elevate cardiac risks, and these people, their age alone, puts them at higher cardiac risk. Add to this, if the person smokes and has other cardiac risk factors this makes this even more worrisome.

And nonstimulants? They too increase cardiac risks. Atomoxetine per FDA guidelines requires some baseline cardiac monitoring before even starting treatment. I've seen several Atomoxetine patients develop significant tachycardia with treatment, e.g. a baseline HR of 160 on Atomoxetine.

 

[Stagg737]

When looking at the data for stims in a large adult TRD data set, response was abysmal at 1/10, remission didn’t happen. If I’ve already done 2nd line (switch or augment), I’d rather reach for TCA or MAOI next than give someone a stim.

If those real depression treatments don’t work, then you need to stop the med pathway and go interventional anyway.

I am speaking only to adult TRD, not Geri.

I haven't seen much success with mild to moderate TRD patients either. Where I have seen stimulants work wonders is when they're started in patients with more acute severe depressive episodes with psychomotor ******ation but not catatonic. A little stimulant to perk them up and get them doing basic ADLs and self-care while other meds/treatment kick in has been quite helpful for some of my patients. That being said, I do not personally use stimulants long-term for depression and pretty much only use them like this on the inpatient or consult side.

 

[annoyedpsychiatrist]

i agree overall. I wonder moreso if theyre underused in the geri patient with frequent falls, depression, psychomotor ******ation, apathy, low energy, etc. Wellbutrin is known to be a solid treatment for depression in parkinsons and ive had amazing success with this route in some patients.

My practice is a higher number of geri patients than the average practice, probably at least half or a bit over half are 65+. I have a 95 year old coming in a few weeks. I also have see a large number of neurological disorders and have wagr syndrom, good bit of FTD, LBD, had a prion case, corticobasil syndrome, parkinsons, MS, downs syndrome, amyloidosis, aphasic patients, etc so sometimes I have to consider all variables.