Attention-deficit/hyperactivity disorder (ADHD)

Attention-deficit/hyperactivity disorder (ADHD) is a neuropsychiatric condition.  It affects children, adolescents, and adults worldwide.  Patterns of diminished attention and increased hyperactivity or impulsivity are characteristics of ADHD. Often there is significant impairment in academics, social, and interpersonal situations. ADHD is associated with other comorbid disorders such as learning disabilities, anxiety, mood, and disruptive behavior disorders.

Risk factors

• Genetics

• Family history

• Neurochemical factors

• Neurophysiological factors

• Developmental factors

• Psychological factors

ADHD affects up to 5 to 8% of school-age children; 60-85% of those diagnosed in childhood continue to be symptomatic during adulthood. Previously there were two subtypes of ADHD. Inattentive and Hyperactive/impulsive type. Currently, these subtypes by three specifiers:

1. Combined presentation

2. Predominantly inattentive presentation

3. Predominantly hyperactive/impulsive presentation

Clinical Manifestations:

ADHD is characterized mainly in adults by inattention, impulsiveness, restlessness, executive dysfunction, and emotional dysregulation. These symptoms together lead to marked deficits in normal daily functioning. The predominant features of ADHD in adults differ from typical ADHD features in children. Inattention symptoms are more prominent in adults, while signs of hyperactivity or impulsivity are less noticeable.

Hyperactivity symptoms

• Restlessness

• Verbosity

• Constant activity, fidgeting 

• A tendency to choose very active jobs

Impulsivity symptoms 

• Ending relationships abruptly and often

• Quitting jobs

• Overreacting to frustrations

• More driving violations

Inattention symptoms

• Procrastination

• Difficulty making decisions

• Poor time management 

• Difficulty in organizing activities, prioritizing tasks, following through, and completing tasks

• Forgetfulness

How is ADHD diagnosed?

ADHD is usually diagnosed during childhood or late adolescence. The individual presents a persistent inattention or hyperactivity-impulsivity pattern that interferes with normal function and development. It requires continuous impairing of inattentiveness or hyperactivity in at least two different settings. 

The Diagnostic and Statistical Manual of Mental Disorders (DSM–5) gives diagnosis criteria to children and adults with ADHD. The DSM-5 requires that at least six inattentive or hyperactive-impulsive symptoms be present before age 12 to diagnose ADHD. 

To diagnose ADHD in adults and adolescents 17 years or older only five signs are needed for diagnosis. Symptoms might be different at older ages. Fidgetiness and verbal impulsivity, respectively, and extreme restlessness or wearing others out with their activity are signs in adults diagnosed with ADHD.

ADHD can be diagnosed by trained professionals such as psychiatrists, pediatricians, and nurse practitioners.

Course and prognosis:

The course of ADHD can be variable; overactivity is often the first symptom to remit, while inattention and distractibility are the last. Remission usually occurs between ages 12-and 20 years of age. Unfortunately, most patients with ADHD undergo partial remission while being vulnerable to mood, antisocial, and drug abuse behaviors. Approximately 60% of all cases persist into adulthood, while learning difficulties continue through life. Monitoring the pharmacological treatment for patients with ADHD is an essential part of the drug response and patient compliance. The goal is to reduce symptoms of ADHD and improve quality of life.

Treatment:

Pharmacologic treatment is considered the first-line treatment for ADHD. Long-acting stimulants are FDA approved for the adult treatment of ADHD. Stimulants are contraindicated in children, adolescents, and adults with known cardiac abnormalities and risks. The FDA approves some non-stimulant medications for the treatment of ADHD. Some antidepressants can be used in children older than six years, with variable success in treating ADHD.

Psychopharmacologic therapy may be needed indefinitely or for life. 

Although ADHD is a psychological condition, it is not a disability. Individuals with ADHD can find help and solutions to overcome any difficulties they may face. Cognitive Behavioral Therapy (CBT) can also help. A trained specialist can guide you or your loved one in managing stress, eating right, getting enough rest, and getting the proper medication to help overcome the symptoms of ADHD. To find out more about treatment options for ADHD, talk to your doctor or healthcare professional.

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.

Sadock, B. J., & Sadock, V. A. (2015). Kaplan & Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolter Kluwer/Lippincott Williams & Wilkins.

https://www.psychiatry.org/psychiatrists/practice/dsm

https://www.cdc.gov/ncbddd/adhd/diagnosis.html

https://www.uptodate.com/contents/approach-to-treating-attention-deficit-hyperactivity-disorder-in-adults?search=adhd%20treatment&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

Case Study: Hyperlipidemia

 

Case Summary

 

Chief Complaint

“I need refills.”

History and Physical

Mrs. JT s is a 56-year-old woman who presents to the pharmacotherapy clinic for intake. She has recently moved to your area and has not seen her primary care provider for the last 11 months. Her prescriptions have expired, and she is coming to you for “refills.”

Past Medical History

·      Obesity (BMI 31.5 kg/m²)

·      Dyslipidemia × 4 years

·      HTN × 15 years

·      Postmenopausal—has not had GYN screening since the onset of menopause (14 years ago)

Family History

·      Father: age 74 with extensive cardiovascular history, most notably first MI at 42.

·      Mother: died at age 61 from MVA, medical history unknown.

·      Patient has one older sister with hypertension and a history of “mini-strokes” and only one younger sister with hypertension.

·      Her children’s medical conditions are noncontributory.

Social History

·      Patient is married with three children who live out of state.

·      College graduate, works as a librarian.

·      Denies current alcohol and tobacco use but does admit to occasional marijuana use when she is visiting her children.

·      Began sporadic exercise regimen when diagnosed with dyslipidemia. Medications (Per Patient History; She Did Not Bring Records)

·      Metoprolol tartrate 50 mg po BID

·      Ezetimibe 10 mg po once daily

·      Aspirin 81 mg PO once daily

·      Ibuprofen 200 mg, four tablets po PRN leg cramps

·      Naproxen 220 mg, two tablets po PRN leg cramps

·      Garlic capsules

Allergies

“Statin” drugs—states she had occasional leg cramps after starting atorvastatin.

Review of Systems

The patient states that she just needs refills. She is argumentative about getting labs done and cannot understand why you would not just refill her medications. She denies any acute changes in health. She denies unilateral weakness, numbness/tingling, or vision changes. She denies CP and only has SOB when she walks in the park. With further questioning, you find that she rarely exercises, but when she does go for a walk, she typically overdoes it. She denies bowel or urinary habits changes and states she does not need to have GYN follow-ups anymore because she has gone through “the change.” She denies any lower extremity edema.

Physical Examination

·      Gen

·      Obese, somewhat agitated Caucasian woman

·      VS

·      BP 162/92, P 89, RR 18, T 37.2°C; Wt. 94 kg, Ht. 5′8″

·      Skin

·      Warm and dry to touch, normal turgor, (–) for acanthosis nigricans

·      HEENT

·      PERRLA; EOMI; funduscopic exam deferred; TMs intact; oral mucosa clear

·      Neck/Lymph Nodes

·      Neck supple, no lymphadenopathy, thyroid smooth and firm without nodules

·      Chest

·      CTA bilaterally, no wheezes, crackles, or rhonchi

·      Breasts

·      Normal, slightly fibrotic, no lumps or discharge

·      CV

·      RRR, no MRG, regular S₁, and S₂; no S₃ or S₄

·      Abd

·      (+) BS, no hepatosplenomegaly

·      Genit/Rect

·      Deferred

·      Ext

·      No pedal edema pulses 2+ throughout

·      Neuro

·      No gross motor–sensory deficits present

Labs (Fasting)

·       Na 142 mEq/L

·       K 4.9 mEq/L

·       Cl 103 mEq/L

·       CO2 23 mEq/L

·       BUN 16 mg/dL

·       SCr 0.9 mg/dL

·       Glucose 105 mg/dL

·       Hgb 11.6 mg/dL

·       Hct 34%

·       Ca 8.2 mg/dL

·       Mg 2.0 mg/dL

·       AST 28 units/L

·       ALT 31 units/L

·       T. bili 0.5 mg/dL

·       T. prot 7.1 g/dL

Fasting lipid profile:   ·       TC 240 mg/dL

·       HDL 41 mg/dL

·       LDL 163 mg/dL

·       TG 183 mg/dL

·       hsCRP 4.6 mg/L

Assessment

Mrs. Thorngrass is an obese Caucasian woman who presents to the pharmacotherapy clinic for intake. She has a significant family history of cardiovascular disease. She has uncontrolled hypertension, treated with metoprolol tartrate and dyslipidemia treated only with ezetimibe and garlic. She reports an allergy to atorvastatin but admits that her leg cramps have not improved since discontinuing the drug and coincide with her rare bouts of exercise. She reports liberal use of ibuprofen and naproxen to relieve the cramps. She also has previously undiagnosed anemia.

CASE SUMMARY TABLE:

Symptoms	·       Leg cramps ·       Hyperlipidemia
Recommended Drugs	1.     Lovastatin (Burchum & Rosenthal, 2018.p. 578). 2.     Colesevelam (Burchum & Rosenthal, 2018.p. 578). 3.     Ezetimibe (Pignone, 2018).
Drug Categories & Subcategories	4.     Lovastatin: HMG-CoA Reductase Inhibitors [Statins] (Burchum & Rosenthal, 2018.p. 578). 5.     Colesevelam: Bile-Acid Sequestrants (Burchum & Rosenthal, 2018.p. 578). 6.     Ezetimibe: cholesterol absorption inhibitors (Vallerand, Sanoski & Deglin, 2017. p. 540).
Drug of Choice	·      Ezetimibe (Zetia)
Rationale	Ezetimibe (Zetia): The 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline on the treatment of cholesterol recommends that adults with an LDL-C level greater or equal than 190 mg/dl be treated with high-intensity statin therapy or non-statin drugs to help reduce the LDL-C levels. Ezetimibe is the drug of choice for this patient since she has a known allergic reaction to statins. When statins are not possible, treatment with ezetimibe is an option. (Pignone, 2018).
Contraindications and Risks	·       Ezetimibe is contraindicated in hypersensitivity; Acute liver disease with moderate or severe hepatic impairment; concurrent use of fibrates. It may cause fetal harm in pregnancy by interfering with cholesterol synthesis. There is potential for adverse effects in nursing infants. Use with caution in children; safety has not been established in children > 10 years of age (Vallerand et al., 2017. p. 540).
Family Teaching	It is recommended that all patients with high cholesterol levels (hyperlipidemia) undergo lifestyle modifications such as weight loss, a diet with low saturated fats, and aerobic exercise. Compliance with the pharmacologic treatment is essential to reduce the risks of cardiovascular disease, stroke, and or heart attack (Pignone, 2018).

 

 

Prescription Pad

Rosabel V. Zohfeld

9999 Mozart Street

Round Rock, TX. 786999

Ph. 512-599-9999 fax: 877-579-9999

 

DEA # RZ123456

NPI #1122334455

License # 99999

 

Patient’s Name:  J. K                                                                         DOB April 30, 1956

Address: 123 South West Rd, Austin TX, 79999.                             Date. June 30, 2018.    F

Allergies: Statins                                                                                Weight: 94 kg

 

Rx:   1. Ezetimibe (Zetia) 10 (ten) mg tablets. Take 1 (one) tablet once daily for high cholesterol. It may be taken with or without meals.

Dispense: # 30 (thirty) tablets with #3 (three) refills before September 30, 2018.

Void after 30 days.

 

Substitution Permitted_______________ Dispense as written_____X_______

 

 

Signature: 

 

 

 

 

Hyperlipidemia

 

Population:

According to the CDC, approximately 33.5% of 71 million adult Americans have high cholesterol. Only 1 out of every 3 adults with hyperlipidemia has the condition under control (CDC, 2015). While not addressed in the 2013 ACC/AHA blood cholesterol guidelines, elevated cholesterol in pediatric patients is a growing concern. Nonetheless, it is addressed in other guidelines (Burchum & Rosenthal, 2018.p. 571).

Pathophysiology

Hyperlipidemia is defined as having too much cholesterol in the blood. An increase in the levels of lipoproteins in the blood results in deposits of fat in the heart, liver, and muscle (McCance, Grey, & Roadway, 2014.p.75). In general, cholesterol has no energy value; however, it serves as the component of the outer membrane of cells and is part of vitamin D, digestive bile, and several sex hormones. While cholesterol comes from animal food sources, our body can also make a certain amount of cholesterol. Too much cholesterol (in excess) in our blood can negatively affect the arteries by adhering to the walls of the arteries as fatty plaque. Arteries then can become clogged and disrupt the normal flow of blood. High cholesterol increases the risk for cardiovascular disease and stroke. A family history of high cholesterol is also a genetic predisposition for high.  Lipids in the blood (UCDavis, 2018).

 

 

Drug: Ezetimibe (Zetia).

 

Drug Class	Cholesterol Absorption Inhibitors (Vallerand et al., 2017.p. 540).
Subclass	Lipid-lowering agents (Vallerand et al., 2017.p. 540).
Indications	Ezetimibe is indicated for managing dyslipidemias, primary cholesterolemia, familial hypercholesterolemia, and sitosterolemia (Vallerand et al., 2017.p. 540).
Mechanisms of Action	Ezetimibe inhibits cholesterol absorption in the small intestine (Vallerand et al., 2017.p. 540).
Pharmacodynamics	When taken orally, Ezetimibe has an unknown onset, peak, and duration (Vallerand et al., 2017.p. 540).
Pharmacokinetics	Ezetimibe is rapidly converted to ezetimibe-glucuronide (active) following oral administration. Its bioavailability is variable. Ezetimibe’s distribution is unknown. Its metabolism and excretion undergo enterohepatic recycling. It is primarily eliminated in feces with minimal renal excretion. Ezetimibe has a half-life of 22 hours (Vallerand et al., 2017.p. 540).

 

Generic Name	Ezetimibe (Vallerand et al., 2017.p. 540).
Brand Name	Zetia, Ezetrol (Vallerand et al., 2017.p. 540).
Dose	10 mg by mouth once daily (Vallerand et al., 2017.p. 540).
Indications	Hypercholesterolemia (Burchum & Rosenthal, 2018.p. 585).
Instructions	Take one 10 mg tablet once daily with or without food (Burchum & Rosenthal, 2018.p. 585).
Side/Adverse effects	·       Some of the side/ adverse effects of Ezetimibe are cholecystitis, cholelithiasis, increased liver enzymes (in conjunction with HMG-CoA reductase inhibitors), nausea, pancreatitis, rash, and angioedema (Vallerand et al., 2017. p. 540).
Outcomes	Treatment with Ezetimibe aims to decrease serum LDL and total cholesterol levels (Vallerand et al., 2017.p. 541).
Counseling: What the patient Needs to know	Hyperlipidemia: High cholesterol can increase the risk of developing heart disease, heart attack, and stroke significantly. There are treatment options available. High cholesterol levels can be lowered with a healthy diet low in saturated fats, weight loss, exercise, and medications. The risk of developing cardiovascular decreases as the cholesterol levels decreases. A lipid-lowering treatment can be lifesaving. (Rosenson, 2018).  You need to know that untreated high cholesterol can lead to plaque buildup in the blood vessels (atherosclerosis). This increase in plaque buildup increases your heart attack, stroke, and peripheral artery disease risks. The treatment of high cholesterol is a lifelong process. It takes approximately 6 to 12 months for the effects of medication and lifestyle modifications to notice results. You must follow your treatment as prescribed and continue with necessary follow-ups with your primary care provider.  It is essential to be compliant with your treatment. Always consult with the health care provider if your medication is not working for you before making any changes or taking any over-the-counter supplements. Unfortunately, garlic supplements have not been proven effective in lowering cholesterol levels (Rosenson, 2018). Ezetimibe: Take ezetimibe as directed. Take it at the same time each day, even when feeling well. If a dose is missed, take the dose as soon as you remember. Do not take more than one (1) dose per day. This medication helps control but does not cure elevated serum cholesterol levels. Ezetimibe should be used in conjunction with diet restrictions, exercise, and smoking cessation. Ezetimibe is not indicated for weight loss. Notify the health care professional if unexplained muscle pain, tenderness, or weakness occurs. The risk may increase when used with HMG-CoA reductase inhibitors. Notify health care professionals of all prescriptions and or over-the-counter medications such as vitamins or herbal products. It is essential to follow up to determine the effectiveness and monitor side effects (Vallerand et al., 2017.p. 541). Ibuprofen & Naproxen: these two drugs belong to the non-steroidal anti-inflammatory drugs (NSAIDS). They should only be used briefly. Liberal use is not recommended. Only a low dose in older adults is recommended due to the risk for gastrointestinal and cardiovascular disease (Galicia-Castillo & Weiner, 2017).  It is recommended to get back on the treatment for high cholesterol with Ezetimibe. Follow up in a month to see if there has been improvement with the leg cramps. Minimize the use of Ibuprofen and Naproxen. If leg cramps do not get, better further testing is recommended before adding another pharmacologic treatment (Rosenson, 2018).

 

References:

 

Centers for Disease Control and Prevention, CDC. (2015). Division for Heart Disease and Stroke Prevention; Cholesterol Fact Sheet. Retrieved June 29, 2018, from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_cholesterol.htm

Burchum, J. R., & Rosenthal, L. D. (2018). Lehne's pharmacology for nursing care (10th ed.). St. Louis, MO: Elsevier/Saunders.

Galicia-Castillo, C. M., & Weiner, D. K. (2017). Treatment of Persistent Pain in Older Adults. In M. Crowley. (Ed.). UpToDate. Retrieved from https://www.uptodate.com/contents/treatment-of-persistent-pain-in-older-adults?csi=92c10aa9-4c4f-429e-82e4-218c482f5e31&source=contentShare

McCance, K. L., Grey T. C., & Rodway, G. (2014). Altered Cellular and Tissue Biology. In K.L. McCance & S. E. Huether (Eds.), Pathophysiology: The biologic basis for disease in adults and children (p.75). St. Louis, MO: Mosby Elsevier.

Pignone, M. (2018). Management of elevated low-density lipoprotein-cholesterol (LDL-C) in primary prevention of cardiovascular disease. In G.M. Saperia (Ed). UpToDate. Retrieved from 

https://www.uptodate.com/contents/management-of-elevated-low-density-lipoprotein-cholesterol-ldl-c-in-primary-prevention-of-cardiovascular-disease?csi=7120eab6-27a2-4cfe-bf9a-70d3daf57a91&source=contentShare

Rosenson, S. R. (2018). Patient Education: High Cholesterol Treatment Options (Beyond the Basics). In G. M. Saperia (Ed.). UpToDate. Retrieved from https://www.uptodate.com/contents/high-cholesterol-treatment-options-beyond-the-basics?csi=0d03a5f0-5e24-4f42-8ef7-4a415d7e500d&source=contentShare

UCDavis. (2018). Hyperlipidemia: Overview of Hyperlipidemia (High Blood Cholesterol). Retrieved from https://shcs.ucdavis.edu/topics/hyperlipidemia

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's drug guide for nurses (15th ed.). Philadelphia: F.A. Davis Company.