Stimulants for the Elderly and Disabled- Why Not?

You are on a dead run home from work. First you picked up Josh at the school after care center and now you are trying to rush through the local grocery store  to pick up a few things you need for dinner.  You astutely head for the checkout lane with only one person ahead of you.  The woman in front of you is elderly with her cane draped over her cart handle and her pocket book perched on the shopping cart.  You try not be annoyed by her slowness so you pick up one of the trade magazines haranguing the evils of stimulants in children with Attention Deficit Disorder while Josh eyes all the candy conveniently placed at his eye level.  What is taking her so long?  Just when you think she has finished, she asks the cashier if someone can fetch her a stick of butter she has forgotten.  It’s enough to make you buy the magazine and the candy bar that Josh has started to unwrap!

Flash back forty years to my Neurology residency.  I was a young, know-it-all , physician in training who decided to make some extra money moonlighting on Saturdays  for a family physician in a small rural town an hour from the University Hospital.  On my first Saturday I had a handful of patients ask me for a refill of their Gervbom Plus.  I had never heard of it, but they had been getting it for a few years and I approved the refill from the pharmacy.  The next week the same thing happened, so I called the pharmacist to inquire as to the contents of this unknown medication.  Remember, this is  long before the Internet, handheld PDAs and smart phones.  He told me that he took Geritol® ( a popular tonic loaded with vitamins and iron) and added a small quantity of amphetamine. Such compounding was popular and legal at the time.

I was outraged and indignant.  This was terrible medicine and most of all “I” had never heard of it.  However, I took a minute to ask the patients how they felt.  Terrific!  They had more energy, felt more focused, didn’t nap all afternoon and were able to participate in the community activities.  I learned something valuable that day.

How Do Stimulants Work?

Amphetamines may have a bad name because of illegal activity and abuse, but they have an important role in the treatment of the elderly and  people with disabilities.  My purpose here is to avoid the entire Attention Deficit Disorder (ADD) controversy and which children or adults with this diagnosis are candidates for stimulants.  Likewise, an entire blog could be spent on the ethical issues of physicians prescribing stimulants to college students who feel they need to take something to be on a level playing field with their fellow students who are taking stimulants.  This was covered in an excellent article on “cosmetic neurology” in the New Yorker.

Neurotransmitters are the chemicals in the brain and nervous system that help carry the message from one brain cell to another. Amphetamines increase the amount of these neurotransmitters available to the brain by a variety of different mechanisms.

A single dose of amphetamine will:

  • Increase wakefulness and alertness
  • Increase initiative, self confidence, concentration and sustained attention
  • Increase physical performance

Who wouldn’t want this advantage?  The military has used amphetamines for years to help pilots fly long missions from the Midwest to the Middle East or keep special forces awake and alert during long missions.    But, what is the role for the use of stimulants in the elderly or people with a stroke or brain injury.

Amphetamines Promote Neural Repair

We know from both animal and human research that the some medications promote recovery and repair of the nervous system, while others work against the patient and their nervous system.  It is beyond the scope of this article to discuss the precise mechanisms, but amphetamines work to promote the repair of the nervous system while drugs such as tranquilizers work against recovery.  In some studies patients who received amphetamines along with their therapy made much better progress and continued to do so even when the drug was stopped. There is evidence that one should start these medications in the acute care hospital, but many physicians are still hesitant to use them because of the stigma and negative perception of stimulants. Yes, they may increase a person’s blood pressure, but we can watch for that.  No, they do not increase the risk of seizures.

One of the major benefits is the improvement in attention, concentration and fatigue.  Many patients come to our rehabilitation after their stroke exhausted and fatigued, finding it difficult to participate in therapy.  They want to sleep or nap. It is frequently amazing to see the transformation that a low dose of Ritalin® makes in these patients.  They are awake, attentive and able to participate in therapy.

Why Not The Elderly?

Physicians have no problem giving antidepressants that may take weeks to work to an elderly person.  Why not give them Ritalin® or its generic, methylphenidate which works quickly to increase attention, concentration, mood and energy levels?  If you ask the people that have tried it, they will tell you how much better they feel.  If you ask the physicians that have a comfort level giving these people stimulants, you will find that they find it an important tool in treating the elderly and disabled.  One study in the Journal of the American Geriatric Society even found improved walking ability with a decreased risk of falling in those patients taking methylphenidate.

Stimulants can make an enormous difference.

All too often we relegate the disabled and the elderly to the category of, “I think you will have to live with that problem at your age.” We expect an older person to tire more easily, nap in the afternoon and be less attentive. Stimulants are a safe and inexpensive way to overcome some of these barriers.   Ask your doctor if a little stimulant might not be right for you or your loved one.

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