What is the recommended starting dose of Adderall (amphetamine and dextroamphetamine) for a 60-year-old woman?

Starting Dose of Adderall for a 60-Year-Old Woman

For a 60-year-old woman, start with 5 mg of immediate-release Adderall once daily in the morning (or 2.5 mg if cutting a tablet is feasible), with more conservative weekly titration compared to younger adults due to age-related increased sensitivity to both therapeutic and adverse effects. 1, 2

Initial Dosing Strategy

Standard adult dosing may be too aggressive for older adults. While guidelines recommend 5 mg twice daily for general adult populations 3, 1, older adults require a modified approach:

• Start with 5 mg once daily (immediate-release formulation) given in the morning after breakfast 1, 4
• Consider 2.5 mg once daily as an even more conservative starting point by cutting a 5 mg IR tablet, particularly appropriate for this age group 1
• Morning administration is critical to minimize sleep disturbances 1, 5, 2
• Avoid late evening doses due to resulting insomnia 4

For extended-release formulation, the standard starting dose is 10 mg once daily in the morning, though this may still be too high for initial use in a 60-year-old 1, 5, 2.

Age-Specific Considerations

Older adults are more sensitive to stimulants due to age-related pharmacokinetic changes, requiring special attention 1, 2, 6:

• Age-related changes in drug metabolism and clearance increase both therapeutic and adverse effects 1, 2
• Lower effective doses are often sufficient in older patients 6
• Cardiovascular monitoring is particularly important in this population 2, 7

Modified Titration Schedule

Use a slower titration schedule than recommended for younger adults:

• Increase by 5 mg every 2 weeks (not weekly as in standard protocols) to minimize side effects 1, 2
• Allow sufficient time between increases to properly evaluate response 1, 5
• Reassess both therapeutic effects and side effects before each dose adjustment 2
• Maximum dose remains 40-50 mg daily, though older adults often require lower doses 1, 5

Mandatory Baseline and Monitoring Requirements

Before initiating treatment:

• Baseline blood pressure and pulse measurement 3, 1, 5
• Baseline height and weight 3, 1, 5
• Screen for contraindications: symptomatic cardiovascular disease, hypertension, hyperthyroidism, glaucoma, history of stimulant abuse 3

During treatment:

• Quarterly blood pressure and pulse checks are essential for adults on stimulants 3, 1, 5
• Weight assessment at each visit to detect appetite suppression 1, 5
• Systematic evaluation of target ADHD symptoms and side effects (insomnia, anorexia, headaches, social withdrawal, tics) 1, 5
• At least monthly in-person visits until symptoms stabilize 1, 5

Critical Cardiovascular Concerns

Amphetamines consistently increase blood pressure and heart rate:

• Systolic blood pressure increases by approximately 1.93 mmHg 8
• Diastolic blood pressure increases by approximately 1.84 mmHg 8
• Heart rate increases by approximately 3.71 beats per minute 8
• These effects are sustained with long-term use 8
• No significant difference in cardiovascular events between amphetamine/dextroamphetamine and methylphenidate in older adults 7

Common Pitfalls to Avoid

Starting too high leads to unnecessary side effects and decreased adherence 1, 5, 2:

• Do not use the standard adult starting dose of 5 mg twice daily in a 60-year-old 1
• Avoid rapid weekly titration; use 2-week intervals instead 1, 2
• Do not skip baseline cardiovascular assessment 3, 1, 5
• Never continue increasing beyond maximum dose (40-50 mg) if ineffective—switch medications instead 1, 5

When Treatment Fails at Maximum Dose

If 40-50 mg provides no benefit, more medication is not the answer 1, 5:

• Switch to an alternative stimulant formulation 2
• Consider non-stimulant medications like atomoxetine 2
• Reevaluate the diagnosis and assess for comorbid conditions 1, 5, 2
• Add environmental or psychosocial interventions 5

Withdrawal Risk

Participants taking amphetamines are 2.69 times more likely to withdraw due to adverse effects compared to placebo, with an absolute risk increase of 4.3% 8. This underscores the importance of conservative dosing in older adults who may be even more susceptible to side effects.