Protocol for Starting Stimulants in a 66-Year-Old with ADHD
Begin with long-acting methylphenidate (e.g., Concerta 18 mg once daily) or lisdexamfetamine (20-30 mg once daily) as first-line therapy after completing cardiovascular screening, then titrate weekly by 18 mg (methylphenidate) or 10-20 mg (lisdexamfetamine) until optimal symptom control is achieved, typically reaching 36-54 mg daily for methylphenidate or 50-70 mg for lisdexamfetamine. 1, 2
Pre-Treatment Cardiovascular Screening
Before initiating any stimulant in a 66-year-old patient, comprehensive cardiovascular assessment is mandatory:
Obtain detailed personal and family cardiac history, specifically screening for sudden cardiac death in relatives younger than 50 years, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, Long QT syndrome, unexplained syncope or seizures, and cardiovascular symptoms such as chest pain or palpitations. 1
Measure baseline blood pressure and pulse in both seated and standing positions to establish a reference point for ongoing monitoring. 1, 2
Assess for symptomatic cardiovascular disease, uncontrolled hypertension, coronary artery disease, serious cardiac arrhythmias, or structural cardiac abnormalities—any of these constitute absolute contraindications to stimulant therapy. 3, 1
If any cardiac risk factors are identified, obtain an ECG and strongly consider cardiology consultation before proceeding with stimulant initiation. 1
Medication Selection and Initiation
First-Line Stimulant Options
Long-acting formulations are strongly preferred over immediate-release preparations due to superior adherence, more consistent symptom control throughout the day, lower rebound effects, and reduced diversion potential—critical considerations for older adults with executive dysfunction. 1
For methylphenidate (Concerta):
- Start at 18 mg once daily in the morning after breakfast. 1, 2
- This initial dose is equivalent to immediate-release methylphenidate 5 mg three times daily. 1
- The OROS delivery system provides 12 hours of continuous coverage with an ascending plasma profile that minimizes abuse potential. 1
For lisdexamfetamine (Vyvanse):
- Start at 20-30 mg once daily in the morning. 1, 4
- The prodrug formulation reduces abuse potential by avoiding rapid plasma peaks. 1
- Provides once-daily dosing with extended duration of action. 1
Titration Protocol
Systematic Weekly Dose Escalation
Do not use weight-based (mg/kg) dosing—systematic titration to the lowest effective dose that produces functional improvement is the evidence-based approach. 1
For methylphenidate:
- Increase by 18 mg weekly (18 mg → 36 mg → 54 mg) based on symptom response and tolerability. 1, 2
- Most adults require 36-54 mg daily for optimal ADHD control. 1
- Maximum recommended dose is 60-72 mg daily, though some patients may require up to 60 mg. 5, 4, 3
For lisdexamfetamine:
- Increase by 10-20 mg weekly based on response. 1
- Target therapeutic range is 50-70 mg daily. 1
- Maximum dose is 70 mg daily. 4
Stimulants produce therapeutic effects within days, allowing rapid assessment of efficacy at each dose level—this is a key advantage over non-stimulants that require 6-12 weeks for full effect. 1, 4
Monitoring During Titration
Weekly Assessment (First 4-6 Weeks)
Measure blood pressure and pulse at each dose adjustment, watching for increases beyond 10 mm Hg systolic or 5-10 bpm heart rate. 1, 4
Obtain ADHD symptom ratings weekly using standardized scales to objectively track improvement across functional domains (work, home, social settings). 1
Assess common adverse effects: appetite suppression, insomnia, headache, anxiety, gastrointestinal symptoms, and cardiovascular effects. 1, 2, 3
Monitor sleep quality and appetite changes systematically, as these are the most frequent dose-limiting side effects. 1, 3
Maintenance Phase Monitoring
Monthly visits initially, then quarterly once stable symptom control is achieved. 1, 2
Continue blood pressure and pulse monitoring at every visit—stimulants can elevate BP by 1-4 mm Hg and heart rate by 1-2 bpm on average. 1
Track functional improvement across multiple settings rather than relying solely on symptom scales. 1
Management of Inadequate Response
If First Stimulant Trial Fails
Approximately 40% of patients respond to both methylphenidate and amphetamine classes, while another 40% respond to only one class—therefore, trial the alternative stimulant class before abandoning stimulant therapy. 1, 6
If methylphenidate is inadequate after reaching 54-60 mg daily, switch to lisdexamfetamine or mixed amphetamine salts. 1, 6
If amphetamine-based stimulants fail, trial methylphenidate formulations. 1
Do not switch stimulant classes until the first agent has been titrated to maximum tolerated dose—premature switching is a common pitfall. 1, 7
Non-Stimulant Alternatives (Second-Line)
Reserve non-stimulants for patients who have failed two or more stimulant trials, experience intolerable stimulant side effects, or have active substance use disorder. 1, 4
Atomoxetine (Strattera)
Target dose: 60-100 mg daily (maximum 1.4 mg/kg/day or 100 mg, whichever is lower). 1, 4
Start at 40 mg daily, titrate every 7-14 days to 60 mg, then 80 mg as tolerated. 4
Requires 6-12 weeks for full therapeutic effect (median 3.7 weeks)—significantly longer than stimulants. 1, 4
Effect size approximately 0.7 compared to stimulants (effect size 1.0). 1
FDA black-box warning for suicidal ideation—requires baseline and ongoing monitoring for suicidality and clinical worsening. 1, 4
Provides 24-hour coverage with no abuse potential, making it ideal when substance misuse risk exists. 1, 4
Alpha-2 Adrenergic Agonists
Extended-release guanfacine (Intuniv) or clonidine (Kapvay):
Effect size approximately 0.7, comparable to atomoxetine. 1
Start guanfacine at 1 mg nightly, titrate by 1 mg weekly to target 0.05-0.12 mg/kg/day (maximum 7 mg). 1
Full clinical effect within 2-4 weeks—faster than atomoxetine but slower than stimulants. 1
Particularly useful when comorbid sleep disturbances, anxiety, or tics are present. 1
Evening dosing preferred due to sedative properties. 1
Critical Contraindications and Precautions
Absolute Contraindications to Stimulants
Symptomatic cardiovascular disease (coronary artery disease, serious arrhythmias, structural cardiac abnormalities, cardiomyopathy). 3, 1
Uncontrolled hypertension—stimulants should be avoided; initiate or intensify antihypertensive therapy first. 5, 3
Concurrent MAOI use or within 14 days of MAOI discontinuation—risk of hypertensive crisis. 3, 4
Known hypersensitivity to methylphenidate or amphetamines. 3
Relative Contraindications Requiring Caution
History of substance use disorder—consider long-acting formulations with lower abuse potential (lisdexamfetamine, OROS-methylphenidate) or non-stimulants. 1, 2
Glaucoma or significantly increased intraocular pressure—prescribe only if benefit outweighs risk, with close ophthalmologic monitoring. 3
Peripheral vasculopathy or Raynaud's phenomenon—careful observation for digital changes is necessary. 3
Common Pitfalls to Avoid
Do not start at excessively high doses—begin conservatively (18 mg methylphenidate or 20-30 mg lisdexamfetamine) to minimize adverse effects and improve adherence. 2
Do not assume the initial dose is sufficient—most patients require titration to 36-54 mg methylphenidate or 50-70 mg lisdexamfetamine for optimal response. 1
Do not switch stimulant classes prematurely—ensure adequate dose optimization (up to 60 mg methylphenidate or 70 mg lisdexamfetamine) before declaring treatment failure. 1, 7
Do not delay ADHD treatment due to age concerns—untreated ADHD in older adults is associated with increased risk of accidents, functional impairment, and reduced quality of life. 1
Do not use immediate-release formulations for convenience—long-acting preparations are superior for adherence and safety in older adults. 1
Do not discontinue effective treatment solely due to concerns about "taking medication long-term"—chronic ADHD requires ongoing management, and discontinuation leads to symptom recurrence and functional decline. 1
Special Considerations for Older Adults
Age-related increased sensitivity to both therapeutic and adverse effects may occur—start conservatively and titrate slowly. 2
Polypharmacy concerns: Review all medications for potential interactions, particularly antihypertensives, anticoagulants, and drugs affecting CYP2D6 metabolism. 5
Cardiovascular monitoring is paramount in this age group—BP and pulse checks at every visit are non-negotiable. 1, 2
Cognitive comorbidities: Screen for early dementia or mild cognitive impairment that may complicate ADHD diagnosis and treatment response. 2
Consider behavioral interventions alongside medication—Cognitive Behavioral Therapy specifically developed for adult ADHD is most effective when combined with pharmacotherapy. 1, 4
Expected Outcomes
70-80% of adults achieve good symptom control when stimulants are properly titrated. 1, 4, 8
Therapeutic effects appear within days, allowing rapid dose optimization. 1, 8
Functional improvement across work, home, and social domains is the primary treatment goal, not just symptom reduction. 1
If adequate response is not achieved after optimizing two different stimulant classes, consider non-stimulant alternatives or referral to an ADHD specialist. 1, 6