Treating adults with Attention Deficit Disorder is complicated and very different than treating children The difficulties in treating children have to do with brain growth and development as well as parenting, education, and social influences on the brain. Each stage of childhood development is different since brains grow and are pruned in spurts up until the late 20s.
Each stage of adulthood and aging is likewise associated with developing illness and medications. Each medical condition affects brain function. Many patients have multiple medical problems. It is apparent, therefore, that individual assessment and treatment is vital, then long term monitoring and management is essential as life “happens”.
Type 2 Diabetes: Approximately 30% of the adult population is diabetic and another 30% pre-diabetic, which mirror the obesity rate of around 60%. When blood sugar levels stay above 180 mg/dl, there is disorder in the energy and repair function of cells, including brain cells. Since the brain is the most metabolically active organ in the body, using 20% of all food derived energy, it is more sensitive to changes in energy disorders, like diabetes. I call this “diabetic dementia”. It is reversible as sugar metabolism improves.
Menopause: Loss of hormones in women and men is associated with less dopamine production in the brain. Dopamine is the neurotransmitter chemical that allows once nerve cell to message an adjacent nerve cell. If there is less domaine production, less dopamine release, or increased breakdown of dopamine, nerve cells “talk” less or “talk” differently to other brain cells. Replacement of hormones requires delicate management to optimize brain function including type of hormone (estradiol vs estrone vs estriol), delivery (sublingual, oral, transcutaneous, pellets), dose, frequency, and combinations such as estrogen alone, estrogen plus progesterone or estrogen, progesterone, and testosterone). In men, the question is also type, delivery, dosing, and combinations.
Drugs of Abuse: Alcohol is the most consumed of the brain-damaging drugs. A majority of American consume alcohol. Approximately 10% fall into an alcohol-use disorder classification. Alcohol damages brain cells to different degrees depending on frequency, dose, and length of use. I use a simple 3 day measure as a gauge of severity—can the patient reframe from use for 3 consecutive days? Can they reframe for 3 days at least once per week? If they cannot, further treatment and counseling is advised. It takes around three days for alcohol to clear out then allow brain cell metabolism to recover. THC or marijuana is the second most used substance that impairs brain function. THC is fat-soluble which is why it takes days or longer to clear out of the brain. The brain contains a high percentage of fat. THC slows brain function. Chronic use leads to permanent changes in various parts of the brain and can lead to changes in behavior, especially anger, and vomiting called cannabanoid hyperemesis syndrome. Reversal of chronic brain changes from THC take many months or longer. Benzodiazepam (Clonopin, valium, Xanax, Ambien) are tranquilizers. As this implies, they sedate the brain. Therefore they are often prescribed for panic and anxiety syndromes. They are habituating and addicting. Withdrawal is sever and can lead to seizures and even death. I no longer accept patients taking benzo medications as they are difficult to improve and almost impossible to withdraw off the medication. Methamphetamines exhaust the brain from overstimulation. Much of the damage occurs from lack of sleep, similar to findings found in sleep-torture individuals. Severe sleep deprivation can lead to death from brain deterioration, in extreme cases. The brain develops “pock marks” from area of injury when visualized on SPECT Brain imaging studies and reversal may takes months or years in extreme cases. Oddly enough, the only treatment found effective so far is replacement with oral slow absorbing amphetamines. Opiates or pain narcotics are frequently prescribed for chronic pain. Opiates also permanently alter brain function and are highly addicting. Brain cell slowing is usual. Chronic opiate users are usually identifiable at a distance due to definable changes in facial appearance and behavior.
Sleep apnea/sleep disorders: Sleep apnea is present in 20% of the adult population. A strong correlation with obesity exists. It often resolves with weight loss and exercise. Sleep apnea leads to frequent breaks in normal sleep patterns in order to awake and breath, when oxygen levels fall low enough to stimulate deep brain structures. Dreaming sleep, required for brain repair and recovery, is often interrupted in sleep apnea. Therefore, brain cells are stunned or die and memories form much less easily. Sleep devices, like CPAP, improve sleep and therefore brain function.
Thyroid disorders: Thyroid hormone is literally a metabolism hormone. Too much thyroid hormone leads to overactivity and hyper excitability. Too little leads to cell lethargy and even death if prolonged and extreme. Thyroid testing should be part of any ADD evaluation in adults or children.
Iron deficiency: Iron is lost from normal menstrual periods. Excessive or prolonged menstrual cycles are often a source of iron deficiency. Occasionally, a lack of iron in the diet fails to keep up with the menstrual blood loss. Iron levels should be tested also in every adult ADD patient. Iron is a cation that carries electrons. If low iron levels exist, the brain cell cannot transmit an electron from one brain cell to another as easily. Patients complain of being tired and sluggish, cold, and have brain “fog”. Replacement can be with oral iron or injections. Iron loss can also occur from intestinal loss from stomach ulceration or cancer. Therefore, iron deficiency always requires an explanation.
B12 deficiency: Vitamin B12 has a complicated absorption system. It requires specialized cells and enzymes in the stomach, an intact distal ileum near the colon, and a normal intestinal bacterial colony. Diseases or surgery of the stomach, Illium and colon, and even antibiotics that interfere with the intestinal bacteria can lead to B12 deficiency. B12 is necessary to form the neurotransmitter dopamine. Without B12 brain and spinal cord neurons can be injured or die. In 1900, if you were diagnosed with pernicious anemia, due to B12 deficiency, it was a fatal diagnosis—you were going to decay and die. Discovery of how to replace B12 was considered a miracle. Now it is an afterthought. B12 levels should also be tested in all ADD patients, especially those with intestinal disease or prior intestinal surgery. Treatment is a monthly injection of B12.
Medications: hundreds of medications can slow brain function including those for epilepsy, chronic pain, neurological diseases, and many more. Adults with ADD should always be treated by someone expert on the effects of medications on the brain. Adjustments, when possible, can make an enormous difference in brain function, often in days or weeks.
