NR546 week 7 test your knowledge quiz
At the age of 10, a 27-year-old bartender was diagnosed with ADHD. She has been on and off
medication since then, first on immediate-release methylphenidate, then on the methylphenidate
patch. She experimented with illegal drugs in her late teens and continues to drink heavily. She
is seeking medical attention once more after self-medicating with alcohol and cigarettes for a
few years. You decide to give her 80 mg of atomoxetine per day, one of the ADHD-fighting
non-stimulants. ANS: Atomoxetine raises dopamine levels in the prefrontal cortex but not the
nucleus accumbens, which accounts for its lack of abuse potential. Rationale: The prefrontal
cortex lacks high concentrations of dopamine transporters (DAT), so in this brain region, DA
gets inactivated by norepinephrine transporters (NET). As a result, both DA and NE are
increased when NET is inhibited in the prefrontal cortex. Atomoxetine does not cause an
increase in DA or NE in the nucleus accumbens, the brain's reward center, because there are
only a few NET there. As a result, it does not have the potential to be abused. There are only a
few NE neurons and NE transporters in the nucleus accumbens. Neither NE nor DA will rise
when NET is inhibited in the nucleus accumbens. Serotonin levels are not influenced by
atomoxetine. The areas of the brain that are involved in reward are not the striatum or the
anterior cingulate cortex. Restless legs syndrome (RLS), also known as ANS, is a common
cause of insomnia. Tx order for ADHD and co-morbidities: ANS-1. alcohol, stimulant, and
substance abuse 2. mental health issues 3. mental health issues 4. ADHD
Adolescents and children 1. Nicotine addiction 2. ADHD
ADHD lifespan considerations - ANS--Symptoms change with age.
- More than just a childhood diagnosis -With age, hyperactivity decreases significantly. -Primary
Symptoms: inattention, restlessness, cognitive & emotional impulsivity, executive functioning
deficits, and self-regulation
-Occupational stress and anxiety may affect adults who struggle with executive functioning and
disorganization. Considerations for the Lifespan of ADHD: Breastfeeding - ANS-Stimulants
should not be used while breastfeeding. Children's ADHD Lifespan Considerations -
ANS—Medications for ADHD are not approved for children under the age of 6. -If your child has
lost a lot of appetite or is underweight, short-acting medications might help them eat more for
lunch and dinner. Considerations for the ADHD Lifespan: Pregnancy - ANS-Stimulants may
harm the fetus, leading to an increase in low birth weight and pregnancy. ADHD Patient
Education - ANS--Common side effects include restlessness, irritability, anxiety, insomnia,
stomachache, headaches, tics, and worsening of aggression symptoms.
-Clients may note a worsening of symptoms, or "crash" when the medication wears off,
especially with immediate-release (IR) medications.
-Medications may cause appetite changes and subsequent weight loss.
• To reduce anorexia, take medication before breakfast. ADHD Prescribing Pearls -
ANS--Before initiation of any stimulant, obtain thorough health history.
, -Check to see if you or your family has a history of heart disease. • An electrocardiogram is
necessary if a first-degree relative has a history of heart disease. -BP, height, & weight should
be monitored regularly during tx
-In clients who have never had a mental illness, CNS stimulants may exacerbate behavior
disturbances and thought disorders or cause psychotic or manic symptoms. -Assess all clients
for bipolar disorder before tx
-CNS stimulants may exacerbate comorbid anxiety & substance use disorders.
-Efficacy of the treatment will be assessed within the first week. -A low dose of a non-stimulant
medication can be used to treat insomnia and increased irritability, allowing the client to fall
asleep. -After using for a long time, abrupt withdrawal can cause irritability and rebound
symptoms. -Stimulants can cause or worsen tics; stimulants may unmask the presence of tics
-When switching stimulants, discontinue the current medication and begin the new one at the
beginning dose the following day. -Stimulant meds available to treat ADHD are available as
immediate-release or sustained-release formulations
-Medications with short half-lives are more likely to be diverted. Monitoring must be performed
with care. Occasional urine drug screens should be obtained to verify the presence of
amphetamines and the absence of other substances of abuse.
ADHD Symptoms: - ANS-Typically start before age 12, may begin to appear early as 3:
-Selective Concentration • a lack of detail-orientedness • careless errors • not being attentive •
losing things
• diverting attention
• Failing to remember -Lack of Sustained Attention
• poor problem solving
• difficulty completing tasks
• disorganization
• having trouble maintaining mental focus -Impulsivity
• excessive talking
• speaking out loud • ignoring one's turn • interfering -Hyperactivity
• fidgeting
• leaving one's seat
• running, climbing
• difficulty playing quietly *Attentional symptoms typically appear two to four years after
childhood hyperactivity symptoms. After 3 months, Cora's mom reports that her irritability has
decreased somewhat with the implementation of the extended-release methylphenidate, but her
teacher notes that she remains argumentative and oppositional at times. Her appetite remains
good, but she is having difficulty sleeping. ANS-add 1 mg of guanfacine daily at this time.
Which of the following medication modifications might you consider making for Cora right now?
Rationale: While methylphenidate is somewhat effective for Cora, her irritability and ADHD may
be better controlled by adding a non-stimulant medication, such as guanfacine, to her daily
medication regimen. Guanfacine taken at bedtime may also help with sleep.
Amphetamine (Adzenys) - ANS is available in an extended-release oral formulation for children
who are unable to swallow pills. -Do not prescribe an MAOI if it has already been used within 14
days. Center in the brain that tells you to go to sleep - ANS-VLPO (Ventrolateral preoptic area)
-tells the 7 wakefulness areas of the brain to "shut off"
At the age of 10, a 27-year-old bartender was diagnosed with ADHD. She has been on and off
medication since then, first on immediate-release methylphenidate, then on the methylphenidate
patch. She experimented with illegal drugs in her late teens and continues to drink heavily. She
is seeking medical attention once more after self-medicating with alcohol and cigarettes for a
few years. You decide to give her 80 mg of atomoxetine per day, one of the ADHD-fighting
non-stimulants. ANS: Atomoxetine raises dopamine levels in the prefrontal cortex but not the
nucleus accumbens, which accounts for its lack of abuse potential. Rationale: The prefrontal
cortex lacks high concentrations of dopamine transporters (DAT), so in this brain region, DA
gets inactivated by norepinephrine transporters (NET). As a result, both DA and NE are
increased when NET is inhibited in the prefrontal cortex. Atomoxetine does not cause an
increase in DA or NE in the nucleus accumbens, the brain's reward center, because there are
only a few NET there. As a result, it does not have the potential to be abused. There are only a
few NE neurons and NE transporters in the nucleus accumbens. Neither NE nor DA will rise
when NET is inhibited in the nucleus accumbens. Serotonin levels are not influenced by
atomoxetine. The areas of the brain that are involved in reward are not the striatum or the
anterior cingulate cortex. Restless legs syndrome (RLS), also known as ANS, is a common
cause of insomnia. Tx order for ADHD and co-morbidities: ANS-1. alcohol, stimulant, and
substance abuse 2. mental health issues 3. mental health issues 4. ADHD
Adolescents and children 1. Nicotine addiction 2. ADHD
ADHD lifespan considerations - ANS--Symptoms change with age.
- More than just a childhood diagnosis -With age, hyperactivity decreases significantly. -Primary
Symptoms: inattention, restlessness, cognitive & emotional impulsivity, executive functioning
deficits, and self-regulation
-Occupational stress and anxiety may affect adults who struggle with executive functioning and
disorganization. Considerations for the Lifespan of ADHD: Breastfeeding - ANS-Stimulants
should not be used while breastfeeding. Children's ADHD Lifespan Considerations -
ANS—Medications for ADHD are not approved for children under the age of 6. -If your child has
lost a lot of appetite or is underweight, short-acting medications might help them eat more for
lunch and dinner. Considerations for the ADHD Lifespan: Pregnancy - ANS-Stimulants may
harm the fetus, leading to an increase in low birth weight and pregnancy. ADHD Patient
Education - ANS--Common side effects include restlessness, irritability, anxiety, insomnia,
stomachache, headaches, tics, and worsening of aggression symptoms.
-Clients may note a worsening of symptoms, or "crash" when the medication wears off,
especially with immediate-release (IR) medications.
-Medications may cause appetite changes and subsequent weight loss.
• To reduce anorexia, take medication before breakfast. ADHD Prescribing Pearls -
ANS--Before initiation of any stimulant, obtain thorough health history.
, -Check to see if you or your family has a history of heart disease. • An electrocardiogram is
necessary if a first-degree relative has a history of heart disease. -BP, height, & weight should
be monitored regularly during tx
-In clients who have never had a mental illness, CNS stimulants may exacerbate behavior
disturbances and thought disorders or cause psychotic or manic symptoms. -Assess all clients
for bipolar disorder before tx
-CNS stimulants may exacerbate comorbid anxiety & substance use disorders.
-Efficacy of the treatment will be assessed within the first week. -A low dose of a non-stimulant
medication can be used to treat insomnia and increased irritability, allowing the client to fall
asleep. -After using for a long time, abrupt withdrawal can cause irritability and rebound
symptoms. -Stimulants can cause or worsen tics; stimulants may unmask the presence of tics
-When switching stimulants, discontinue the current medication and begin the new one at the
beginning dose the following day. -Stimulant meds available to treat ADHD are available as
immediate-release or sustained-release formulations
-Medications with short half-lives are more likely to be diverted. Monitoring must be performed
with care. Occasional urine drug screens should be obtained to verify the presence of
amphetamines and the absence of other substances of abuse.
ADHD Symptoms: - ANS-Typically start before age 12, may begin to appear early as 3:
-Selective Concentration • a lack of detail-orientedness • careless errors • not being attentive •
losing things
• diverting attention
• Failing to remember -Lack of Sustained Attention
• poor problem solving
• difficulty completing tasks
• disorganization
• having trouble maintaining mental focus -Impulsivity
• excessive talking
• speaking out loud • ignoring one's turn • interfering -Hyperactivity
• fidgeting
• leaving one's seat
• running, climbing
• difficulty playing quietly *Attentional symptoms typically appear two to four years after
childhood hyperactivity symptoms. After 3 months, Cora's mom reports that her irritability has
decreased somewhat with the implementation of the extended-release methylphenidate, but her
teacher notes that she remains argumentative and oppositional at times. Her appetite remains
good, but she is having difficulty sleeping. ANS-add 1 mg of guanfacine daily at this time.
Which of the following medication modifications might you consider making for Cora right now?
Rationale: While methylphenidate is somewhat effective for Cora, her irritability and ADHD may
be better controlled by adding a non-stimulant medication, such as guanfacine, to her daily
medication regimen. Guanfacine taken at bedtime may also help with sleep.
Amphetamine (Adzenys) - ANS is available in an extended-release oral formulation for children
who are unable to swallow pills. -Do not prescribe an MAOI if it has already been used within 14
days. Center in the brain that tells you to go to sleep - ANS-VLPO (Ventrolateral preoptic area)
-tells the 7 wakefulness areas of the brain to "shut off"
