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Articles by Dr. Billy Levin
My Oldest ADHD Patient
©Dr. W.J. LEVIN MB ChB (Pta)
This article was written by Dr Billy (although as you will see in the * Post Script the original artical was written by the patient herself and transcribed by Dr Billy including his own medical aspects as well as her sentiments, with her permission) especially for adders.org and it tells about the success story of the oldest patient he has diagnosed and treated for ADHD - it is truely an inspiration!
As all patients have a legal and ethical right to confidentiality about their medical condition, I as the treating doctor, first had to obtain the patient's permission to discus her condition in public. As her situation was unique I felt there was need to write about it. She herself felt that, if more people could know about her situation it might help others receive recognition and treatment before the age of 84. She was 83 years old when I first diagnosed her with ADHD and depression.
Mrs G.C's son, an adult, phoned to ask if I would be able to help his mother. When I asked why he had phoned me his reply was that I was treating somebody he knew with possibly a similar problem. When I was told how old she was, I admitted to have never treated anybody that age before but an assessment would soon tell if there was a problem serious enough to warrant treatment.
Prior to coming to see me she had experienced resentment about her situation and conflict with people who did not understand her problem. She had been isolated from society to a point of desperation and seriously contemplated committing suicide. Fortunately her strong Christian belief prevented her from ending it all. This strength also allowed her to persevere with my treatment as I proceeded very slowly and carefully with my treatment because of her age. This resulted in me achieving therapeutic levels of her medication at a much slower pace than usual and she had to wait many months before she experienced an improvement. One must certainly give her full credit for having the courage to continue with my treatment under these circumstances. I feel her son's support must also have played a roll. Her son transported her and accompanied her to the first appointment and every follow up thereafter.
The neurological evaluation in October 2007, revealed an elderly woman with major problems of depression having had numerous and varied treatments over a period of 30 years without any success. She was also hypertensive but mentally very alert indeed and very "with it". She also had undiagnosed and untreated adult ADHD. That was the major diagnosis that I made. Nobody had given any thought to the possibility of ADHD at that age. Neglected ADHD is one of the major causes of depression and is not responsive to antidepressants unless the ADHD is treated at the same time. Everything started to fall into place.
A program was discussed and a plan was suggested. Her hypertension would have to be controlled to start with. Then a trial on Ritalin would be started and the dose increased very slowly in view of the hypertension and her advanced age. Over the next few months the dose was slowly increased and monitored with a modified Conner's rating scale. Both she and her son completed these rating scales on a monthly basis about herself. Her son's opinion was obviously about his mother's progress.
The Blood pressure came down and stayed at acceptable levels on antihypertensive treatment monitored monthly and she has remained on this treatment. It is interesting to note that many years ago, Ciba pharmaceuticals (Now Novatis, the marketers of Ritalin ) brought out a medication for Hypertension called Serpacil. It worked very well but caused depression. To counter the depression caused by Serpacil, Ciba researched and marketed an antidepressant that could be safely used with hypertensive patients. The products name……Ritalin! Once her blood pressure was stable the ADHD treatment was started.
When the Conner's rating scale suggested that an optimal dose of the Ritalin, given three times a day had been reached, an antidepressant, Welbutrin was also started, and monitored with a Hamilton scale completed by her only. The Ritalin was changed to an equivalent dose of once a day Concerta for convenience only, once it was clear what her optimal dose was. She has remained on this as well and currently is doing very well indeed as suggested by the rating scales based her, and her son's opinion.
Although small improvements were eventually noted in March 2008 when the Ritalin was at an optimal dose the really major improvement only started when the antidepressant was added to the stimulant in April 2008. It should be noted that in the past without Ritalin, her antidepressants had no beneficial effect whatsoever!
The patient's most emotional comment on treatment was "despite the fact that I was 83 years old the doctor decided to treat me and today I can testify that I am living a full life instead of a half life" . This she has stated in her own hand writing to me! She continues to do well on her treatment which is monitored on a monthly basis including with her permission, her son's opinion of her progress.
As her enthusiasm for life rekindled, she admitted that her love for reading had returned but her failing eyesight made it difficult. I suggested that a yellow globe might help. I asked her to read a passage to me with a yellow transparency over a page of a book. There was an instant surprise of excitement when suddenly she was able to read with comfort and ease. Helen Urlen's discovery could work as well for Dyslexia as for the aged. She took the yellow transparency home with her to the Old Aged Home where she stayed. On her return a month later for a reassessment of my treatment, she walked into my consulting room with a small pile of yellow transparencies, obtained from my receptionist. When I asked why so many, she replied that all the old ladies at the home where she stayed, also wanted one!
ADHD in adults can certainly be treated even at the age of 83 despite the fact that it was only recognised in this patient at this age for the first time!
* Post script: The original article was written by the patient herself in Afrikaans. Rather than just translating it verbatim I have taken the liberty of writing this story to include my medical aspects as well as her sentiments, with her permission.
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