Wall Street Journal - July 17, 2003
Christopher Windham, Staff Reporter of The Wall Street Journal

Geriatricians who have prescribed the drug say it can quickly combat depression and apathy in seniors suffering from a variety of illnesses, including stroke, dementia and cancer. Though the drug makes hyperactive children slow down and focus, it works differently in older patients, helping them get up and moving. But some potential side effects -- loss of appetite, elevated blood pressure and increased heart rates -- are more worrying for elderly people, so most doctors are wary of trying the drug.

Nevertheless, a number of older people who have taken Ritalin, or its generic equivalent, report swift and positive results. Edie Dominquez, a 62-year-old liver-transplant patient, was exhausted and dejected following his operation last year. His mood and energy were so low that he couldn't begin physical therapy, and he had trouble walking.

"I felt like garbage," says Mr. Dominquez, who worked as a porter before his illness.

His doctor put him on methylphenidate, the generic form of Ritalin, and he quickly became more responsive, talkative, and began eating better. "I don't feel depressed," says Mr. Dominquez, who has used the drug for five months.

The benefits of Ritalin, made by Novartis AG, and its generic form seem particularly clear in cases such as Mr. Dominquez's, in which depression inhibits an elderly patient's interest in physical therapy. The common treatment in such circumstances is antidepressants, such as Prozac, but they can take three or four weeks to kick in. Doctors say it usually takes two days for a patient to respond to Ritalin or methylphenidate. The time difference is critical to elderly patients because the sooner they can begin physical rehabilitation for hip fractures or other injuries, the faster they can leave a nursing facility.

Ritalin is less expensive than newer antidepressants such as Zoloft and Paxil, which like Prozac are in a drug class called selective serotonin reuptake inhibitors. SSRIs also can cause fatigue, which doesn't help if you're trying to get an elderly patient to participate in physical therapy.

"Methylphenidate has a real niche in the treatment of the elderly that other antidepressants don't, because they work more slowly," said Ira Katz, director of the geriatric psychiatry program at the University of Pennsylvania. "If a geriatrician never used the medicine, you're probably missing the chance to help elderly patients."

Ritalin has been used by adults with attention disorders for years. But at Florence Nightingale Health Center in New York, about 30 patients annually use Ritalin or its generic equivalent mainly for short-term recovery from a stroke or brain injury, says medical director Brad Cash. He says the facility has seen good results, including increased alertness and cooperation that allowed patients to complete physical therapy.

But other doctors say potential side effects are so troubling that they would never consider the drug. Besides raising heart rates and blood pressure, it can inhibit the metabolizing of other medications. "The side effects more than outweigh any benefit from the short-acting profile," said Charles Cafalu, chief of the geriatrics program at Louisiana State University. "There are too many drugs that are much safer."

Ritalin has been on the market since 1955 and is approved by the federal Food and Drug Administration for treatment of attention-deficit/hyperactivity disorder, or ADHD, and narcolepsy. But as with all approved drugs, doctors are free to prescribe it for other uses, although drug companies can't legally market it for unapproved purposes.

Ritalin stimulates the central nervous system by releasing a neurotransmitter called dopamine in the front of the brain. Dopamine is thought to help people focus; it also tells them when things are pleasurable. So the drug's effects depend on the ailment of the person taking it. In children, it will boost their ability to focus. In elderly people it will work on motivation, making them feel good enough to want to get out of bed.

Though Ritalin has never taken off as a drug for the elderly, research for years has hinted at benefits for older patients. In a 1975 study of 44 withdrawn, apathetic patients, published by the Journal of the American Geriatrics Society, researchers found that methylphenidate, the generic form, improved their mental state and behavior. Other studies have found it to be effective in treating hemineglect, a disorder in stroke patients in which people ignore one side of their visual field. For older cancer patients, some studies suggest that methylphenidate can help control pain and improve awareness and mood. And in elderly patients infected with the human immunodeficiency virus, which causes AIDS, the drug was effective in increasing attention and reducing depression, according to a study.

However, much of the research on Ritalin in seniors is preliminary. There hasn't been a study examining its long-term effects on the elderly body, which worries some doctors.

The pharmaceutical industry isn't eager to conduct more research because the potential profitability of the new market won't be great enough.

Ritalin has had generic competition since 1967, driving down its price and making it less profitable. Furthermore, sales in the U.S. of Ritalin and its generic equivalent declined more than 30% last year, according to IMS Health, a health-care market-research firm, as some newer, longer-lasting treatments for ADHD in children, such as Johnson & Johnson's Concerta and Shire Pharmaceutical's Adderall, have gained share. Novartis, the originator of Ritalin, says it has no plans to study the drug in elderly patients.

Still, the idea of prescribing Ritalin to motivate and boost the alertness of patients suffering from Alzheimer's and other geriatric illnesses is worth exploring to some physicians. "It's a good example of a useful medication that hasn't been studied enough," said the University of Pennsylvania's Dr. Katz.

Write to Christopher Windham at christopher.windham@wsj.com

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