PERT Program

Tip of the Month: March 2003


The Use of Methylphenidate (Ritalin®, Concerta®)
in Geriatric Palliative Care


Recently, a nurse who had participated in classes using the PERT Curriculum raised the following question regarding the use of Ritalin® (methylphenidate) for symptom palliation:

"My coordinator would like to try Ritalin® in our facility but our Medical Director is strongly opposed to this. She's wondering if there are any articles out there about use of Ritalin® in long-term care. I know we touched on this issue when we were in class."

Much of the current literature about methylphenidate focuses on cancer and geriatric populations, with sedation and depression as the predominant symptoms to be treated. A recently published article by Rozans et al, provides a good overview of the use, effect, and dosing of methylphenidate when used to treat opioid-induced somnolence, enhance analgesia, treat depression, and improve the cognition of cancer patients.

(Complete reference: Rozans M, Dreisbach A, Lertora JJL, Kahn, MJ. Palliative uses of methylphenidate in patients with cancer: a review. J Clin Oncology 20: 335-339, 2002. For copies of the article, contact the PERT program.)

There is also information on the palliative use of methylphenidate in the Pain and Symptom Management section of the PERT syllabus. Included is The Management of Persistent Pain in Older Persons, a set of guidelines developed and written by the American Geriatric Society Panel on Persistent Pain in Older Persons. Page S217, bullet #5, mentions treatments for opioid-induced sedation/fatigue, including the use of methylphenidate. The population to which this entire set of guidelines refers is older persons with chronic nonmalignant pain.

Anna Du Pen, ARNP describes the use of methylphenidate in her own practice. She suggests starting at very low doses and titrating slowly ("start low and go slow") with the goal of counter-acting the sedative effects of opioid medications. A suggested starting dose is 2.5 mg PO twice daily at 8am and 12 noon; increase by 2.5–5 mg PO every 2 or 3 days as tolerated, until the desired response is achieved. Adhering to a dosing schedule of 8am and 12 noon, at doses of 5–15 mg has been effective in her practice. She has not experienced the need to prescribe greater than 30mg/day total dosing. Also, if she has any concerns about the interaction with a resident's other medications, she utilizes the expertise of a pharmacist to help assess drug compatibility.

Jon Younger, MD suggests there are numerous articles addressing the use of methylphenidate in the geriatric population, especially for treatment of depression, but also for treatment of sedation as a side effect of narcotics in dying older patients. He points out the following as three of the many articles available:
  • Depression and the dying older patient, Clinics in Geriatric Medicine, Vol 16, #2, May 2000.
  • Methylphenidate augmentation of citalopram in elderly depressed patients, Am J Geriatric Psychiatry, 2001, Summer 9 (3).
  • Trials of methylphenidate in geriatric patients, J Amer Geriatrics Assoc, 1 April, 2001.

During the Cohort Two discussion of the use of methylphenidate in the long-term care setting, it was noted that Ritalin® is a schedule II drug and subject to scrutiny for appropriate use. The Quality Assurance nurses from DSHS who are PERT participants noted that with proper documentation, the use of this medication would cause no concern. They emphasized that proper documentation would include the reason for using methylphenidate and the response to the therapy.

What has been your experience utilizing this medication for the treatment of opioid-induced sedation? We welcome your comments. To contribute your anecdotes or to request copies of the articles listed above, please use the PERT Program contact page.