ADHD in Older Adults

By Jaimie Lazare
Undiagnosed ADHD in older patients can lead to lifelong functional and psychosocial impairments, but other comorbidities can make diagnosing an older patient’s ADHD complex.
Attention deficit hyperactivity disorder (ADHD) is characterized by inattentiveness, compulsivity, and hyperactivity. It has often been viewed as a childhood disorder, but a study published in the British Journal of Psychiatry found that about 3% of older adults continue to be affected by ADHD.1 Little is known about ADHD in the geriatric population, but many older patients who are diagnosed with it report lifelong struggles academically as well as in their careers and personal lives.
Martin W. Wetzel, MD, an adjunct clinical professor at the University of Nebraska Medical Center and author of The Adult ADHD Handbook for Patients, Family & Friends, says that as a child matures, brain growth and development can lead to a change in how ADHD presents.
“About half of kids with ADHD continue to have it as adults, but most cases become primarily an inattentive type. With age, most patients tend to outgrow their hyperactivity. But functionally, we see that they still have a lot of problems,” he says. “Not only does ADHD change with human development, but healthcare providers aren’t looking for it as much in older populations.”
With older adults, to get the conversation started about ADHD, Wetzel uses the Adult ADHD Self-Report Scale-v 1.1 (ASRS-v1.1) Symptom Checklist, which has been validated in studies. “People with ADHD tend to have a very consistent pattern of struggles, all related to this difficulty with maintaining focus and concentration,” Wetzel says. (The 6 Question ADHD-ASRS Screener v1.1 and 18 Question ADHD-ASRS Symptoms Checklist v1.1 are available through these links.)
Wetzel has treated older physicians, attorneys, and corporate executives who have struggled with ADHD throughout their lives. Often they’ve been able to achieve success because they have found other ways to compensate, which have been exhausting. These patients usually seek an evaluation because they have suspected that something has been wrong their entire lives.
Marc E. Agronin, MD, medical director for mental health and clinical research at Miami Jewish Health Systems and author of How We Age: A Doctor’s Journey Into the Heart of Growing Old, says the evaluation also requires an in-depth history in which clinicians must obtain corroborating information from family, friends, or others about the patient’s inattentiveness.
For example, Agronin recalls an 80-year-old woman who suffered from frequent falls. His evaluation indicated she was neurologically intact but inattentiveness likely contributed to her falling. Discussions with the woman’s family members revealed that she had a long-standing history of inattentiveness, which confirmed his suspicions.
Having a discussion with family members is not only useful in assessing ADHD in an older adult, but it can also help to identify other comorbidities such as depression or cognitive impairment that may aggravate ADHD, Agronin adds.
Clinicians should inquire about sleep and caffeine intake, Wetzel says. A good sleep history is important because adults with ADHD tend to have significant sleep problems that further complicate their focus and concentration, and adults with ADHD tend to use and abuse caffeine to self-medicate their ADHD. “So I think it’s really important that we get a good sleep history, and we also get a good history about caffeine use,” he says.
Managing ADHD
Although older adults may have been treated for anxiety and depression, it’s not unusual that patients are not asked about or screened for ADHD, Wetzel says. “But once you treat ADHD, it doesn’t matter whether they’re 6 or 66, they have a very good response rate to stimulant treatment,” he says.
Agronin says there are two critical issues to consider in adult ADHD. “The diagnosing physician should have a strong grasp of how ADHD presents in adults, and the clinician should be able to separate out the fact that, for some people, giving them a stimulant enhances performance, independent of its true effect on inattentiveness or impulsivity,” he says.
“You also run the risk of precipitating more impulsivity if you have someone whose diagnosis is actually a bipolar disorder or a depression with irritability,” Agronin continues. “Sometimes a stimulant can overstimulate them and cause agitation. So you do have to be more cautious in terms of the behavioral effects.”
Another side effect of stimulant drugs in older patients is worsening cardiac problems, specifically with conduction problems in the heart. Stimulants can potentially lead to arrhythmias and increases in blood pressure, Agronin says.
Tony W. Wilson, PhD, an assistant professor in the departments of pharmacology and experimental neuroscience, and neurological sciences and the scientific director at the Center for Magnetoencephalography at the University of Nebraska Medical Center, says exercise helps many patients. “Those who exercise seem to have decreased symptoms, and the patients that do exercise often will make note that on days they don’t exercise, they do have more symptoms, or those are the days that they kind of forget the most things,” he says.
Wilson notes that having an organized system is helpful for older adults with ADHD. Patients who have either a spouse or someone who has helped them with organization experience better outcomes and more normal day-to-day lives, he says.
Unfortunately, older patients with ADHD tend to experience many disappointments in life, such as underperforming academically and in their jobs, Wetzel says. “They also tend to have higher rates of divorce and a lot of frustration. So I often tell my older patients with ADHD and their families that it’s never too late to regain control of their lives,” he explains.
Advancing ADHD Research
For children who do not outgrow their ADHD, their symptoms generally change as they age. That usually involves less hyperactivity and more difficulty maintaining attention, Wilson says.
As principal investigator of a study that investigated gamma-frequency neuronal activity in adults with ADHD2, Wilson notes that, in general, there is limited brain imaging research that addresses ADHD in adults over the age of 40. His study enrolled a few research participants in their 50s, but the overall mean age was about 40.
Magnetoencephalography (MEG) instruments measure brain function, providing a picture of the parts of the brain that are used while a patient performs a specific task, Wilson says. “Mostly what we’re seeing is that compared to age-matched healthy persons, patients with ADHD have a reduced amount of activity, particularly in the prefrontal cortex. Gamma activity, the fast spiking activity in neurons, is what we’ve found to be especially decreased in [ADHD] patients,” he explains.
“The prefrontal brain area is really underactive, and we believe that causes posterior regions to be overactive. Essentially, there’s nothing holding them back and they overtake the network,” Wilson says. “Once patients are actually medicated, we see increased activity in their prefrontal cortices, and then we also see that regions in the back of the brain are more subdued.
“By increasing activity in the frontal cortex, which is very important for executive function, the patients are able to potentially concentrate more and also control the feed-forward sensory systems integral for rapid action. Longer term, I think MEG will become essential in screening patients who may or may not have different disorders,” he says.
Older adults are living longer and working well past retirement age, which is why it’s important to initiate the conversation and screen patients with suspected ADHD because it’s never too late for patients to gain control and live a confident life.
— Jaimie Lazare is a freelance writer based in Brooklyn, New York.
References
1. Michielsen M, Semeijn E, Comijs HC, et al. Prevalence of attention-deficit hyperactivity disorder in older adults in The Netherlands. Br J Psychiatry. 2012;201:298-305.
2. Wilson TW, Wetzel MW, White ML, Knott NL. Gamma-frequency neuronal activity is diminished in adults with attention-deficit/hyperactivity disorder: a pharmaco-MEG study. J Psychopharmacol. 2012;26(6):771-777.

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