ADHD Among Seniors: APSARD Members in the News
APSARD members David Goodman, Kathleen Nadeau, Lenard Adler, and Sandra Kooij recently discussed with the Wall Street Journal’s Sumathi Reddy the importance of properly diagnosing and treating ADHD among older adults. The article, ‘An Unexpected New Diagnosis in Older Adults: ADHD’, juxtaposes patient perspectives with those of expert care providers in this underserved demographic and highlight the need for better provider education. Read the article here:
For years, ADHD has been considered a disorder of kids and younger adults. Now, doctors are realizing older people have it too—and it’s sometimes mistaken for dementia.
Many seniors get diagnosed with conditions like dementia or heart disease.
Not Timothy McMichael. At the age of 60, he was diagnosed with a condition most often associated with school children: attention-deficit hyperactivity disorder. He started taking a low dose of a stimulant about a year-and-a-half ago and says his attentiveness and concentration at work have never been better.
“I’ve been fairly successful in my life and career, and did not think of ADHD as an adult thing,” says Mr. McMichael, a 61-year-old Leonardtown, Md., resident and engineer for the Department of Defense. “But I had spent the last 40 years coming up with coping mechanisms.”
Like many older people diagnosed with ADHD for the first time, Mr. McMichael didn’t consider the condition until his then-11-year-old son went through the diagnosis and treatment process about five years ago. He recognized many of the symptoms and struggles of his son and raised the issue with his son’s psychiatrist, David Goodman.
Dr. Goodman, an assistant professor of psychiatry and behavioral sciences at Johns Hopkins University School of Medicine, sees patients between the ages of 15 and 85. He has a particular interest in ADHD patients who are over 50 and have never been diagnosed.
Until just a few years ago, older adults were hardly ever diagnosed with ADHD. But as awareness of the condition among younger people has surged, doctors are beginning to make the diagnosis more often in seniors as well.
Doctors don’t believe the actual prevalence of the condition among seniors has increased, or that they are developing the condition as they age. Instead, doctors suspect many seniors have lived their whole lives with ADHD, and only now are getting diagnosed. Many found ways to manage their symptoms in earlier stages of life, but hit a new hurdle as they aged that prompted a flare-up—or simply recognized the symptoms after a younger relative’s diagnosis.
People with ADHD experience symptoms of inattention, disorganization and hyperactivity. Often hyperactivity diminishes with age, but challenges with attention and organization don’t.
Research on ADHD in seniors is nascent, but one study estimated the prevalence rate in people over 50 at 3%. That compares with about 8% in U.S. children and about 4.5% in adults under age 45. Some studies have found that about half of the children diagnosed with ADHD no longer meet diagnostic criteria by the time they reach adulthood.
One challenge to diagnosing ADHD in seniors is that symptoms look similar to age-related ailments. Cognitive difficulties in older people are often attributed to memory impairments or early signs of dementia, says Dr. Goodman. For women in their early 50s, such complaints are often attributed to perimenopause, the time before a woman reaches menopause.
Treatment presents another hurdle. The most common ADHD treatment among younger people is stimulants. But those are riskier in older adults because they can raise heart rate and blood pressure, so they need to be monitored closely.
Kathleen Nadeau, founder and clinical director of the Chesapeake Center, an ADHD, learning and behavioral health clinic based in Bethesda, Md., says she has seen three typical patterns for a diagnosis in seniors. Some patients were in treatment for another condition, like depression, and their psychiatrist suggested they get evaluated for ADHD. Another group had a relative or friend diagnosed. A third had a change in their life that increased the demands on them and they couldn’t cope.
She says ADHD symptoms rise and fall in people depending on how stressful their circumstances are. “If you don’t have to work or raise children anymore, it may look like you have less ADHD, but you actually have less demands,” says Dr. Nadeau. “If you’re put back in a situation you may have similar difficulties. This doesn’t go away and people still need help” at older ages.
Lenard Adler, director of the adult ADHD program at NYU Langone Health, says more people over the age of 60 are coming in with ADHD symptoms. Of the older patients he’s treated, some found him after other psychiatrists were unwilling to treat them, he says. One patient had a history of hypertension and cardiac problems. He was able to successfully treat the patient with a long-acting amphetamine.
Dr. Adler says it’s important to distinguish between memory and ADHD issues in seniors. “We’re dealing with a population that may have some age-related memory decline,” he says.
In some cases, patients may mistakenly be diagnosed with mild cognitive impairment, often a precursor to dementia. But other times families may be looking for any diagnosis besides cognitive decline. One family brought in their loved one hoping it was ADHD and not dementia. The patient, says Dr. Adler, was “having a substantial cognitive decline and it obviously was dementia. So it can go both ways. It’s important to get the diagnosis right.”
Doctors say that age-related memory impairments come on later in life and are primarily memory deficits, while ADHD symptoms start in childhood or early adolescence and revolve around inattention. While neuropsychological tests can’t distinguish between the two, certain cognitive impairments are associated with pre-dementia, such as difficulty remembering a word or getting lost while driving a familiar route.
Treatment of ADHD in older adults is similar to that of younger patients. Treatment can combine prescription stimulants with non-medication approaches such as cognitive behavioral therapy and organizational skill work. A study published last year showed that CBT was an effective treatment for older ADHD patients.
Dr. Goodman says most ADHD studies of stimulants don’t include seniors because of greater risks with heart rate and blood pressure. There is also a risk of developing insomnia, agitation and psychosis.
Dr. Goodman’s experience in treating some 800 seniors over the past three decades has shown few side effects, he says. He says diagnostic accuracy is crucial in seniors before prescribing any medications. “Dosing is thoughtfully slow while monitoring improving cognitive symptoms, side effects and blood pressure,” he says.
Sandra Kooij, an associate professor of psychiatry at Amsterdam University Medical Center, studies ADHD in seniors in the Netherlands. At her clinic they have treated about 150 seniors age 55 and older with stimulants, in addition to psychoeducation and cognitive behavioral therapy, for ADHD.
Dr. Kooij says they are analyzing the treatment and side effects for a study they hope to publish later this year. Overall efficacy has been similar to younger adults, and the medications were well tolerated with appropriate management of cardiovascular risks, she says. Patients were also treated for conditions like anxiety and depression that often present in ADHD patients, and sometimes occur as side effects of stimulants.
Seniors that have lived with ADHD all their lives and don’t feel impaired shouldn’t be treated, she notes. “Only people who feel impaired by their symptoms should be treated,” she says.
Joan Friess, a 76-year-old who lives in a senior community in Coconut Creek, Fla., was diagnosed with a precursor to Alzheimer’s disease about five years ago and started taking medication for it, says her son, Steve Friess, a freelance writer who lives in Ann Arbor, Mich.
But Ms. Friess never believed the neurologist who diagnosed her, both mother and son say. She is an advanced bridge and mahjong player and sings with an elite choir with no problem.
After her husband died and she moved to a different part of Florida, she decided to see a different neurologist.
Mr. Friess talked to the neurologist, who asked him if his mother’s behavior was different than most of her life. “I said, ‘No, not really,’ ” he recalls. “She was always losing things and a bit forgetful.”
The neurologist did some brain scans. Comparing them with previous scans, she said she saw nothing to indicate Alzheimer’s disease or dementia. Instead, she diagnosed Ms. Friess with ADHD.
Ms. Friess says she was relieved to confirm what she knew all along. “My husband thought I was forgetting things, but I knew there was nothing wrong with me,” she says.
Mr. Michael, the Department of Defense engineer, says even though he’s had a successful career, he can’t help but wonder how earlier treatment might have helped him. He says even his colleagues noticed his improved performance at work. “I’m much more focused on individual tasks,” he says. “I’m more efficient in how I use my day. I think my life absolutely would have been a lot easier had I known.”
Read the Article on the WSJ site:
Write to Sumathi Reddy at sumathi.reddy@wsj.com