3 Rules for Evaluating and Treating ADHD in People Over 50
by Lilly Constance, ADDitude
January 16, 2019

Though attention deficit disorder (ADHD or ADD) accounts for roughly 4.4% of all major psychiatric conditions in the U.S.1 - second only to generalized depression - adults in their 50s, 60s, and 70s with ADHD often go undiagnosed and untreated. Some experts call this a public health crisis - but one that's within our power to resolve.

At the core of this diagnostic disconnection is a paucity of reliable information and data on ADHD in older populations. The longest childhood ADHD trial which lasted 33 years2 ended when participants were in their 40s. The cut-off age for research protocols in clinical drug trials typically has been 65, so older adults are never included. What's more, the likelihood of finding adults over the age of 60 who were diagnosed as children is very slight; past researchers studying "hyperkinetic impulse disorder" focused almost solely on disruptive behaviors exclusively in boys.

Even today, clinicians receive very little training in adult ADHD; psychiatric programs typically offer only one or two lectures on the subject. "Ninety-three percent of adult psychiatrists, when asked, report that they've never had any ADHD training, either in their residency or in their continuing medical education, whether in children, adolescents, or adults," says ADHD expert Dr. William Dodson. As a result, many physicians are ill-equipped to diagnose adult ADHD and, when presented with cognitive complaints in a person over 50, tend to attribute the symptoms to age-related mental decline, anxiety and depression, or dementia - without considering ADHD.

Yet the prevalence of ADHD in older populations suggests that clinicians should perform ADHD screenings and other assessments when adult patients present with cognitive issues. An ADHD diagnosis and treatment can relieve symptoms that have persisted and debilitated a patient for decades. Medical attention can improve the quality life for individuals at any age, says Dr. David W. Goodman, assistant professor in psychiatry at Johns Hopkins School of Medicine.

Dr. Goodman, an internationally known expert on adult ADHD, has been a principal investigator for ADHD clinical trials and written more than 30 peer-reviewed articles on the subject. He has also presented more than 600 lectures to professional audiences. In the recent ADDitude webinar, "ADHD Over 50: Old Age, ADHD or Something Else?" he discussed how to diagnose ADHD in older adults, how to evaluate overlapping age-related cognitive changes, and the efficacy of medication and psychotherapy in managing symptoms. Below are Dr. Goodman's three rules for clinicians:

1. Never Use the DSM In Isolation
ADHD in older adults should be diagnosed using symptom criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM V) in conjunction with an in-depth clinical interview. Although DSM V doesn't explicitly list the ways that ADHD manifests in people over 60, Dr. Goodman urges physicians to extrapolate from the guidelines on hyperactivity, inattention, and impulsivity - primary areas of impairment in older adults with ADHD.

As with children, adult patients must exhibit at least five out of the nine DSM symptoms in inattention and/or impulsivity/hyperactivity to merit an ADHD diagnosis. What's more, the symptoms must impair their functioning in multiple settings (inattentiveness at the dinner table with a spouse is not, in itself, enough to warrant an ADHD diagnosis). Observations by loved ones can help to document these challenges.

The essential piece of the puzzle, however, is the patient interview. Dr. Goodman says an in-depth clinical interview should document a person's history of symptoms starting in childhood and continuing through adulthood. ADHD typically begins at a young age and persists chronically throughout a person's lifetime. It almost always impacts an individual's professional and family life. While some individuals cultivate compensatory skills and appear to function well, something as seemingly positive as a job promotion with increased responsibilities can trigger extreme anxiety or depression in a person with ADHD who feels overwhelmed already. As a person's responsibilities increase with age, the impairments of ADHD often become more - not less - apparent.

2. Question Symptom Continuity and Persistence
Clinicians evaluating older adults for ADHD should ask the following critical question: "If I interviewed you 20 years ago, would you have been talking about these symptoms?"

If the patient replies "No<," ADHD is probably not the correct diagnosis. An adult with ADHD will typically reply, "I can't remember never being this way."

If a patient complains that his or her cognitive issues have developed only in the previous few years, ADHD may be ruled out, and other possible causes investigated, Dr. Goodman says.

3. Remember, ADHD Typically Occurs with Other Conditions
Overlapping psychiatric and medical conditions may complicate an ADHD diagnosis and treatment. The majority of patients with ADHD have at least one other psychiatric condition, which may manifest in symptoms similar to those of ADHD. A 2012 study of adults with ADHD in the Netherlands3, for example, found that about 40% of participants also suffered from depression, 24% had bipolar disorder, and about 20% experienced anxiety. Since medications can affect cognitive ability, the researchers also noted that 75% of respondents took six medications daily.

This means that prescribing clinicians must closely monitor not only a patient's ADHD medications, but also any other pharmaceuticals taken for common conditions such as hypertension, hyperthyroidism, and diabetes. Because the most effective treatment for adult ADHD is stimulants (in conjunction with individualized psychotherapy), Dr. Goodman says physicians should consider all potential drug interactions before selecting an appropriate medication for ADHD.

While cardiac issues don't preclude the use of ADHD medications, consultation with a cardiologist is advised for those people with cardiac conditions. Older patients with ADHD should also be evaluated for their intake of substances including caffeine, tobacco, alcohol, recreational drugs, and even over-the-counter supplements. All of these may impact a medication's efficacy.

Footnotes
1"The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication," Am J Psychiatry. 2006 Apr; 163(4): 716723."

2"Clinical and Functional Outcome of Childhood ADHD 33 Years Later,". Arch Gen Psychiatry. 2012 Dec 1; 69(12): 12951303.

3"The comorbidity of anxiety and depressive symptoms in older adults with attention-deficit/hyperactivity disorder: A longitudinal study," Journal of Affective Disorders, 2013 Apr; 148(2-3): 220-227.