A Critical Need Ignored: Inadequate Diagnosis and Treatment of ADHD After Age 60
Preliminary research suggests that seniors with ADHD experience unique and evolving symptoms that are commonly mistaken for — and overlap with — normal signs of aging. Misdiagnosis and mismanaged treatment after age 60 are serious problems, says Kathleen Nadeau, Ph.D. Here, she outlines her emerging research and explains how clinicians can better serve older patients.
ADHD doesn’t diminish — like your hairline or stamina — with age.
In fact, symptoms of attention deficit disorder (ADHD or ADD) may flare and grow after midlife — especially when mixed with normal age-related cognitive decline, worsening physical health, and the lack of structure that often comes with retirement. Why then, do the unique needs of this large (and growing) population remain largely ignored in diagnostic tests, accepted treatment practices, and peer-reviewed research?
The needs of seniors with ADHD are “completely ignored” said Kathleen Nadeau, Ph.D., during her recent presentation at the 2018 Annual Meeting of the American Professional Society of ADHD and Related Disorders (APSARD). There, Nadeau presented her own preliminary research on how ADHD manifests after age 60, and advocated for drastic clinical changes to improve outcomes for underdiagnosed, undertreated, and overlooked older adults. To that end, she underscored the unique challenges doctors face when managing ADHD in this population, and outlined the steps professionals can take to better diagnose, treat, and understand seniors with ADHD.
What Does ADHD Look Like in Older Adults?
Nadeau’s research is preliminary, she said, but it is beginning to paint a picture of what ADHD looks like in adults over the age of 60. So far, she’s conducted in-depth interviews with more than 70 women and men diagnosed with ADHD, covering their symptom progression, their experience with medical professionals, and their biggest challenges (both ADHD-related and otherwise) associated with aging.
Nadeau says her findings show that ADHD can look markedly different throughout a person’s lifetime — symptoms shift during the transition from childhood to adolescence and young adulthood, again when a person enters midlife, and again during the senior years. While every subject has a unique symptom profile, she said, Nadeau has identified the following patterns that appear fairly consistently in older adults with ADHD:
- “Swiss cheese memory,” or a memory that is not consistently failing, but also can’t be reliably counted on. Certain things are easy to remember for her subjects, she said, while others slip through the cracks.
- Other working memory issues such as being easily thrown off course mid-task
- Misplacing items
- Forgetting words or names
- Brain going “blank” periodically
- Difficulty learning new things
- Talking too much, often without realizing it
- Interrupting others
- Trouble following conversations
- Difficulty maintaining relationships and keeping in touch
These symptoms, less present in her subjects’ younger years, could have pervasive negative effects, Nadeau said. Based on her research, Nadeau said, “these adults [with ADHD] need a lot more support” than average aging adults. They struggle to manage their time, conduct themselves appropriately in social settings, or accomplish short- and long-term goals — especially after retirement and the loss of a reliable day-to-day routine.
When asked to identify their biggest challenges, Nadeau’s subjects pointed to the following five:
- Not getting things done – procrastination, lack of self-discipline
- Out-of-control emotions – feeling irritable more frequently than in the past, struggling with anxiety/depression
- Time-management challenges – setting and sticking to a daily routine, being aware of time’s passing
- The “remnants” of hyperactivity – feeling restless, talking too much, “random thoughts whirling in my head”
- Social challenges – feeling misunderstood or judged, speaking impulsively, missing social cues
“Some of the challenges of later years parallel those faced by young people with ADHD as they’re leaving home,” Nadeau said. Both groups lose much-needed structure as they leave the workplace or their parents’ supervision, and both groups are at risk for developing poor sleeping or eating habits (or otherwise neglecting their self-care) as a result. This can, in turn, make ADHD symptoms significantly worse.
ADHD? Cognitive Decline? Dementia? Or Just Aging?
One major concern — for both patients and clinicians alike — is that the ADHD symptoms found in older adults (particularly those related to memory, routines, and executive functioning) don’t immediately signal attention deficit to most clinicians, Nadeau said. They more often are interpreted as mild cognitive impairment or even dementia — conditions more familiar to medical or mental health professionals that can affect any aging brain, ADHD or not.
Mild cognitive impairment (MCI), an intermediary stage between “normal aging” and dementia, can result in memory lapses, impulsive decision-making, or decreased executive functioning skills. When seniors — particularly those who haven’t been previously diagnosed with ADHD — visit their doctor complaining of memory loss, doctors commonly assume MCI, Nadeau said. Even when the patient has an ADHD diagnosis, it can be difficult to differentiate symptoms of MCI from those of attention deficit, as it’s possible that the two conditions can occur together. The distinction between the two is a “hugely important question that not a lot of research has gone into,” she said.
According to the Mayo Clinic, 10 to 15 percent of MCI cases progress to full-blown dementia. There is no evidence of a direct link between ADHD and Alzheimer’s, Nadeau said. Some studies have found a slight association between Lewy Body dementia and ADHD, but the connection remains murky — particularly given the lack of understanding we have about ADHD’s presentation in seniors. Some researchers have hypothesized that any apparent link between ADHD and dementia may be attributed to lifestyle patterns — poor sleeping habits, unhealthy diet, etc. — that appear regularly in people with either condition. In addition, both dementia and ADHD are highly hereditary, however attention deficit was seldom diagnosed in the parents of today’s seniors, who have an incomplete family medical history as a result.
Though MCI and dementia are hardly ubiquitous, cognitive decline is a natural part of aging, as blood flow to the brain decreases over time. This is particularly true for women, for whom hormonal changes can exacerbate cognitive challenges. Clinicians must learn to differentiate this normal decline from symptoms of ADHD “in order to not dismiss people that come to us with genuine ADHD that needs to be treated,” Nadeau said.
Difficulties in Diagnosing and Treating ADHD in Older Adults
Difficulties separating ADHD symptoms from signs of normal aging stem from the way most clinicians currently diagnose (and understand) attention deficit. Most ADHD symptom criteria and diagnostic questionnaires are appropriate for the diagnosis of children, not adults. Patients aged 60 (and beyond) without a formal diagnosis may exhibit symptoms of ADHD that differ significantly from those listed in the DSM. They also may not be able to consistently recall when their symptoms started or how they’ve changed over time.
Researchers need to develop an ADHD screening tool specifically aimed at older adults, Nadeau said. In the meantime, doctors evaluating symptoms like those described above should take a full patient medical history (including family background) and dig deep into symptoms, particularly if they suspect MCI. To further rule out ADHD, she said, a clinician should determine whether symptoms are new or have “always kind of been there” — “which is certainly not true when you’re dealing with mild cognitive decline.”
Many clinicians misdiagnose ADHD later in life due to lack of specialized training, Nadeau said. Most physicians receive 20 minutes of instruction (or less) on ADHD in medical school, she said, and nearly all that time is spent on pediatric diagnosis and treatment. In one survey, 40 percent of primary care physicians said they had never encountered an adult patient (of any age) with ADHD. In reality, “that’s an impossibility,” Nadeau said. Rather, the likely problem is that “they have absolutely no idea what it looks like.”
Finding treatment is formidable roadblock as well. Even after being diagnosed, Nadeau’s subjects frequently reported trouble getting a doctor to prescribe them ADHD medication — even if they’d taken it without incident earlier in life. Concerns about cardiac issues, conflicting medications, or side effects make some doctors reluctant to prescribe stimulants to adults over 60, Nadeau said.
“We need to develop some parameters that physicians can be comfortable with,” Nadeau said, in order to ensure that seniors aren’t denied access to critical ADHD treatment.
Next Steps for Patients and Clinicians
“Our world is becoming both ADD-friendlier — because of all the digital supports — and more ADD-stressful, in that there are so many more distractions,” Nadeau said. Older adults with ADHD face new and exceptional challenges — one subject was nearly evicted because of his inability to organize his apartment, she said, while countless others were still working well into their 80s because they hadn’t saved enough for retirement. Many face relationship challenges that persist into their later years. Nadeau said her research indicates that “there is a greater likelihood for people with ADHD to end up alone, because of the higher divorce rate among people with ADHD.”
But aging with ADHD is “not all negative — not by a long shot,” she said. “Some people are having the time of their lives.” Finding a more supportive romantic partner after a divorce had a significant positive impact on the lives of many of her subjects, as did being active in one’s community — volunteering at a local church, for instance, or participating in social events at a nearby senior center.
“There’s a huge range of outcomes, from very positive to very sad,” she said. “A lot of that is hugely affected by individual circumstance.” In order to guarantee the most optimal outcomes possible, she said, doctors need to be better prepared to handle older adults with ADHD. “We really need to educate healthcare providers.”
To better serve this population, the medical community must devise better diagnostic tools for seniors, conduct in-depth research on the difference between ADHD and cognitive decline, and become more comfortable with appropriate treatment practices. Nadeau’s research is still in progress, she said, but one key point has become clear to her: “There are a lot of people out there who could greatly benefit from medication — from our help.”