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.
In fact, symptoms of attention deficit hyperactivity disorder (ADHD) 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 of adults with ADHD remain largely ignored in diagnostic tests, accepted treatment practices, and peer-reviewed research?
The status quo is not working for older patients with ADHD; we need new protocols. Drastic clinical changes must take place to improve outcomes for underdiagnosed, undertreated, and overlooked older adults. Doctors face unique challenges when managing ADHD in this population, so professionals must take equally specialized steps to better diagnose, treat, and understand seniors with ADHD.
What Does ADHD Look Like in Older Adults?
Preliminary research is beginning to paint a picture of what ADHD looks like in adults over the age of 60. I have conducted in-depth interviews with more than 130 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.
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, the following patterns 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
- Difficulty maintaining order within their homes
- Tremendous struggles to make ends meet financially after a lifetime of poor money management
These symptoms, not always present in subjects’ younger years, could have pervasive negative effects. Adults with ADHD need a lot more support than do average aging adults. They struggle to manage their time, conduct themselves appropriately in social settings, and/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, older adults with ADHD 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 and/or mood disorders
- 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. Both groups lose much-needed structure as older adults leave the workplace or young adults leave 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. They more often are interpreted as mild cognitive impairment or even dementia — conditions more familiar to medical or mental health professionals.
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. 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 deserves greater research.
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 dementia or Alzheimer’s disease. 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. Importantly, in making the diagnosis in a senior, it’s incumbent upon the clinician to ask about succeeding generations – whether there is ADHD diagnosed in their children and/or grandchildren.
Regardless, 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 who come to us with genuine ADHD that would benefit from treatment.
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 for identifying symptoms in old age. 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. Of utmost importance, to further rule out ADHD, clinicians should determine whether symptoms are new or span a lifetime — which is certainly not indicative of mild cognitive decline.
Many clinicians misdiagnose ADHD later in life due to lack of specialized training. Most physicians receive 20 minutes (or less) of instruction on ADHD in medical school, 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. Rather, the likely problem is that they have absolutely no idea what ADHD looks like later in life.
Finding treatment is a formidable roadblock as well. Even after being diagnosed, many adults with ADHD frequently report 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.
We need to develop some parameters with which physicians can be comfortable to ensure that seniors aren’t denied access to critical ADHD treatment.
Next Steps for Patients and Clinicians
Our world is becoming both friendlier to adults with ADHD — because of all the digital supports — and more stressful with its myriad new distractions. Older adults with ADHD face new and exceptional challenges — one subject was nearly evicted because of his inability to organize his apartment, 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. Research indicates a greater likelihood for people with ADHD to end up alone due to a higher-than-average divorce rate among couples touched by ADHD.
But aging with ADHD is not all negative — not by a long shot. Some of the subjects of my research are having the time of their lives. Finding a more supportive romantic partner after a divorce has had a significant positive impact on the lives of many, as has being active in one’s community — volunteering at a local church, for instance, or participating in social events at a nearby senior center.
I have noted a huge range of outcomes, from very positive to very sad. A lot of that is hugely affected by individual circumstance. In order to guarantee the most optimal outcomes, 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. My own research is still in progress, but one key point has become clear: There are a lot of people out there who could greatly benefit from our help.
The following information came, in part, from Kathleen Nadeau’s 2018 APSARD presentation titled “Still Distracted After All These Years: The Unexplored Territory of ADHD After 60” which will also be the title of her upcoming book on older adults with ADHD.