Inside the Aging ADHD Brain
The latest research on how the ADHD brain changes over time. Plus the differences among normal aging, mild cognitive impairment, early dementia, and some classic attention deficit symptoms, and why it is never too late to be diagnosed and treated for ADHD.
After more than 40 years of psychoanalysis, behavioral therapy, and bitter frustration, it was a 2006 TV talk show that finally pointed 63-year-old Zophia in the right direction.
“Everyone told me there was nothing wrong with me,” she said. “But I had such yearning, such anguish inside. I wanted to excel, but something was holding me back.” Zophia flipped on the TV one Saturday morning, and the host launched into a frank confession about her own ADHD. “The more I heard, the more I knew she was talking about me, too,” said Zophia.
She made an appointment with a local psychologist, who ordered a battery of eight one-hour tests. The conclusion was unambiguous: ADHD. “After I found out about ADHD, I thought, ‘Gee, Zophia, why didn’t you come up with that answer a long time ago?'”
For John Washbush, the road to diagnosis took seven decades. “For 70 years, I lived my life day-by-day in the dark, totally clueless,” he said. “I got the same instructions as everyone else, I went through the same motions as everyone else, but rarely did I get the same results.”
In his early 60s, he suspected he had ADHD, but it was still a long road to the official verdict. “I was diagnosed at 70 and took my first dose of Ritalin on my 72nd birthday,” he said. “I knew within 20 minutes that I was on a path to discovering the real me.”
Your Brain on Attention Deficit
Zophia and John are among a growing number of older adults who are being diagnosed with ADHD at 40, 50, 60, and beyond. Clinicians report a steady increase in requests for ADHD testing by bewildered yet determined adults who grew up in the 1940s, 1950s, and 1960s, when ADHD was rarely recognized in children, let alone adults.
There is a lack of hard data on the aging ADHD population. Most researchers are reluctant to add the confounding factor of age (50+) to ADHD studies. A few pioneering studies from around the world indicate that the prevalence of ADHD among older adults (ages 45-85) is probably about 3 percent, slightly lower than the estimated 4.4 percent prevalence among adults up to age 44. The prevalence for children is estimated at 8 to 9 percent.
Like Zophia and John, most older ADHD adults have spent years trying to answer a question: “What’s wrong with me?” Most have been previously diagnosed with other psychological disorders, most frequently mood disorders and learning difficulties. ADHD coexists with several other conditions, so the original diagnoses were probably accurate but were incomplete.
Identifying ADHD can be tricky at any age. There is no blood test or brain scan that reveals latent ADHD. Instead, behavioral markers gathered through in-depth intake interviews are the gold standard for clinicians evaluating ADHD (as well as other psychological disorders). For a clinical diagnosis of ADHD, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) requires six impairing symptoms in children and adolescents age 17 and younger. For adults over the age of 17, only five symptoms are required. ADHD may present differently in old age, leading some researchers to suggest that even fewer symptoms might be appropriate for diagnoses of the 40-plus crowd.
It is challenging to evaluate older adults for ADHD because the normal aging process mimics some classic ADHD symptoms. ADHD symptoms, in turn, overlap with some telltale signals of mild cognitive impairment and early dementia. A clinician has her hands full sorting out the differences.
Normal cognitive aging begins in our mid-30s, when brain processing speed and motor response time start their gradual slowdown. In the mid-40s, our verbal and mathematics reasoning starts to fade. Selective attention — focusing on a specific thing while ignoring irrelevant information — also declines with age. The same is true for working memory, our ability to retrieve a recent thought or idea after being momentarily distracted.
Many executive functions diminish as we age — inhibiting our responses (thinking before we act) and our reactions to motor stimuli (safely driving a car). Geriatric researchers report a higher incidence of driving accidents among older adults, some attributed to normal aging, others to dementia, poor vision, medical problems, and/or medications.
Mild Cognitive Impairment (MCI) is a more serious condition, but in its early stages, its symptoms are also similar to normal aging. People with MCI have trouble remembering names of people they met recently or keeping up with the flow of a conversation. They have a tendency to misplace things, problems with organization and planning, trouble with attention and focus, a slowdown of language skills, and impaired executive function.
If this partial list of issues that swirl around aging and cognitive impairment sounds familiar, it’s because it touches on many symptoms of adult ADHD. ADHD brains tend to process information more slowly (possibly because they are churning through dozens of possible outcomes). Twenty to 30 percent of ADHD children and adults have a learning disability, with mathematics, verbal learning, and reading problems as the most common challenges.
Working memory glitches plague virtually all adults with ADHD, as do attention issues. A 2014 study showed that drivers with ADHD were 50 percent more likely to be involved in a serious car crash, although the researchers excluded adults over the age of 46. Executive function — planning, organization, follow-through, and time awareness — is a continuing challenge for children and adults with ADHD. Adults with the condition misplace things, and have trouble with attention and keeping up in conversations.
It’s not surprising, then, that older adults, with normal cognitive aging challenges, jump to the seemingly logical conclusion that they have “developed” ADHD. The truth is there is no “adult onset” ADHD. It doesn’t “develop.” ADHD starts at birth and continues, largely unchanged, through a person’s life.
“Clinicians working with older adults who have trouble focusing tend to overlook ADHD as a contributing factor,” said Anthony Rostain, M.D., professor of psychiatry and pediatrics at the University of Pennsylvania. “The salient feature is the difference between someone who has never had ADHD symptoms but now is more forgetful versus someone who has always been distracted.”
The consistent marker for ADHD is longevity of symptoms. If Mom yelled because your room was a mess, if you were fired from your first job because you were consistently late, ADHD might be the reason. On the other hand, if you were organized and neat until midlife, when things began to fall apart, you may be experiencing normal aging.
Complicating a later-life diagnosis for women is the influence of a powerful female hormone, estradiol, one of three estrogens active in women’s bodies. Estrogen/estradiol acts as the strong supporting cast in the brain to sensitize neural receptors to make better connections between key neurotransmitters: norepinephrine and dopamine. Norepinephrine and dopamine help maintain alertness, focus, and motivation.
“It was Alzheimer’s research that revealed the effect of estrogen on the brain,” said Patricia Quinn, M.D., a developmental pediatrician and founder of ADDvance, for ADHD women and girls. “If you lower estrogen, you lower dopamine and norepinephrine, which, in turn, lowers cognitive function. That holds true for all women. For ADHD women, lower estrogen means their symptoms get worse. They aren’t just imagining it; it’s a biological fact.”
Quinn reports that many women are diagnosed with ADHD in their late 30s or 40s during perimenopause, the years before actual menopause. At perimenopause, estrogen abandons its regular monthly ebb and flow and does an erratic fan dance. As time goes on, estrogen goes missing more often, bringing ADHD symptoms front and center.
“A lot of women come forward who ‘think’ they have ADHD,” said Quinn. “They are losing things, they are disorganized, but they were perfectly fine before perimenopause. Then it becomes a question of ‘is it ADHD or is it menopause?'” In addition, women who are over 40 have extra stress. They often belong to the “sandwich generation,” caring for parents, children, and/or grandchildren. They may be grieving over a divorce or the death of a spouse, or they may have emerging health problems of their own.
“The demands on women are incredible,” said Rostain. “If your [ADHD] brain is trying to function at its upper limit, and suddenly you are not able to mount that extra effort because estradiol is no longer around to facilitate neurotransmission, you will be more tired and things will take longer than before.” His ADHD patients report that they feel that they have regressed to their pre-treatment ADHD level.
Hormone issues for ADHD men are less dramatic; estrogen levels, while lower than in women, remain constant for men until age 70. Testosterone, however, decreases gradually, leading to more intense mood swings, sleep disturbances, and cognitive decline. “Twice as many men as women come in to our clinic seeking a possible diagnosis of ADHD,” said Rostain.
Stimulant medications are still the ADHD treatment of choice for older adults. “Children, adolescents, and adults respond at the same dosage ranges, and they all have the same side effects,” said William Dodson, M.D., a psychiatrist and founder of the Dodson ADHD Center, in Greenwood Village, Colorado. There has been some concern over cardiac issues, but, with the proper dosage, Dodson believes that almost anyone can take stimulants safely. He cites three large studies conducted by the FDA that found no increased risk of stroke or heart problems in people who take ADHD stimulants.
“The rule with stimulant medication is that the right molecule at the right dose should have no effect on the heart,” he said. Many physicians use the lower number of a blood pressure reading (the diastolic pressure) as a sensitive and accurate guide to stimulant dosing. “If the medication is below the optimal dose of stimulant, the number does not change,” he said. “If the dose goes even a few milligrams too high, blood pressure will jump 10 to 15 points.”
Estrogen therapy has proven successful in treating ADHD symptoms at menopause, according to Quinn. “The sooner you start estrogen therapy, the greater the effect on cognitive decline,” she said. For women with ADHD, she recommends “unopposed estrogen,” since progesterone has a negative effect on focus. She cautions that women should add in a course of a progestin at regular intervals to protect against uterine cancer. Postmenopausal ADHD women should consult their doctors about continuing hormone therapy, especially those with a history of vascular problems or cancer.
“Women now spend one third of their lives in postmenopause,” said Rostain. “What used to be easy becomes difficult, but if you have ADHD, it’s doubly difficult.” Both doctors strongly recommend that women maintain their regimen of ADHD treatment along with estrogen therapy, if therapy is chosen. “To maintain effective treatment, ADHD women should expect to make changes in their treatment regimen throughout their lifetime,” said Quinn.
Since older adults often take other medications for unrelated health problems, drug interactions are an important consideration in ADHD treatment. “The first-line stimulants and the alpha agonists (clonidine, guanfacine) can be taken with most commonly prescribed medications,” said Dodson.
Conversely, some non-ADHD medications cause deficits in attention and information processing (tricyclic antidepressants, antihistamines), according to a 2012 Canadian study. As always, talking with your doctor is the best way to ensure effective treatment for all illnesses and disorders.
Is It Too Late for Me?
Older adults who suspect they have ADHD are sometimes skeptical of the value of a full-fledged diagnosis. “Is it even worth it at age 73, when I am functioning OK?” asked Arnold.
The answer depends on life circumstances. An ADHD diagnosis is absolutely necessary for medical treatment of symptoms. Testing, pharmaceutical treatment, psychotherapy, and other behavioral interventions require a diagnosis if they are to be covered by medical insurance. Age should never be a deterrent to an ADHD evaluation or treatment.
“Cognitive impairment is serious,” said Rostain. “When an older adult comes into the clinic, he or she deserves the same workup to determine what’s going on as anyone else.”
Most important, treatment of midlife and senior ADHD can change lives, as it did for John Washbush, now 75 years old. “It’s as if I have been on a strict emotional consumption plan, and some of my lifelong habits don’t fit me any more,” he said. “My handwriting is noticeably different (since my diagnosis and treatment). I bought anchovies for the first time in 40 years, and I’m going to try them on pizza.”
Finding out about ADHD at midlife or older can be devastating, or it can open doors to long-discarded dreams. “To have ADHD as long as I have had it, to carry that with your aspirations and dreams is very painful,” said Zophia, now 72 years old. “But that strong desire to make a difference in the world has been reawakened. I’m not going to give up. To my last breath, I will move toward my goals!”