ADHD in Older Adults: Distinct Diagnostic and Treatment Considerations
ADHD is among the most prevalent and persistent psychiatric conditions. It is extensively studied and identified — apart from when it happens in older adults. For numerous reasons, analysis on ADHD in older age has traditionally lagged, resulting in a dearth of relevant diagnostic and treatment tools. Recent years, alternatively, have brought increased awareness of and pastime in this underserved crew, specifically other people over the age of 50 with attention deficit hyperactivity dysfunction (ADHD or ADD).
Regardless of study deficits, it's abundantly clear that older adults with ADHD have unique needs and traits – together with age-related cognitive adjustments, co-existing psychiatric and medical stipulations, and extra – that influence evaluation and treatment for the disorder. To higher serve this aging inhabitants, clinicians must await and perceive these myriad factors.
ADHD in Old Age: Diagnostic Approaches
The ADHD Evaluation
DSM-5 and Clinical Interviews for ADHD
Clinicians must glance past DSM-5 criteria alone when comparing older patients for ADHD. Though the diagnostic handbook used to be rewritten in 2013 to incorporate descriptors for adult ADHD, it still does not adequately imagine how the disorder manifests and evolves in sufferers previous mid-life. The medical interview is, therefore, a essential instrument for extrapolating beyond the descriptions of inattention, hyperactivity, and impulsivity outlined in the DSM-5, in addition to different diagnostic parameters.
To merit a diagnosis, grownup sufferers should exhibit a minimum of five out of nine ADHD symptoms in inattention and/or hyperactivity/impulsivity, provide with impairments in a number of settings, and, most importantly, the indications should be lifelong — stretching back to early life.
But the absence of an ADHD analysis in childhood does not preclude diagnosis later in existence. Research12 shows that almost all adults with ADHD had been by no means identified as youngsters, possibly for the reason that disorder was so poorly understood in decades previous. In some cases, signs might manifest or transform unmanageable right through the transition to heart or past due maturity, the place distinctive challenges and demands overpower available coping abilities3. Most clinicians follow the guideline that a patient reporting cognitive demanding situations on account of physiologic and environmental changes likely does not have ADHD unless the cognitive difficulties predated those adjustments. But how do you successfully gauge the longevity of a challenge?
One revealing query I ask my older sufferers is this: “If I interviewed you 10, 20, or 30 years in the past, would you could have been talking about these symptoms?”
Cognitive Testing for ADHD
Neuropsychological testing isn't dependable for diagnosing ADHD in older adults. We know this from analysis. One learn about on greater than 300 Alzheimer’s heart sufferers between the ages of 62 and 91 years discovered that about 4.Five percent of participants met the standards for ADHD, indicated by way of a ranking scale4. But when neuropsychological testing was accomplished to tell apart these folks with ADHD from participants who didn’t have ADHD, no important variations were noted4. These findings are in keeping with results from literature that show cognitive tests do not reliably distinguish ADHD cases in adults5.
Another study on neuropsychological deficits throughout more youthful and older adults with ADHD found that, in comparison to younger adults, older adults if truth be told exhibited fewer deficits6. Both teams have been subjected to neuropsychological checks that measured operating memory, inhibition, switching, making plans, pace of processing, and other domains.
Cognitive testing will also be costly for patients. Unless this kind of trying out will supply definitive solutions for diagnostic and treatment choices, clinicians will have to seldom employ this software. (In my apply, I reserve neurological testing to inspect different parts of a affected person’s cognitive skill, however now not for an ADHD analysis.)
ADHD and Its Comorbid Conditions
Age-Related Considerations with ADHD
Complicating diagnosis in older adults are age-related stipulations and components, particularly those who impact cognitive ability, like:
- Depressive pseudodementia, which compromises pondering ability, motivation, and temper
- Age-related cognitive decline, exhibited by way of forgetfulness, memory loss, etc.
- Mild cognitive decline (MCI), which places a person at increased risk for dementia
- In women, menopause-related cognitive impairment
- Sleep disturbances or apnea
- Increasing polypharmacy (a couple of medications for a number of medical diseases)
While symptoms of cognitive decline can look very similar to those of ADHD, the fact that they occur in mid- to late-life is telling, as symptoms should be continual and quite unchanging over the patient’s lifespan to indicate ADHD. At the same time, cognitive lawsuits in older sufferers should not be routinely discounted as age-related decline, as this is able to outcome in misplaced alternative to offer efficient treatment to the patient. (In observe, on the other hand, this is seldom regarded as – a study published that simplest 20 percent of memory clinics reported screening frequently for ADHD7, suggesting that clinics will not be making an allowance for ADHD symptomatology as premorbid baseline cognitive functioning.)
Psychiatric Conditions & Mental Health Considerations with ADHD
Older adults with ADHD have a significant number of comorbid psychiatric stipulations, mental health issues, and personality traits that clinicians should keep in mind. In one learn about on adults with ADHD aged 50 and over, more or less half reported psychiatric comorbidities8.
- Mood and anxiety disorders: About 25 percent of adults with ADHD elderly 50 and older report bipolar disorder; 36 % record depression; and about 26 p.c document anxiety8. Another find out about on older adults with ADHD (ages 60-94) discovered that this team, compared to controls with out ADHD, had extra depressive and fearful symptoms9.
- Self-esteem: Compared to older adults with out ADHD, older adults with ADHD report lower vainness and sense of mastery, and higher levels of neuroticism and social inadequacy10. The former partly explains the affiliation between ADHD and depressive symptoms in old age.
Clinicians who do make a prognosis of ADHD in older adults will have to make sure that that they have also regarded as and screened for these comorbid conditions.
ADHD in Old Age: Treatment Options
Medication for ADHD in Older Adults
Determining suitable psychopharmacological interventions for ADHD in older adults continuously involves cautious attention of those factors:
Medication Interactions: Considerations for Older Adults with ADHD
In a find out about on adults elderly 50 and over, about Seventy six % reported ongoing drug treatment together with antihypertensives, antidepressants, analgesics, and extra for coexisting sicknesses11. Drug interactions and the suitability of medicine for a patient are seriously essential, so clinicians should ask patients about their current drugs and over the counter supplements. For sufferers with coexisting psychiatric stipulations, clinicians will have to determine treatment prioritization in an effort to ameliorate symptoms of 1 situation with out worsening the others.
Stimulants for ADHD in Older Adults
Older adults are underrepresented in pharmaco-kinetic and pharmaco-dynamics research. Clinical trials for ADHD medication have steadily excluded other people over the age of 65 in an try to streamline analysis or meet standards, as older adults generally tend to have existing medical stipulations and/or are taking drugs for other problems, which could introduce confusing elements into research’ effects. This lack of systematic learn about, however, has left unanswered questions in regards to the effectiveness of stimulants and tolerability in this population. Clinicians have largely trusted to be had (although hardly ever considerable) research to inform their medical judgement.
Today, the maximum FDA-approved ages for stimulant use range from Fifty five to 65 years. (Lisdexamfetamine, offered underneath Vyvanse, simplest had trials for adults as much as age 55; mixed amphetamine salts XR/OROS MPH, Adderall and Concerta respectively, are approved as much as age 65.) These limits regularly purpose issues, as Medicare may not duvet these medications as a result of they lack FDA approval for patients over the age of 65.
Still, clinicians are obviously prescribing ADHD drugs to regard symptoms in older adults. About 63 percent of adults with ADHD aged 50 and older report present ADHD drugs use, according to one study, with the majority on stimulants11. About 1 / 4, however, are not taking ADHD medication, and 35 % document present process non-pharmacological treatment for ADHD (i.e. ADHD remedies, talents and conduct coaching, and many others.)11.
Medicated people in this study reported higher consideration compared to non-medicated individuals, in addition to higher ability to regulate day by day calls for versus individuals who had stopped ADHD medicines11.
Given the vast selection of stimulant choices on the market, how will have to clinicians make a decision on the most productive and most secure ADHD medicine for older grownup sufferers?
- Select by way of compound (methylphenidate, D-MPH, MAS, amphetamine, D-Amph) and measure affected person response. Most clinicians make their selection in keeping with revel in with training, efficacy, and familiarity.
- Delivery device era determines how briskly it starts and how long the medication lasts, in addition to possible negative effects. This decision will depend on the patient’s wishes and how reliably they take the prescribed dose.
- Certain stimulant negative effects could also be extra of a subject for older adults. Dry mouth, for example, can chronically boost up gum recession and building up the danger for cavities, and can complicate denture fittings and adhesion. Patients with hypertension and cardiac issues want to have blood pressure and pulse robotically monitored.
Medication response does now not ascertain analysis. People without ADHD given stimulant drugs will report development in temper, cognition, and power. This does no longer ascertain a diagnosis of ADHD. It simple reflects the psychological revel in of fixing dopamine and norepinephrine in the brain. Clinicians must subsequently try to verify diagnosis first with medical interviews and patient history, and then prescribe ADHD medication.
Psychotherapy for ADHD in Older Adults
While non-pharmacological interventions can cope with organizational talents, behavioral adjustments, and government functioning challenges, one vital however lost sight of good thing about psychotherapy is progressed vainness and self-concept for older adults with ADHD, especially patients diagnosed past due in life.
Undiagnosed and untreated ADHD can result in impairments in nearly all daily domain names, which will impact quality of existence and self-perception for many years. An ADHD analysis — coupled with effective treatment — can act as a favorable, liberating, and life-changing revelation for those individuals. Psychotherapy will also be a very powerful intervention for helping the affected person deal with emotional difficulties and psychiatric conditions coming up from those stories and newfound diagnosis. Patients, therefore, are never too outdated to know the adaptation between ADHD and who they're as an individual.
The content for this article used to be derived from the ADDitude Expert Webinar “The Science Behind Diagnosing and Treating ADHD in Older Adults” [Video Replay & Podcast #344] with David Goodman, M.D., FAPA, which was broadcast live to tell the tale February 16, 2021.
Old Age and ADHD: Next Steps
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