ADHD Underappreciated in Older Adults

Marcus A. Banks

September 25, 2023

Less than half of older adults with attention deficit disorder are diagnosed with the condition, and many never receive treatment.

Negative consequences can develop from not treating attention deficit disorder (ADHD), including job loss, suppressed income levels, low educational attainment, and difficulty maintaining relationships. Perhaps as many as 5% of adults have ADHD, which is highly hereditary. 

Primary care physicians or family medicine clinicians are often best placed to diagnose ADHD in older adults, according to experts who spoke to Medscape Medical News. But first these providers need to tease out whether a patient has ADHD or another condition that is causing difficulties for these older adults.

However, clinicians may have a hard time discerning the symptoms of ADHD from that of other conditions of aging such as mild cognitive impairment. Literature is lacking on best practices for screening and treating the condition in this population, according to a recent review published in the Expert Review of Neurotherapeutics, and a 2020 study by the same authors, epidemiologists and psychiatrists based in Europe.

"If you don't manage it, who will? It can be very hard to get psychiatric consults, almost impossible in some cases," said Brendan Montano, MD, an internist in Cromwell, Connecticut, who specializes in treating ADHD. 

A Critical Role for Primary Care and Family Medicine

Although no formal US guidelines exist on diagnosis of adult ADHD, Montano stressed that adults usually present with symptoms such as chronic forgetfulness, distractibility, or procrastination. Hyperactivity is more internalized as a feeling of internal restlessness in this age group, Montano said, rather than the more visible hyper behavior seen in children.

"The two big ways that people present are thinking they have it or in chaos of some sort," perhaps because they have been fired or their spouse has asked for a divorce, Montano explained.

To assess the possibility of ADHD, a clinician could give a patient a six-item screening test that asks questions such as how often over the previous 6 months have they had trouble completing assignments or remembering appointments. If they report difficulty in four or more of the six areas in the brief screener, clinicians can move on to a longer 18-item screening tool developed by the World Health Organization, Montano said.

To make an ADHD diagnosis definitively, however, a patient needs to report sustained difficulties in at least two aspects of life: work, home, or social situations. And they have to indicate to a clinician that these troubles began before age 12.

"You have to really sit down and paint the picture with the patient: there are no shortcuts here," said Lenard Adler, MD, a psychiatrist who directs the Adult ADHD program at New York University. Adler helped develop the six-item screener and is currently on a committee developing formal screening guidelines for adult ADHD in the United States.

He said that often, "ADHD cotravels with other mental health disorders like depression, bipolar disorders, anxiety disorders, and substance use disorders at least half the time."

To tease out if a patient really has ADHD, clinicians can start with a more general screening for anxiety and hone in on the possibility of the condition if the anxiety screening reveals challenges with distractibility and forgetfulness, according to Karen Smith, MD, a family physician in Raeford, North Carolina.

"We can't expect patients to walk through the door with the diagnosis stamped on their foreheads," said Smith, who is a member of the board of directors for the American Academy of Family Physicians.

But a patient's apparent signs of ADHD could be due to another condition such as hyperthyroidism or diabetes, Smith said. The driving principle is to take enough time to figure out exactly what is going on, Smith said, and then to treat accordingly.

"If you ask the right questions, patients will give you good answers," Smith said. 

Medications are often prescribed to help manage ADHD symptoms. These can include stimulants, controlled substances that include methylphenidate or amphetamine, or nonstimulants, such as atomoxetine and bupropion. Montano starts his patients on a lower dose and titrates them up rapidly until they reach the optimum dose that allows them to sustain focus and feel more productive. Patients complete frequent self-reports during this process.

"Any diversion is inappropriate," Montano said, who writes a contract with his patients saying that stimulant medications will not be refilled if they are used more quickly than prescribed.

For older adults, physicians should make sure that stimulants do not exacerbate any underlying cardiovascular conditions, Montano said, and consult a cardiologist when needed.

The benefits of proper ADHD treatment can be profound, Adler noted, no matter when it begins.

"Older adults have lived their lives feeling they've been disorganized and a burden to their significant others, and only when they've taken medication have they really been able to organize their days and feel effective in their social interactions and with their families," Adler said.

Montano has reported relationships with AbbVie, Axsome, Corium, Idorsia, Intracellular, Otsuka, Supernus, Sage/Biogen, Biohaven, Boehringer Ingelheim, Cassava, Eli Lilly, Intracellular, Janssen, Jazz, Sage, Supernus, Otsuka, and Tonix. Adler has reported relationships with Shire/Takeda Pharmaceuticals, National Football League, Major League Baseball, Corium, Otsuka, Neurocentria, Bracket/Signant, and SUNY; and receiving royalty payments for developing adult ADHD assessments. Smith has reported no relevant financial relationships.

Expert Rev Neurother. 2023;23:883-893. Full text

Marcus A. Banks, MA, is a journalist based in New York City who covers health news with a focus on new cancer research. His work appears in Medscape, Cancer Today, The Scientist, Gastroenterology & Endoscopy News, Slate, TCTMD, and Spectrum.

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