Inside the Aging ADHD Brain

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 says. “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,” Zophia says.

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 says. “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 says. “I knew within 20 minutes that I was on a path to discovering the real me.”

[“If Only I’d Known This 20 Years Ago”]

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.

Research is beginning to paint a picture of what ADHD looks like in adults over the age of 60. “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,” says Kathleen Nadeau, Ph.D., founder and clinical director of the Chesapeake ADHD Center of Maryland, Learning and Behavioral Health.

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 aged 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.

However, most ADHD symptom criteria and diagnostic questionnaires are appropriate for the diagnosis of children, not adults. “For an adult to meet the child-based criteria, they would have to be functioning on the level of an elementary school-age child with untreated ADHD,” says William Dodson, M.D., LF-APA, a board-certified adult psychiatrist who was one of the first practitioners to specialize in adults with ADHD 25 years ago. “Though it was officially acknowledged in 1980 that ADHD usually persists into adult life, work has only just begun on writing official adult ADHD criteria 43 years later.”

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.

“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,” says Nadeau. “They more often are interpreted as mild cognitive impairment or even dementia — conditions more familiar to medical or mental health professionals.”

[Signs of Adult ADHD? Or Old Age?]

Normal cognitive aging begins in our mid-30s, when brain processing speed and motor response time gradually slow down. 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). 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. Car crashes were 74% more likely, traffic tickets were 102% more likely, and hard-breaking events were 7% more likely among adults aged 65 to 79 with ADHD than they were among neurodivergent drivers of the same age, according to a 2023 cohort study lead by researchers at Columbia University Mailman School of Public Health. ¹,

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).

Executive function — planning, organization, follow-through, and time awareness — is a continuing challenge for 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,” says 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.”

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.

[Free Download: What Every Thorough ADHD Diagnosis Includes]

“It was Alzheimer’s research that revealed the effect of estrogen on the brain,” says 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,” Quinn says. “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,” Rostain says. “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 to our clinic seeking a possible diagnosis of ADHD,” Rostain says.

Treatment Tools

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,” Dodson says. With the proper dosage, Dodson believes that almost anyone can take stimulants safely — regardless of age. Further, a November 2022 meta-analysis of 19 observational studies from the last 15 years, including 3.9 million participants, found no statistically significant association between ADHD medications and cardiovascular disease, even among middle-aged and older adults.  That study, published in JAMA Network Open, was the most comprehensive systematic review and meta-analysis of longitudinal observational studies to date on the association between ADHD medication use and the risk of CVD and included patients from the United States, South Korea, Canada, Denmark, Spain, and Hong Kong.²,

“The rule with stimulant medication is that the right molecule at the right dose should have no effect on the heart,” Dodson says. 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 says. 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,” says 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,” Quinn says.

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,” Dodson says.

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?” Arnold asks.

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,” Rostain says. “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 says. “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,” says 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!”

Aging ADHD Brain: Next Steps

• Read: Is It Worth Seeking an ADHD Diagnosis After 50?
• Download: Do I Have ADHD? A Guide for Adults
• Read: Is it ADHD or Menopause?

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