ADHD in Older Adults: Distinct Diagnostic and Treatment Considerations

ADHD is one of the most prevalent and chronic psychiatric conditions. It is widely studied and recognized — except when it occurs in older adults. For a variety of reasons, research on ADHD in older age has historically lagged, resulting in a dearth of relevant diagnostic and treatment tools. Recent years, however, have brought increased awareness of and interest in this underserved group, particularly people over the age of 50 with attention deficit hyperactivity disorder (ADHD or ADD).

Regardless of research deficits, it is abundantly clear that older adults with ADHD have unique needs and characteristics – including age-related cognitive changes, co-existing psychiatric and medical conditions, and more – that influence evaluation and treatment for the disorder. To better serve this aging population, clinicians must anticipate and understand these myriad factors.

ADHD in Old Age: Diagnostic Approaches

The ADHD Evaluation

DSM-5 and Clinical Interviews for ADHD

Clinicians must look beyond DSM-5 criteria alone when evaluating older patients for ADHD. Though the diagnostic manual was rewritten in 2013 to include descriptors for adult ADHD, it still does not adequately consider how the disorder manifests and evolves in patients past mid-life. The clinical interview is, therefore, a critical tool for extrapolating beyond the descriptions of inattention, hyperactivity, and impulsivity outlined in the DSM-5, as well as other diagnostic parameters.

To merit a diagnosis, adult patients must exhibit at least five out of nine ADHD symptoms in inattention and/or hyperactivity/impulsivity, present with impairments in several settings, and, most importantly, the symptoms must be lifelong — stretching back to childhood.

But the absence of an ADHD diagnosis in childhood does not preclude diagnosis later in life. Research^{1 2} shows that most adults with ADHD were never diagnosed as children, perhaps because the disorder was so poorly understood in decades past. In some cases, symptoms may manifest or become unmanageable during the transition to middle or late adulthood, where unique challenges and demands overpower available coping abilities³. Most clinicians follow the guiding principle that a patient reporting cognitive challenges as a result of physiologic and environmental changes likely does not have ADHD unless the cognitive difficulties predated these changes. But how do you effectively gauge the longevity of a challenge?

[Read: Inside the Aging ADHD Brain]

One revealing question I ask my older patients is this: “If I interviewed you 10, 20, or 30 years ago, would you have been talking about these symptoms?”

Cognitive Testing for ADHD

Neuropsychological testing is not reliable for diagnosing ADHD in older adults. We know this from research. One study on more than 300 Alzheimer’s center patients between the ages of 62 and 91 years found that about 4.5 percent of participants met the criteria for ADHD, indicated by a rating scale⁴. But when neuropsychological testing was done to distinguish these individuals with ADHD from participants who didn’t have ADHD, no significant differences were noted⁴. These findings are consistent with results from literature that show cognitive tests do not reliably distinguish ADHD cases in adults⁵.

Another study on neuropsychological deficits across younger and older adults with ADHD found that, compared to younger adults, older adults actually exhibited fewer deficits⁶. Both groups were subjected to neuropsychological tests that measured working memory, inhibition, switching, planning, speed of processing, and other domains.

Cognitive testing can be costly for patients. Unless this type of testing will provide definitive answers for diagnostic and treatment options, clinicians should seldom employ this tool. (In my practice, I reserve neurological testing to examine other elements of a patient’s cognitive ability, but not for an ADHD diagnosis.)

[Read: Is It ADHD, or Is It Age?]

ADHD and Its Comorbid Conditions

Age-Related Considerations with ADHD

Complicating diagnosis in older adults are age-related conditions and factors, especially those that impact cognitive ability, like:

• Depressive pseudodementia, which compromises thinking ability, motivation, and mood
• Age-related cognitive decline, exhibited by forgetfulness, memory loss, etc.
• Mild cognitive decline (MCI), which puts an individual at increased risk for dementia
• In women, menopause-related cognitive impairment
• Sleep disturbances or apnea
• Increasing polypharmacy (multiple medications for several medical illnesses)

While symptoms of cognitive decline can look similar to those of ADHD, the fact that they occur in mid- to late-life is telling, as symptoms must be chronic and relatively unchanging over the patient’s lifespan to indicate ADHD. At the same time, cognitive complaints in older patients should not be automatically discounted as age-related decline, as this could result in lost opportunity to provide effective treatment to the patient. (In practice, however, this is seldom considered – a study revealed that only 20 percent of memory clinics reported screening regularly for ADHD⁷, suggesting that clinics may not be considering 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 conditions, mental health concerns, and personality characteristics that clinicians must take into account. In one study on adults with ADHD aged 50 and over, roughly half reported psychiatric comorbidities⁸.

• Mood and anxiety disorders: About 25 percent of adults with ADHD aged 50 and older report bipolar disorder; 36 percent report depression; and about 26 percent report anxiety⁸. Another study on older adults with ADHD (ages 60-94) found that this group, compared to controls without ADHD, had more depressive and anxious symptoms⁹.
• Self-esteem: Compared to older adults without ADHD, older adults with ADHD report lower self-esteem and sense of mastery, and higher levels of neuroticism and social inadequacy¹⁰. The former partly explains the association between ADHD and depressive symptoms in old age.

Clinicians who do make a diagnosis of ADHD in older adults should ensure that they have also considered and screened for these comorbid conditions.

ADHD in Old Age: Treatment Options

Medication for ADHD in Older Adults

Determining appropriate psychopharmacological interventions for ADHD in older adults often involves careful consideration of these factors:

Medication Interactions: Considerations for Older Adults with ADHD

In a study on adults aged 50 and over, about 76 percent reported ongoing drug treatment including antihypertensives, antidepressants, analgesics, and more for coexisting illnesses¹¹. Drug interactions and the suitability of medication for a patient are critically important, so clinicians must ask patients about their current medications and over-the-counter supplements. For patients with coexisting psychiatric conditions, clinicians must determine treatment prioritization in an effort to ameliorate symptoms of one condition without worsening the others.

Stimulants for ADHD in Older Adults

Older adults are underrepresented in pharmaco-kinetic and pharmaco-dynamics studies. Clinical trials for ADHD medication have often excluded people over the age of 65 in an attempt to streamline research or meet criteria, as older adults tend to have existing medical conditions and/or are taking medicine for other issues, which could introduce confusing factors into studies’ results. This lack of systematic study, however, has left unanswered questions regarding the effectiveness of stimulants and tolerability in this population. Clinicians have largely relied on available (though hardly abundant) research to inform their clinical judgement.

Today, the maximum FDA-approved ages for stimulant use vary from 55 to 65 years. (Lisdexamfetamine, sold under Vyvanse, only had trials for adults up to age 55; mixed amphetamine salts XR/OROS MPH, Adderall and Concerta respectively, are approved up to age 65.) These limits often cause problems, as Medicare may not cover these medications because they lack FDA approval for patients over the age of 65.

Still, clinicians are clearly prescribing ADHD medications to treat symptoms in older adults. About 63 percent of adults with ADHD aged 50 and older report current ADHD medication use, according to one study, with the majority on stimulants¹¹. About a quarter, however, are not taking ADHD medication, and 35 percent report undergoing non-pharmacological treatment for ADHD (i.e. ADHD therapies, skills and behavior training, etc.)¹¹.

Medicated individuals in this study reported better attention compared to non-medicated participants, as well as better ability to manage daily demands versus individuals who had stopped ADHD medications¹¹.

Given the vast number of stimulant options on the market, how should clinicians decide on the best and safest ADHD medication for older adult patients?

• Select by compound (methylphenidate, D-MPH, MAS, amphetamine, D-Amph) and measure patient response. Most clinicians make their selection based on experience with training, efficacy, and familiarity.
• Delivery system technology determines how fast it starts and how long the medication lasts, as well as possible side effects. This decision depends on the patient’s needs and how reliably they take the prescribed dose.
• Certain stimulant side effects may be more of an issue for older adults. Dry mouth, for example, can chronically accelerate gum recession and increase the risk for cavities, and can complicate denture fittings and adhesion. Patients with hypertension and cardiac issues need to have blood pressure and pulse routinely monitored.

Medication response does not confirm diagnosis. People without ADHD given stimulant medication will report improvement in mood, cognition, and energy. This does not confirm a diagnosis of ADHD. It simple reflects the psychological experience of changing dopamine and norepinephrine in the brain. Clinicians must therefore attempt to confirm diagnosis first with clinical interviews and patient history, and then prescribe ADHD medication.

Psychotherapy for ADHD in Older Adults

While non-pharmacological interventions can address organizational skills, behavioral changes, and executive functioning challenges, one critical but overlooked benefit of psychotherapy is improved self-esteem and self-concept for older adults with ADHD, especially patients diagnosed late in life.

Undiagnosed and untreated ADHD can lead to impairments in practically all daily domains, which can impact quality of life and self-perception for decades. An ADHD diagnosis — coupled with effective treatment — can act as a positive, liberating, and life-changing revelation for these individuals. Psychotherapy can be an important intervention for helping the patient treat emotional difficulties and psychiatric conditions arising from these experiences and newfound diagnosis. Patients, therefore, are never too old to understand the difference between ADHD and who they are as a person.

The content for this article was 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 on February 16, 2021.

Old Age and ADHD: 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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