Just as there have been concerns about the treatment and potential increased societal burden as we improve disease recognition with adolescents recently diagnosed with ADHD aging into adulthood, there are similar concerns as middle aged adults recently diagnosed with ADHD become older adults with ADHD. In fact, the largest percentage growth in stimulant prescriptions in the last year is in adults over the age of 50 years of age (Adler LA. ADHD in Older Adults. Paper Presentation at the Annual Meeting of the American Psychiatric Association, New York , New York, May 2014). However, there are special concerns re: the diagnosis and treatment of older adults which merit heightened attention.
The evidence basis for ADHD in older adults is quite small, when compared to the literature for childhood and adult ADHD. In fact a recent Pubmed search found 100 times fewer peer-reviewed publications on geriatric and older adults with ADHD, than for adult ADHD in general (Adler LA 2014).
The epidemiology of ADHD in older adults indicates:
- Similar prevalence to overall adult ADHD
- Some diminution in symptom severity with age – this is true through the lifespan, not just true with geriatric ADHD.
- Impairment: Notable deficits in social interactions, which is larger than younger adults with ADHD
- The diagnosis of ADHD in older adults is complicated by potential overlap with disorders of cognitive decline, such as Mild Cognitive Impairment (MCI).
- Inattentive (IA) symptoms (relative to hyperactive-impulsive (HI) ones) increase with the transition from childhood to adulthood (Kessler RC. Arch Gen Psychiatry 2010). It is not clear that this pattern continues with the transition to older adulthood. It is also not clear if the number and burden of IA symptoms might be limited with retirement as individuals perform less cognitively challenging tasks.
The co-morbidities seen in adults with ADHD are similar to those seen in adult ADHD in general.
Symptoms also seem similar. However, there is some support in the literature for increasing rates of depression as adults with ADHD become geriatric adults.
A specific co-morbidity which must be addressed in the evaluation of adults for ADHD is Mild Cognitive Impairment (MCI). It is critical that physicians examine whether there are formal memory deficits. Deficits in MCI are more memory-related as compared with attentional issues seen in ADHD. Other potential issues in establishing this differential include that executive function deficits are somewhat less common in MCI as compared with ADHD in general (except for amnestic MCI).
The time courses of the illnesses differ with an older onset in life for MCI, while ADHD is more or less present throughout the lifespan. A MMSE may be quite helpful in establishing whether memory deficits are present, or formal neuro-psychological testing can be obtained to further delineate the presence of memory vs. attentional issues.
There are special treatment considerations for older adults with ADHD. ADHD medications should be used carefully, with regular cardiovascular monitoring and consultation with primary care physicians as all FDA approved medications for adult ADHD (sustained release stimulants and atomoxetine) have a small risk for increasing the heart rate (on the average 5 beats/minute) and blood pressure (on the average 3 mm Hg); this is especially important as geriatric adults have higher rates of cardiovascular illness and hypertension. Geriatric adults with ADHD should also be monitored for potential agitation or activating effects of the medication.
In conclusion, just as ADHD persists from the transition from adolescence into young adulthood, it also persists in the transition to older adulthood. As always, clinicians should perform careful clinical evaluations and establish appropriate treatment programs, taking into account the special issues involved with the older adults.