Diagnostic & Treatment Considerations for Older Adults with ADHD

Diagnostic & Treatment Considerations for Older Adults with ADHD

Posted on: July 5th, 2021 by Neurohealth Associates

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.

Diagnostic Approaches for ADHD in Older Adults

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 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 abilities. 

Most clinicians follow the guiding principle that a patient reporting cognitive challenges as a result of physiologic and environmental changes likely do not have ADHD unless the cognitive difficulties predated these changes. But how do you effectively gauge the longevity of a challenge?

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 scale. 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 deficits. 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.

ADHD & Comorbid Conditions

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 a 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 symptoms.

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 inadequacy. 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.

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.

Neurofeedback Therapy

Here at Neurohealth Associates, we specialize in Neurofeedback treatments. Neurofeedback may be helpful for treating ADHD symptoms, especially if you are unsure about the use of stimulant medication. The easy, noninvasive treatments can painlessly improve your mental health condition and outlook on life.

Schedule a consultation with NeuroHealth today and find out how we can help you.

Original article posted by ADDitude Mag.

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