Kathleen Orr, a 68-year-old clinical social worker, complains to her doctor that she struggles to remain focused, becomes easily distracted and has difficulty completing tasks at work and chores at home. After asking a few questions, her physician tells her that this is part of normal aging. Mary says, “But I’ve had this issue on-and-off my whole life.” The physician dismisses the remark and remains confident with his conclusion. What’s wrong with this picture? Mary’s last remark alludes to the possible diagnosis; unfortunately, her physician is unaware of the persistence of attention deficit hyperactivity disorder in people over the age of 50.
Mary’s situation with her physician is problematic but not uncommon, as physicians in the U.S. aren’t adequately trained to consider ADHD when their older adult patients complain of concentration difficulties, forgetfulness and other cognitive symptoms. Both health care providers and patients need to be better informed about the prevalence of ADHD in people over 50 to increase identification, diagnosis and treatment, and ultimately improve the quality of life of people suffering from treatable cognitive complaints. Optimally, Mary ought to receive a comprehensive psychiatric evaluation to accurately determine a diagnosis. If diagnosed with ADHD, then the doctor should offer effective medication and psychotherapy to Mary.
Traditionally considered a childhood disorder, ADHD persists into adulthood, according to international research over the past two decades. Studies following children with ADHD into adulthood for up to 30 years have given us a better understanding of adult symptoms and impairments. However, research on ADHD in adults over the age of 50 is scarce. Because of this lack of research, there are many questions left unanswered. Do ADHD symptoms look different in older adults? How do symptoms impair performing the chores of daily life? Will medication even be helpful? Will medical illnesses and other medicines complicate the use of ADHD medications? What nonmedication treatments might be effective at improving quality of life? How are families affected by an older parent with ADHD?
According to the Diagnostic and Statistical Manual of Mental Disorders, ADHD requires symptoms of inattention and/or hyperactivity and impulsivity persisting over time and impairing the person’s daily functioning. A recent study from the Netherlands estimates the prevalence of ADHD in older adults ages 55 to 85 at almost 3 percent. By these estimates, 1.8 million older adults have ADHD in the U.S. now, and by 2050, there will be 2.5 million older adults with ADHD.
A survey of memory clinics in the U.S. demonstrated that only 1 in 5 clinics screen for ADHD. Although an increasing number of aging adults complain of normal cognitive changes, there exists a set of adults with ADHD whose cognitive complaints could be ameliorated with appropriate treatment.
Making a diagnosis of ADHD in older adults is further complicated by co-occurring psychiatric disorders – like depression (40 percent), anxiety (20 percent) and bipolar disorder (24 percent) – other medical conditions or medications that may contribute to cognitive changes. The necessary clinical skills needed to distinguish these conditions may be a challenge to primary care medical providers. Yet as of 2009, nonpsychiatrist primary care providers wrote 53 percent of all stimulant medications, and that percentage is likely higher now.
In a survey of 149 adults with ADHD over age 50, the average age of diagnosis was 50. Why are these people diagnosed so late in life? These adults grew up in the 1950s and 1960s when ADHD wasn’t widely recognized in children, except for those who were obviously hyperactive and disruptive. The concept that ADHD persists into adulthood wasn’t recognized by experts until the 1990s and is only now broadly recognized by health care and mental health providers. From this survey, 64 percent of adults with ADHD continued taking medications, and those adults on medication reported better attention and better ability to manage daily demands, compared to their time prior to treatment.
Now, people may ask Mary: “If you’ve had this problem for so long, why bother treating it now?” Imagine you believed yourself to be as others labeled you throughout your life – careless, irrational, a daydreamer, dumb or just plain odd. Then, you realize a treatable disorder caused these symptoms, and they aren’t a reflection of who you are. It’s liberating to understand the difference between what you have – a disorder – and who you are – a person.
Older adults with the disorder are the next clinical frontier in understanding ADHD. More research studies are desperately needed so physicians can offer the best care possible based on a scientific understanding of the disease in an aging population. I’ve personally taught thousands of physicians and health care providers about the identification, diagnosis and treatment of ADHD in adolescents and adults. And, if other health care providers and the general public understand the persistence of ADHD throughout one’s life and the improvement in quality of life with effective treatment, it can advance our care of patients.