499- ADHD in Older Adults: Clinical Guidance and Implications

Carol Fleck

Welcome to the Attention Deficit Disorder Expert podcast series by Attitude magazine.

Hello everyone, and thank you for joining us. I'm Carol Fleck, and on behalf of the attitude team, I'm pleased to welcome you to today's ADHD experts presentation titled ADHD in older adults. Clinical guidance and implications leading today's presentation is Doctor David Goodman. Doctor Goodman is an assistant professor in psychiatry and behavioral sciences at the Johns Hopkins School of Medicine. He is also a clinical associate professor at the Upstate Medical University in New York.

He's also involved in the effort to develop the first us clinical practice guidelines to to diagnose and treat ADHD in adults. Right now, us clinical guidelines for ADHD only address symptoms and treatment for children. They do not inform clinicians on how to evaluate, diagnose, and treat adults of any age, let alone older adults. And that's a big problem. When older adults inform their providers about memory problems, mood changes, and other cognitive concerns, they are rarely evaluated for ADHD.

In today's webinar, we'll discuss the importance and the challenges of diagnosing and treating ADHD in older adults. Doctor Goodman will also address concerns around stimulant medication use and cardiovascular risk. Finally, the sponsor of this webinar is play attention. Attention and mental sharpness are vital at any age, especially for adults over 50. Managing ADHD.

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Attitude thanks our sponsors for supporting our webinars. Sponsorship has no influence on speaker selection or webinar content. So without further ado, I'm so pleased to welcome Doctor David Goodman. Thank you so much for joining us today and for leading this discussion. Thank you, Carol, and thank you so much for inviting me to talk about this important and very infrequently discussed issue with patients.

David Goodman

This is my area of focus and expertise. I've been in clinical practice now for almost 40 years, having seen thousands of patients, and very little attention gets paid to those adults over the age of 50 who've never been diagnosed and yet suffered and compensated for their ADHD over their entire life. My wife likes me to include this slide. It's her concept of our vision for the future. Hopefully we can achieve this.

She's a darling woman. The objectives I think Carol enumerated. We're going to talk about ADHD that occurs in patients over the age of 50. We're going to talk about how to distinguish some of the medical and psychiatric explanations and how to consider making an accurate diagnosis. A lot of people now have been hearing about ADHD related to dementia and going, oh, my gosh, does it mean I'm going to fall apart as I get older?

We'll talk about those findings, which are, by the way, very preliminary. We'll talk about treatment options. I'll focus especially on medication because that's a. That's a medical issue with people who have medical illnesses. And then we'll talk about the safety issues and how to dose, perhaps, and get into a little bit more of that.

I do look forward to the question and answers because that's really where the meat of everyone's concern is. And I do want to also thank you for taking your time. Those of you who don't know this, I'm now looking at 1600 people who are now in attendance. I'm actually overwhelmed by that level of interest, so that's great. When I talk about ADHD to my colleagues, they say, look, the person's over 50, they're 60, they're even 70.

Why bother treating this? They spent decades living with it. They've compensated, and it probably isn't that much of a big deal. I'm going to walk through my answer with you in great detail as to why this is really an issue that should be addressed. Let me phrase that.

A lot of what I'm going to present is clinical, some of which is parsed in the language of experts and clinicians and providers who work in this area. So if you're a consumer, if you're a patient, if you're part of the general public, I hope to finesse this so that everybody understands what I'm trying to convey. What you're looking at now is a slide of the prevalence rate of major psychiatric disorders in the United States. And you'll notice that schizophrenia on the right is at 1%, major depression is at around 7%. This is in the general population of adults in the US.

ADHD actually is 4.4%. ADHD is the second most common psychiatric disorder in adults. That rarely gets focused in clinical training programs. Whether you're a psychiatric resident, psychologist, nurse practitioner, social worker or physician's assistant, this is why? After 20 or 30 years of adult ADHD research, we're now only coming up to speed to accurately diagnosing people in older adults.

The prevalence rate is about 3% in the United States. If you look at worldwide literature, this is done on a meta analysis of studies, it's about 2.5%. That really is significant. Then when you look at its prevalence of other psychiatric disorders, we're not talking about a rare phenomenon, we're actually talking about a disorder that is very, very common in clinical practice. It's very important to conceptually understand the diagnosis of ADHD.

ADHD is anchored in childhood and early adolescence, so the symptoms occur, the symptoms cause impairment, and then the child gets referred to being evaluated and diagnosed. Most children are males, not females. So the ratio of male to females, about three to one. And why is that? Males tend to be more disruptive.

And if you are a pain in the butt to your teacher, that's when you get sent off to get evaluated. If you're Susie sitting in the back of the room, spacing out and getting B's on your assignments, you're probably not going to be referred. But what if the impairments don't show up until later in life? You're able to manage to get through school, high school, you get into college, things start falling apart. You get your first job, things start falling apart.

Well, it's at that point that you might get referred or self referred for an evaluation and diagnosis. And at this point you're going for an evaluation because your symptoms are a problem to you, much more so than the problem to the environment. Well, what happens if you're much older? You're over the age of 50 now. You come in complaining about inattention and distractibility and inefficiency, inconsistency, and the provider has to figure out what might you have, and they have to consider all the possibilities.

So some of the issues that contribute to cognitive difficulties when you're older are medical illnesses. If you're on several medications, or if you're drinking too much or using other drugs that can burn holes in your head and cause cognitive problems. The other issue is that you're going to have a depression where you're not complaining about sadness, but you're complaining about not motivated and your cognition is fuzzy. So you complain that you can't think and you can't focus and you can't remember, may actually be an outgrowth of depression. The other elements when you get older are age related cognitive declines or menopause.

So many women complain that their cognitive ability diminishes during the perimenopausal phase. You also can develop what's called MCI, mild cognitive impairment. These are memory problems, word spelling problems that don't rise to the elevation of dementia, but still are subjectively problematic. And then, of course, you can have early dementia or dementia. The question is, for the older adults who complain about cognitive difficulties, how do you sort this out?

That's the job of the clinician, who hopefully has been adequately trained in order to sort this out. Let me go back, though, to the prevalence. How do we know that ADHD in older adults occurs at about 3%? A lot of this evolves out of research done in the Amsterdam. They have a great research team over there.

And so I'm showing you research from the first epidemiologic study of older people with ADHD. About 1500 people, 230 had a very specific diagnostic interview. They were using the DSM four criteria, which was six out of nine symptoms in inattention and hyperactivity. Anyway, if they used all this criteria, syndromic ADHD, that is, meet full criteria was 2.8% and syndromic, and then symptomatic is just having the symptoms. Now, you may not have six of nine symptoms, but you're impaired to a degree that would qualify you for ADHD, and for that it's about 4%.

4.2. So split the difference, let's make it 3%. They also found that at this age, men and women reported similar symptoms of ADHD symptoms. And actually there wasn't really a difference between those who had inattention and those who had hyper active, impulsive symptoms. So males and females had the same constellation of symptoms.

Sadly, though, this is a study now ten years old, but it does convey a particular point. This is looking at memory clinics in the United States. One out of five clinics reported seeing patients with ADHD, but they weren't making the diagnosis, they weren't making the diagnosis. And so ADHD symptoms, that is, the cognitive symptoms, were not being considered as a pre morbid baseline to cognitive function. What does that mean?

You come in complaining of cognitive difficulties in memory clinics and they don't even consider ADHD as a possibility. That's problematic. That's why I'm giving this presentation today. In March, just a few weeks ago, I was at the American association of Geriatric Psychiatrists and gave a presentation in the same topic, which is important for geriatric psychiatrists to consider when they're evaluating people with cognitive difficulties. So conceptually, whether you're a provider or whether you're a patient.

It's important to understand two concepts. One is differential diagnosis. That is, when you present to a clinician and complain about different symptoms, that clinician is going to ask you a series of questions, and then in their head they're going to consider what are the possible explanations? Is it depression? Is it anxiety?

Did you have a stroke? Did you have a heart attack? Are you on medications? Did you have repetitive head trauma? What are the possibilities that I have to consider?

And it's not often binary. It's not that you have ADHd or you have anxiety, you have ADHD or you have depression. It may be that you have both. That goes then to the next concept, coexisting disorders. It's not you have ADHd or depression.

You may actually have adhd and depression, and the depression is worsening your cognitive symptoms. Then we go on to deciding which disorder gets treated 1st, second and third, and we can talk about that as I move through this program. So keep that in mind. Now, the medical symptoms have to be considered and medical diagnoses have to be considered. So this is a long list, but not inclusive of everything to think about.

These are general possibilities. And so the first is psychiatric disorders that can cause cognitive symptoms. We talked about mild cognitive impairment. I'll say a little bit more about that in a moment, but perimenopausal. So if some woman comes to me at age 52 and is complaining about cognitive difficulties that have worsened over the last couple of years, she may have cognitive changes related to perimenopause.

However, the same woman may also have ADHD. But if you don't go looking for the ADHD in the history, you'll simply of conclude this is perimenopausal cognitive changes and not diagnose ADHD. Also, dementias are important to consider. There are several Alzheimer's, I'll mention in a moment, frontotemporal Lewy body dementia, which is what Robin Williams suffered with. And then we have vascular, often dementias.

The most common dementias are a combination of Alzheimer's and vascular Parkinson's disease. Most people think about Parkinson's disease as a tremor in the hands. But in Parkinson's disease you can have deterioration in areas of the brain that cause people to have depression and cognitive changes. Even before the tremor develops. You have toxic metabolic, inflammatory and tumor processes.

Infections, especially in older adults who develop bladder infections or urinary tract infections that can actually cause people to be confused. They have memory problems and they appear to be in a somewhat delirious state, you can have encephalopathy. So these are damages to the brain, increased polypharmacy. So if you're on six medications, two of those may complicate your. Your cognitive ability, and the clinician needs to sort that out and then sleep.

Apnea is an issue often not diagnosed, usually later in life. Perhaps it's been diagnosed, but I always go looking for it. This is the person who snores, grunts, has periods of time when they're not breathing, and then has a snort to capture their breath, and in the morning, they just don't feel rested, even though they were asleep in their mind for the whole period of. Of time. I time mentioned perimenopause, and I want to mention some aspects about this because there's a lot of misinformation by well intended people, but the research doesn't support much of what is being advocated.

So some people, some women have a syndrome of cognitive difficulties emerging in midlife that resemble cognitive impairments that are reported with ADHD. That is, distractibility, inattention, forgetfulness, misplacing things as you go through perimenopause and into menopause, there's a decline in estrogen. Estrogen is actually pro cognitive. If you have estrogen, you're thinking well, and if you have less estrogen, you're probably not thinking quite as well. Estrogen receptors are actually present in several places of the brain, but particularly of interest, they're in the prefrontal cortex.

The front part of your brain has estrogen receptors. The rest of the brain, the cortex, does not think about the prefrontal cortex in regards to memory, organization, and executive function. Despite what people are saying, there are no studies that have investigated the hormonal fluctuations due to menopause or the effects of hormone replacement therapy in women with ADHD at older ages, there are no studies. MCI, mild cognitive impairment. The definition here is memory complaints, preferably corroborated by an informant.

So a spouse, a partner, someone you're living with, someone you're working with, may notice objective memory impairment, but normal general cognitive functioning, intact daily living functioning. So there's no immediate impairment in what you're doing, and clearly, they don't have dementia. What is the prevalence rate, then, of MCI in the general population? So you'll see this broken out by ages 60 to 64 is about 7%, 65 to 69, about 8%. And as you get older, the prevalence increases.

If you have MCI, what is the likelihood of going on to develop dementia? It's about 40%. So just because you have MCI doesn't mean you're going to develop dementia, but having MCI is a risk factor for going on to develop dementia.

Clinicians will say, look, this is all very good, it's all very complicated. I'm not really trained for this. I'm sending my person for some neuropsychological testing and I'll let the psychologist sort out what the deficits are and then tell me what they think the diagnosis is. Sounds reasonable, sounds like it should work and in fact it doesn't. Psychological tests are not a basis to make an accurate diagnosis.

And the reason this is said is because neuropsychological testing will show you what the cognitive deficits are, but they don't tell you why the cognitive deficits exist. Neuropsychological test is also not a criteria to make a diagnosis of ADHD. Now these statements here are not my editorial opinion. These statements have been made in some international guidelines for the diagnosis of ADHD in adults. So what's most important though are symptom rating scales by patients or executive function rating scales.

And that has to do with working memory, time management, organization, task shifting. Those patient self ratings actually correlate much better with daily function and quality of life than the neuropsychological tests. The reason neuropsychological tests are problematic in interpreting is because neuropsychological tests are done in what we say is a cold environment. You sit in a room, there's no distractions, it's very quiet, and your cognitive function is optimal in that set of circumstances. If you were to do those same neuropsychological tests in an environment with distracting noises and movements, you'd find the deficits are actually worse.

That's called ecological validity. That is, what are the deficits as I function in the world around me? Not what are the deficits if I sit in a quiet room without distractions? That's why the test results don't correlate very well with daily functioning.

So lets talk about childhood diagnosis versus an adult diagnosis. The first thing to know is that if you receive a diagnosis of ADHD as an adult, its not based on the fact that you had ADHD diagnosed as a child. The large epidemiologic study done in the United States, done many years ago, published in 2006, looked at general population ages 18 to 44, and what they found was that 75% of the adults that would fulfill criteria for ADHD were never diagnosed as children. Let me say that again, 75% of adults who would fulfill criteria for ADHD were never diagnosed as children. So I tell myself, clinicians, that making a diagnosis of ADHD in adults is not predicated on having been diagnosed as a child.

It's predicated on having symptoms as a child. In this study, this is out of an Alzheimer's disease center. We're not even looking at ADHD populations. We looked at 310 respondents, 62 to 90. They used a wender Utah rating scale for their ADHD symptoms for childhood assessment, and they decided about 4.4 had childhood ADHD.

They then did neuropsychological tests on this group of patients. They found that if you scored positive for childhood symptoms or whether you scored negative for childhood symptoms, the neuropsychological tests couldn't differentiate either group. This is very consistent with the findings of cognitive tests for younger adults that they do not reliably distinguish ADHD cases. I make this point because it's very expensive to get neuropsychological testing. It can cost three to $5,000.

And the question is, are you getting out of it what you need in order to determine what the diagnosis is?

What about older adults with ADHD and other psychiatric conditions? In the dutch study, they looked at a sample, mean age 71, and found that ADHD patients had more depressive symptoms and more anxiety symptoms than the same aged matched participants without ADHD. There's a Norway study that looked at older patients. 47% had another psychiatric condition, and that is a third had depression. A quarter had anxiety and a quarter had bipolar disorder.

There's a very small study in the United States, again showing very similar findings of depression, anxiety, and bipolar. The reason we highlight this is because often up to 80% of adults with ADHD will have another psychiatric disorder. So you have to take that into account when you're both deciding what disorders account for the cognitive difficulties and then in what sequence you treat the psychiatric disorders. Again, in older adults, as you would understand, 75% have ongoing medications for medical illnesses. When you're using several medications and adding new medicines, the clinician has to consider drug drug interactions that may occur and compound potential side effects.

So typically we start with lower doses and move more judiciously in dosing patients upward. So what are the treatment options here? When I see my patients, I segment them into four groups and I'll explain why. There are those who were diagnosed and treated as children. They dropped out of treatment, usually late adolescents and early twenties, and now they're coming back because their symptoms are problematic, their environmental demands are exceeding their ability to compensate, and or a family member said, you know what?

Let's just get this treated, because I'm tired of dealing with you, forgetting things and misplacing things and running through stop signs. There's those who are diagnosed and treated for many years without interruption, and they understand what ADHD is. They've been in treatment, they've talked to clinicians, they've presumably been on medication all this time. It's an ongoing continuation of their treatment. There are those who were diagnosed and treated for anxiety and depression, and the ADHD diagnosis was missed.

And as a result, the patients create this psychological narrative to explain their challenges based on anxiety and depression. When the ADHD is accurately diagnosed and effectively treated, the symptoms of ADHD reduce. They understand that many of the symptoms they had were from their ADHD, not from the anxiety and depression. And we have to rework the psychological narrative in psychotherapy so that they understand how ADHD has been affecting them over the course of their lives. And the last group are the newly diagnosed at an older age.

Just earlier this week, I had a 78 year old female physician come to see me. She'd been in therapy for years. She was having cognitive difficulty. It had not been addressed or diagnosed because she's a very high functioning woman with an iq of 135, which puts her at the top 1% of the general population. But we had to go through an educational discussion about what ADHD is and how it has affected her life.

Each of these segmented populations, for me, requires a different educational approach. What about medications? This is a study out of Europe, 150 older adults. They weren't diagnosed until they were in their early fifties.

64% were on ADHD medication. A quarter had stopped their ADHD medication. A quarter had never received ADHD medication, 35% were in psychotherapy. And these don't add up to 100% because there's an overlap. You can be in two categories simultaneously.

What was prescribed, 82% got a methylphenidate preparation. Well, why is that? That's because it's a european study. 80% to 90% of stimulants prescribed are methylphenidate. It's not as though methylphenidate is preferable in older adults, it's that in Europe, methylphenidate is the preferential prescription.

In this population, 10% were on amphetamines and 5% were on non stimulants. Who was writing the prescriptions? Almost 60% of these prescriptions in this study were family docs. Now, that's actually not dissimilar, although higher than the US, where about 45% of all stimulant medications are being written by primary care prescribers, what did they report was the benefit? Well, those who were on medication had better attention, better ability to manage their daily function and demands.

If you were on an extended release, a once a day methylphenidate, you were more likely to stay on the treatment because it's a lot easier to remember taking a pill one a day in the morning than three times over the course of the day. In this study, he noted that ADHD individuals later in life may not respond as well to medications. That has not been my clinical experience over the years of treating patients. I think this is an observation made by this author that really would need replication. What are the medications that you have available to you?

Well, the first thing to know is that older adults are excluded from ADHD studies. So there are no research controlled trials of medications in ADHD over the age of 65. And why is that? They don't allow patients of this age into studies because there's diagnostic uncertainty, both from the patient recall and the absence of collateral informants. Also the possibility of more adverse events with medication, so that they want to minimize that in their research protocols, safety concerns, because they have other medical illnesses that are often excluded when you run trials on younger adults.

Also, drug interactions. You can't enroll patients at age 70 who are on hypertensive medications and cardiac medications and then ADD an ADHD medication. And then it's just difficult to get patients who would fulfill all the exclusion criteria. If you can't be on medication and you can't have medical illnesses, et cetera, it's going to be very hard to find patients who fulfill the criteria. When you look at the age of FDA approval for medications, Lisdex amphetamine, that you know as Vyvanse is only FDA approved up to age 50.

So technically that means if I write for Vyvanse in a 62, I've written the medication off label for mixed amphetamine salts XR, which is Adderall XR or orismethylphenidate, which is concerta, it's up to age 65. This is also true for medication called midaius, which is a triple beaded amphetamine, and for focalinxr, which is a dex methylphenidate. Those are the medications that are approved for adults with ADHD in the stimulant category. But any prescription written over the age of 65 is considered off label. There really is a lack of systematic study, and it leaves it unclear to what degree the stimulants are helpful or tolerated.

And also there's an underreporting of older adults in regards to drug interactions. These are all the limitations to understanding how to best use these medications. The safety concerns. If I'm prescribing medications, I monitor for conditions that worsen, increase, that would worsen the symptoms. For sympathetic tone, that means.

So hypertension, arrhythmias, urinary problems, narrow angle glaucoma, and Raynaud's. Raynaud's is a vasculopathy. It's when your hands turn white or they turn purple because of capillary constriction or dilatation. The thing that's most clinically relevant, though, is people who are taking over the counter stimulants. So caffeine, pseudoephedrine, over the counter appetite suppressants, which also often have herbs and supplements, that we don't really understand how they interact with stimulant medications.

So all of these factors on top of stimulant medications can increase heart rate and blood pressure. So we're just mindful of this. It's not atypical for me to see a patient who is drinking six cups of coffee, has ADHD never diagnosed, and then we put them on medication and they can gradually taper off the caffeine because the caffeine was actually self medication for their ADHD. Last but not least, the fear factor. The fear factor here is there is a growing body of literature that looks at ADHD and its relationship to neurodegeneration.

The question is, does ADHD cause and lead to neurodegeneration? Does the medication you're prescribing for ADHD lead to neurodegeneration? Is it a combination of both disease and medication, or are there other factors that haven't been enumerated that account for this association? But it is association that we're seeing, and it is scaring patients with ADHD. Let me walk through a little bit on this, and then we'll go to questions and answers.

There's a critical appraisal of eight published studies. These studies looked at an increased risk later in life for new degeneration. There's a particular association with Lewy body dementia at up to five fold higher risk. That's a serious consideration that we need more research to verify. In a 17 year follow up study of over 100,000 adults on the risk of ADHD and dementia, the risk was 2.77 fold higher, even when you adjusted for increased risk factors like obesity and diabetes.

So this is the preliminary research. Now, the other thing I mentioned was, well, maybe if you're on medications for 20 years that's causing the dementia. And actually that's not the case. So you see in this small little graph here, those who were exposed to stimulants had much less risk of dementia. The more you move to the right, the greater the risk.

So the first line of stimulant unexposed in ADHD shows a higher risk. So bottom line here is the medications being prescribed for ADHD are not causing the risk for dementia. So what did you learn? Hopefully it really is important to screen for ADHD when people present with cognitive complaints, even in older adults. Older adults who have cognitive complaints should not be easily discounted as having age related cognitive decline and dismissed.

Really assess for ADHD, because every once in a while you'll find somebody who has you go ahead and treat them and you'll look like a genius. Besides the fact that the patient is appreciative and the family is appreciative, you really do need to look for medical etiologies for cognitive implants. But the medical etiologies often occur in adulthood. These are not symptoms that started as a child. Like ADHD.

Coexisting illnesses compound cognitive symptoms, so you have to sort out which disorders are contributing to the cognitive symptoms. Impairments persist in older adults. This idea that older adults have nothing to do but sit on a rocking chair is antiquated and not true any longer. As I mentioned, my 78 year old physician still seeing patients in a three quarters time capacity. She's doing a great job.

So ADHD treatments, even for older adults, are very effective. They improve cognition, they improve daily function, they improve self confidence, they improve mood. So whether you're 50, 60, 70, 80, it really is never too late to treat. And with that, we're going to go to Q and A. Thank you for your attention and your time.

Carol Fleck

Thank you so much. Doctor Goodman. Before we start the Q and A, I'd like to thank play attention once more for sponsoring this webinar. I'd also like to share the results from today's poll question. For those of you with ADHD who were diagnosed at older ages, what was your biggest barrier to getting an accurate diagnosis and effective treatment?

Here's what you said. 30% said lack of awareness among providers, 20% said limited access to specialized ADHD care, 23% said underestimation or dismissal of symptoms, 9% said stigma around ADHD, and 12% said something else. Now to your questions. How do you evaluate an older adult for ADHD? And how is this similar or different to younger adults?

David Goodman

The evaluation for older adults has to take into consideration the medical issues, I think that's paramount. A comprehensive psychiatric evaluation, regardless of age, includes not only the presenting symptoms. That is, you complain about anxiety, depression, cognitive difficulties. And after the clinician inquires about that, then they really ought to go through a lot of the other major psychiatric conditions. So you get questions about history of major depressive episodes, history of mania, suggesting bipolar disorder, history of social anxiety, generalized anxiety, ritualistic behavior.

That would be obsessive compulsive disorder, panic symptoms, eating disorder. There is a high association between ADHD and eating disorders. Even though we know that there's a high association of obesity to ADHD, there's a higher association with eating disorders. The point here is that a comprehensive psychiatric evaluation goes beyond the presenting symptoms. Now, in addition to that, then you have to look at medical aspects.

You inquire about the current medical symptoms, but you also inquire about rule outs. Have you ever had a heart attack, cardiac surgery, stroke, seizure, repetitive concussive injuries, combat experience where you may have had traumatic brain injury from repetitive explosions? I'm looking for medical issues that might contribute to cognitive symptoms, and then I want to know what medications you're on so that if I consider prescribing medications, I have an idea of what the potential side effects might be from the drug interactions. I'm also looking for family psychiatric history. We know that ADHD is highly genetic.

75 80% of the cause is genetic. So you didn't wake up one morning at age six and say, I think I'll have ADHD for the rest of my life, and it didn't happen because you fell off your bed when you were sleeping. It's highly genetic. You didn't decide to have ADHD. It's simply the crapshoots of genetics and God.

It's important to understand it's what you have, it's not who you are. And that issue is a theme throughout ADHD treatment. It's especially true for those who were diagnosed later in life and had never considered that they had ADHD, but they always knew there was something wrong. There's a tremendous relief to get a diagnosis and get treatment and understand there's a difference between what you have and who you are. I hope that answers that question as comprehensively as possible.

It takes me about 90 minutes to go through an evaluation. There are also some ADHD symptom checklists that I use both for childhood recollection of symptoms and the presentation in adulthood. Let me just mention, and I'm sorry, I speak in paragraphs when I administer the self checklist for adult ADHD. If you're 75 years old, I'm going to ask you to fill this out based on how you were in your forties, because if you fill it out based on how you are now, I won't be able to separate out age related issues, perimenopausal issues, medical issues, all of which contribute to your ADHD or your cognitive symptoms. I want to know if you had those cognitive symptoms in your forties and if you had them in your forties, then it's a continuation of those symptoms.

If you didn't have them in your forties and these are symptoms that just started in the last months or last few years, then you don't have ADHD. You have something else that I have to consider, and the last element of this was I mentioned the family psychiatric history. If you have a first degree family member with ADHD and you're presenting with very similar symptoms, that increases the accuracy of making the diagnosis. So I'll stop there. Carol, you have another question.

Carol Fleck

Well, it's interesting because the next question was, can ADHD symptoms become more apparent as we age into our seventies and beyond? So you sort of touched on that. Yeah, let me elaborate on that, too. So patients get diagnosed because of impairments. I mentioned the boys often get diagnosed because their disruptive behavior is a pain in the butt to other people.

David Goodman

As you get older, your ADHD symptoms and the impairments they cause become a pain in the butt to you or to people you live with. But they're not complaining that you're disruptive. They're complaining that you're tardy, inconsistent, can't remember, and can't follow through. As you get older, you're going to have several processes that contribute to cognitive difficulty, of which ADHD is only one. So is ADHD getting worse?

Probably not. The experience of ADHD worsens, waxes, and wanes, depending on the demand in the environment. So if you have ADHD and you're an accountant and you work for a top five, a top 500 Forbes company, you're 50, probably going to have a lot of impairments that you experience and. But if I take the same person and say, now you're going to sell hot dogs on a caribbean beach, probably not going to be an issue. As you get older, the ability to handle the cognitive demands of explanation of benefit statements from your medical insurer and medicare explanations and bills and paperwork become more and more challenging.

You realize that with the cognitive demand, you're not able to keep up. Part of that has to do with other processes that are affecting your cognition beyond ADHD. But it's not that ADHD is getting worse.

Carol Fleck

Okay, that's an important distinction. We've had a few questions around medication, so I'll just go ahead and ask, might I need to change my ADHD meds or dosages as I age?

David Goodman

So the reasons to make a change in dosing over the age of 50 would probably be a side effect issue or a medical issue. So if you find that you're developing side effects that are problematic, one of which is dry mouth. For older adults, dry mouth is problematic because if you wear dentures or dental appliances, they won't stick as well without the saliva as a glue, if you will. Also, chronic dry mouth causes recession of gums and increases the possibility of cavities. I'm very mindful when I speak to my older adults about stimulant medications.

Do they have dry mouth? Is the dentist saying that that's an issue? Other side effects develop as you get older. So for males, for example, if you have benign prostatic hypertrophy and you're having difficulty urinating, the urinary hesitancy can be worsened by a stimulant medication, and you may have to change the dose of the medication or the preparation of the medication. Remember, there's over 30 different preparations of stimulant medications, and then we have two non stimulant medications that we can use.

The non stimulants haven't been studied in older adults any more than the stimulant medications have been, so we just don't have any research support for their use. Other reasons to adjust medication might be that the environmental demands are less and that you don't feel as though you need the umph from that dose of medication. Another reason might be that the appetite suppression from the stimulant medication might now become problematic as you age because the general appetite diminishes as you age. And so if you're losing weight unnecessarily, that might be another reason. So off the top of my head, those might be the reasons to change.

Another reason might be if a tolerance has developed, and that is you've been on medication for years and it's no longer serving its purpose, you've increased the dose, but it can't recapture the benefit, you might think about changing to an alternative to recapture the effect of the medication. Another question is, are stimulants versus non stimulants? Which is better for older adults in your experience? Well, that's a good question because there's no way I can answer the question. There's no research on non stimulants over the age of 65.

None. So I can't comment as to whether it works, whether it doesn't work, at what dose or what side effects. It becomes a clinical decision on the part of provider whether or not they want to try using a non stimulant. Because perhaps the stimulant medication in someone who's developed hypertension is now exacerbating the ability to treat the hypertension. So you might think about going to a non stimulant.

Having said that, though, non stimulants also cause increase in blood pressure and pulse, but it's variable from one patient to another. It just depends on the clinical presentation and the experience of the clinician prescribing. But I can't recommend one over the other. We certainly have more information on stimulants in older adults, not for ADHD. But stimulants have been around for decades and they've been used in dementia for apathy and emotivation.

They've been used in medical patients who again, become depressed and are not participating in treatment. So that's the extent of the literature. I've used these medications in a broad range of ages of patients. But if you ask me to give you opinion based on research, there's really not much there. Wow.

Carol Fleck

Someone asked, can stimulate medication be safely prescribed for patients with heart conditions?

David Goodman

The short answer to that is yes. The complicated answer to that is, it depends on the nature of your cardiac condition. If you've had a heart attack and you're outside the heart attack, six months probably, it's relatively safe. If you have atrial fibrillation and I have prescribed. In patients with atrial fibrillation, you have to be very careful the stimulant medication doesn't worsen the AFIB.

Often when I have patients who have significant cardiac issues, I'm going to talk to their cardiologist. Anybody who has cardiac issues over the age of 50 probably has a cardiologist, and I'm going to talk to them in Baltimore. My experience with cardiologists have been, thank you for calling. I never get a call from a psychiatrist, and then they say, it sounds like you're knowledgeable. Here's what I want you to check for, and if there are any symptoms, stop the medication and refer the patient to me.

If you've had a stent surgery, you should be able to be on stimulant medications. I've had patients on with multiple stents on medications. If you have hypertension, hopefully that hypertension is treated and controlled. And if you add a stimulant medication, you monitor your blood pressure and pulse at home. And if there's elevations, you talk to the primary care doc or the cardiologist.

So the bottom line here is, and by the way, there are now umpteen articles reviewing all of this. That is stimulant medications in cardiac patients, stimulant medications in older adults. And the bottom line to all of that is, look, it is relatively safe. And so cardiac illness should not be the absolute contraindication to prescribing the stimuli medication, because the quality of life of untreated ADHD is significant. And if you can get a benefit and moderate the risk, then why not go ahead and treat?

Carol Fleck

Someone asked, does ADHD medication boost short term memory and help with emotional regulation? So if you have ADHD, all ADHD medications, whether they're stimulants or non stimulants, will improve memory, attention, focus, sustained attention, motivation, initiative and impulsivity and emotional regulation. This has been looked at very specifically, and the ADHD medications in the context of ADHD will actually improve emotional reactivity. Now, if you think of the brain as always having the accelerator on, that means that you're racing along, you're not paying attention, you're verbally impulsive, and you're emotionally reactive. Medication essentially serves to put a brake on the system, and as a result, thoughts are more focused and linear impulses are better controlled.

David Goodman

Emotional reactivity is diminished. And so you see that. Now, what's curious is, and it's hotly debated, whether emotional dysregulation should be included as a symptom criteria in ADHD. This has been debated. The last revision of the Diagnostic and statistical manual, five did not include that, the DSM six, which is likely to come out in two to three years, I'm quite sure that that's going to be actively debated.

It wouldn't surprise me if emotional dysregulation becomes a diagnostic criteria for ADHD in the future, but it is not yet. I have to tell you that whenever we do surveys, emotional dysregulation is like the number one most impairing symptom for many, many people with ADHD. You know, that's a good point, because most people will associate ADHD with performance issues. That is, my cognition is impaired and I can't do things as well. What they don't think about is ADHD in regards to the impulsivity and emotional reactivity that has a very negative impact on social relationships, both at work and at home.

And it doesn't surprise me at all that adults say, you know, of the symptoms I have. What causes me the greatest degree of distress in my life is how I interact with others and the difficulties I have and the level of intensity and disproportionality of my emotional reactions, which I know I shouldn't be, but I just can't control it. Yeah. Someone writes, how can we talk to our doctors who refuse to take our ADHD seriously or prescribe stimulants because of our age? I'm so tired of these outdated beliefs that prevent me from receiving effective treatment.

Good for you, and I wish you good luck. I'm sorry I say that tongue in cheek. I teach my residents. I say it's easier to educate the uninformed than it is the misinformed. If you have a doctor that you genuinely try to have this conversation with and they're reluctant, and you bring in some research, some quality research, go to pubmed dot Gov.

Pub dot as in publication med as in medical med, pubmed dot gov comma, and you can pull up your research abstracts and bring them in. At some point, either the clinician is going to say, look, I'm not comfortable doing this, and at that point, don't push them and say, can I go seek a second opinion from an ADHD expert? And would you respond to them? See if they'll respond to new information if they're absolutely not going to do it. I never prescribe these medications to somebody your age.

I'm not going to prescribe it to somebody who has your medical illnesses. It may be time to find a new physician. Okay. My mother is 66 and it's pretty clear she has ADHD but won't seek a diagnosis, how can I talk to her about this? What should I say to start the conversation.

At that age? It's a challenge. If you have somebody in a first degree family member, like, let's say this is an adult daughter who got diagnosed and then looks at mom and says, wow, you've always been this way. You might have the conversation by explaining, this is my experience. Does that resonate with you?

So you bridge this gap by having a common experience. But even if she admits to having a common experience, she grew up in an age where ADHD really wasn't a topic of conversation. And she'll say, look, I live this long without getting treated. What's the purpose? And then you say, look, if there was a way that your memory, your function, your forgetfulness was better, would you want to take the opportunity to see if that would get better?

If you phrase it that way, people more often than not will say, sure, I would do that. Then you start with a common goal, and then you say, okay, if that is a goal of yours, can I get you to see this person who's an expert in this and see what they have to say? So you always start with a common goal in negotiating, and then you walk through a baby step each way to get them to do that. Now, if you believe they have ADHD and they don't want to seek treatment, you can alter your perspective, though. You can say, okay, I'm dealing with my mom who has ADHD.

She's not going to be able to remember. So in the way I communicate, information needs to be in a written form so she can reference it. And so start working with this person as if they have ADHD and adjust the way in which you communicate with them that facilitates more productive interactions with them. Don't expect them to remember things. Expect them to show up 10, 15, 30 minutes late.

Don't say, mom, why can't you do this? Simply understand that they have this disorder. It causes impairment and disability. You wouldn't yell at a blind person for walking into the furniture. Why do you yell at an untreated ADHD person for showing up 20 minutes late?

Carol Fleck

We get a lot of questions, as you might imagine, around menopause, so many people say that going through menopause has made their ADHD symptoms much worse. The questions are, how can we manage this better? This is a very interesting question.

David Goodman

Let me organize my thoughts here first. As I said, there are no research controlled trials on perimenopause, menopause, ADHD hormonal associations, or the use of ADHD medication. So when I do my evaluation, 52 year old woman comes in and says, look, my concentration, my attention are clearly worse over the last few years. We talk about when their last period was. Has it stopped entirely?

Is it irregular? Are these symptoms worse in the last few years? Yes. Let's talk about how you were ten years ago. And they say, well, I've always had ADhD.

I got diagnosed as a kid. I never went on medication. I tried medicine several years ago. It was helpful, but I couldn't get the prescription filled, and then I just stopped taking it. And here we are.

The question is then, is this ADHD, or is it perimenopause? And again, in my presentation, I said, it's not a binary choice. It can be both. Then the question is, let's assume it's both. You have ADHD compounded by perimenopause.

What is the treatment? Do we increase your ADHD medication or do we put you on hormone replacement therapy for three months and see what improves? Now, in doing that, you have to talk to the gyn who may or may not be inclined to do that. That goes back to the previous question. What do I do with my doctor who's not receptive to listening to me talk about ADHD?

You have to talk to your gyn and see whether or not they'd be willing to do a three month trial of hormone replacement therapy. Now, hormone replacement therapy is more effective on the mood and cognition symptoms during perimenopause. It is not particularly useful in postmenopause. So there's a window of opportunity in which hormone replacement can be helpful. Now, let's say you go on hormone replacement, the symptoms get worse.

You still have your adhd, though. So you treat your adhd, you stay on hormone replacement for a period of time, and that becomes diagnostic. The gyn says, look, I did it for three months. That's what you asked. I'm not doing it any longer.

And at that point, then you come back to someone like me who says, okay, well, we know that there's a hormonal influence. Let's see if we can overcome that hormonal influence by increasing the ADHD medication. Now, everything I've just said has no research documentation in ADHD. Perimenopausal women. This is simply my clinical experience over the last 20 some odd years of watching my patients age and seeing older and older adults.

But that's generally how I'm trying to figure this out. The other doing element of this, though, is if you're in perimenopause and you clearly have heightened anxiety or a major depressive episode, those elements also have to be treated because they can contribute to soft cognitive symptoms as well. I hope that's clear, but it really is quite challenging. What's really clear is how we are well past time for research in women and adults with ADHD. Unfortunately, that has to be our last question because we're out of time.

Carol Fleck

But Doctor Goodman, thank you so much for joining us today and for sharing your expertise with our ADHD community. You're welcome, Carol, thanks for inviting me. I really enjoyed it. We appreciate you and thanks to today's listeners. If you would like to access the event resources, visit attitudemag.com and search podcast 499.

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499- ADHD in Older Adults: Clinical Guidance and Implications

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1: Introduction and Overview

2: Challenges in Diagnosis

3: Treatment Approaches

4: Impact on Quality of Life

5: Q&A and Closing Thoughts

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