ADHD in Adults--An Overview

By Nancy Gadol
Reviewed by Nicole Foubister, MD, Assistant Clinical Professor of Child & Adolescent Psychiatry and Psychiatry, New York University School of Medicine

Take Note

• Attention deficit hyperactivity disorder (ADHD), previously thought to be a childhood disorder, is now viewed as a neuropsychiatric disorder that develops in childhood and persists into adulthood, negatively affecting quality of life by impairing professional, economic, social and emotional well-being.
• Diagnosis in adults should include past and current symptoms and control for comorbid mood disorders and their effect on symptom-cognition relationships.

Attention deficit hyperactivity disorder (ADHD) can be a tough diagnosis in patients of any age. Its symptoms are often similar to those of several other conditions, including anxiety or other mood disorders.1 ADHD was previously considered to be a childhood disorder, partly because adults were never even asked about symptoms related to the condition. Major US surveys, including the Epidemiologic Catchment Area Study, whose results were published in 1991, and the National Comorbidity Survey of 1994 did not include questions on ADHD symptoms in adults. 2 It is now clear that ADHD can persist into older ages in many patients, affecting functionality in many aspects of life that may lead to interpersonal problems, employment and financial difficulties3 and negatively affecting quality of life by impairing professional, social and emotional well-being. 4
Interest in adult ADHD continues to rise, and an increasing number of adults over age 50 are seeking assessment for the condition for the first time. Most studies on adult ADHD have focused on young adults, and optimal criteria for the diagnosis of ADHD and methods of treatment in older adults have not been systematically researched. However that doesn’t mean that making an accurate diagnosis of ADHD in adults is not worth the time and effort.
"Most adults that I have worked with report a great sense of relief at finally being diagnosed with ADHD. Understanding ADHD has helped my patients put into context decades of frustration with themselves and often with their place in the world,” says Joanna Bornstein, MD, a psychiatrist in private practice in San Francisco who specializes in the diagnosis and treatment of adults with ADHD.
“With treatment, many not only report an improved ability to focus and complete tasks, but, more notably, report a profound shift in their understanding and sense of themselves. For most, this leads to a significant improvement in their quality of life. Refining our tools to identify and treat ADHD in older adults could allow a wider range of patients to find a similar sense of relief, self-understanding and healing,” continues Dr. Bornstein.
Two recent reviews attempt to better define ADHD in older adults by examining studies to date on the prevalence, clinical presentation, diagnosis, and treatment of ADHD in individuals over the age of 50 years. 1,5
Prevalence
Many adults over age 50 who received an ADHD diagnosis as adults were not diagnosed as children, in part because the diagnostic landscape was so different decades ago. Even younger adults may have been overlooked as children, as suggested by findings that 75% of adults in the 18-44-year age range with ADHD were not diagnosed during childhood. 5
The data available from recent studies assessing individuals in various age ranges have found prevalence rates of ADHD in adults ranging from 1% to 6.2%.1 A Dutch study of 1,419 participants aged 55 to 85 years showed that adults 60 to 70 years old reported more ADHD symptoms (4.0%) than adults 71 to 94 years old (1.1%), using the Diagnostic Interview ADHD in adults. 6 This decline in prevalence with age was also noted in the Australian Personality and Total Health (PATH) Through Life Project in which older-age adults (68 to 74 years) reported significantly fewer ADHD symptoms than did middle-aged adults (48 to 52 years), as measured by the World Health Organization adult ADHD Self-Report Scale. 3

Clinical presentation and diagnosis

ADHD may present in one of three ways. Affected individuals may have inattentive type, hyperactive and impulsive type or a combination of both types. In addition, ADHD can present differently over development. For example, motor hyperactivity in children with ADHD can appear as an “inner” hyperactivity in adults, with characteristics such as restlessness, inability to relax, or excessive fidgeting and talking. Impulsivity in adults may be expressed as angry outbursts or making decisions without thinking while inattention may appear as disorganization, forgetfulness or inability to plan and complete tasks. 1
There is no specific test required to diagnose ADHD as part of the DSM-V criteria of 2013. Clinicians use the patients’ self-assessment, rating scales, family observations, and medical or school records to determine if diagnostic criteria are fulfilled. Normal aging, dementia and mild cognitive impairment can exhibit the same attention, behavior, memory and executive function deficits as those of ADHD and need to be considered in the differential diagnosis. Comorbid disorders most often associated with adult ADHD include anxiety disorders, mood disorders, antisocial personality disorder, and substance abuse disorders. 1
ADHD is often a chronic and persistent disorder contributing to symptoms in older adults. Pharmacotherapy and psychotherapy should be adjusted to minimize symptoms and maximize and individual’s capacities. Environmental and behavioral supports are also very useful in optimizing function. Longitudinal studies of ADHD adults into older age may clarify optimal criteria for identifying this condition. David W. Goodman, MD, FAPA, Assistant Professor, Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine and the author of one of the reviews covered in this report succinctly explains:
"It is becoming evident that ADHD is a lifelong disorder extending into later adult years. Given the paucity of research, this will be the next clinical frontier for ADHD.”
Originally Published: 02/24/2016
References:

1. Torgersen T, Gjervan B, Lensing MB,Rasmussen K. Optimal management of ADHD in older adults. Neuropsychiatr Dis Treat. 2016;12:79-87.
2. Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: Results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006; 163:716–723.
3. Das D, Cherbuin N, Easteal S, Anstey K J Attention deficit/hyperactivity disorder symptoms and cognitive abilities in the late-life cohort of the PATH through life study. PLoS One, 2014;9: e86552.
4. Brod M, Schmitt E, Goodwin M, Hodgkins P, Niebler G. ADHD burden of illness in older adults: a life course perspective. Qual Life Res. 2012;21:795-799.
5. Goodman DW, Mitchell S, Rhodewalt L., Surman CB. . Clinical presentation, diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD) in older adults: a review of the evidence and its implications for clinical care. Drugs Aging 2016;33:27-36.
6. Michielsen M, de Kruif JT, Comijs HC, et al. The burden of ADHD in older adults: a qualitative study. J Atten Disord. 2015; pii: 1087054715610001. [Epub ahead of print]