January/February 2022

ADHD in Older Adults
By Mark D. Coggins, PharmD, BCGP, FASCP
Today’s Geriatric Medicine
Vol. 15 No. 1 P. 14

This disorder often goes undiagnosed — don’t overlook it in your older patients.

ADHD is a neurological disorder characterized by persistent problems of inattention, hyperactivity, and impulsive behavior that can have a significant impact on an affected person’s life. ADHD symptoms begin in childhood and for many will continue into adolescence and throughout adulthood. The consequences of ADHD and inadequate treatment can lead to damaged relationships, poor work and academic performance, poor self-image, increased accidents, unemployment and financial problems, and other challenges and failures that can touch almost every aspect of one’s life.

For many, receiving a diagnosis of ADHD as an adult generates a number of questions along with simultaneous and conflicting emotions ranging from disbelief to relief to anger. Fortunately, an appropriate diagnosis can also provide insight into the person’s past behaviors and challenges while getting them an opportunity to seek treatments that can help them experience improved functioning, better health-related quality of life, and stronger self-esteem. Health care professionals who work with adults with ADHD—especially those with a recent diagnosis—may have an opportunity to help these persons better understand their disorder and the role of medications and therapy in ensuring appropriate treatment.

Adult ADHD Is Common
ADHD affects 9.4% of American children with clinically significant symptoms persisting into adulthood in about 60% of cases (4.4% of American adults).1

Receiving an ADHD diagnosis, or having the diagnosis excluded, is an important part of managing ADHD. Without an accurate diagnosis, persons with ADHD can go through life not understanding symptoms associated with impulsivity, poor decision making, difficulty concentrating, and emotional challenges that can affect them socially, mentally, and professionally. Unfortunately, despite a high prevalence, ADHD is frequently unrecognized, underdiagnosed, and undertreated, with only 10% to 25% of adults with ADHD diagnosed and adequately treated.2,3

Reasons for Underdiagnoses and Undertreatment
Reasons leading to underdiagnoses and treatment of ADHD are multifaceted and may include inadequate medical training, failures to recognizing symptoms that vary from person to person, and stigmas associated with ADHD.

Inadequate Training
ADHD is often misunderstood by medical professionals, who often receive minimal training about the disorder. One review found that despite seeing a health care professional in the past year, more than 40% of the patients who met the criteria for adult ADHD had not been diagnosed, and that only 10% of adults with ADHD were adequately treated.4 Futhermore, females are at an even greater risk for nondiagnosis than men because women tend to have less obvious or socially disruptive symptoms.

Failure to Recognize Symptoms
ADHD symptoms vary from person to person and can be difficult to recognize. For instance, a young boy with hyperactive symptoms that result in disruptive behaviors is more likely to be recognized as having ADHD, while a young girl with inattentive symptoms such as careless work, trouble staying focused, or lack of organization may go unnoticed.

Hyperfocus
Persons with ADHD have an issue with regulation of attention. But challenges with inattention only tell part of the story; they don’t mean that affected individuals can never pay attention. Persons with ADHD also can be able to hyperfocus, which is often considered a positive attribute by many with ADHD. When hyperfocused, the person with ADHD may be able to demonstrate an intense and deep concentration on a particular subject, task, or activity—sometimes referred to as “getting into the zone.” When hyperfocus is applied to schoolwork, for example, identification of ADHD may be less likely. Hyperfocus can also have significant negative implications, as other important tasks may go uncompleted or the focus may be misapplied to tasks that are not a priority.

Stigmas and Myths
Stigmas based on false beliefs that persons with ADHD are lazy or use the diagnosis as an excuse can prevent adults from seeking a diagnosis just as they may prevent parents from seeking a diagnosis for a child. Similarly, stigma associated with potential substance abuse with stimulants can contribute to undertreatment in individuals who have been diagnosed.

Comorbid Conditions
ADHD is a highly comorbid condition, with about 75% of adults with ADHD having at least one other psychiatric diagnosis including mood disorders, anxiety, personality disorder, substance misuse, depression, social phobias, and PTSD.5 Other conditions such as chronic fatigue syndrome, sleep disorders, and pain are also common. It is not uncommon for these conditions to be diagnosed while ADHD goes missed.

Structured Environment
Adult diagnosis of ADHD requires the existence of childhood symptoms consistent with ADHD or a childhood diagnosis. Children with high intellect may be able to compensate for some of their symptoms, and/or persons with primarily inattentive subtypes of ADHD may have symptoms of ADHD that remain hidden until life becomes less structured and demands increase. For example, an ADHD diagnosis may only come only after the person with ADHD transitions from structured environments such as school into environments with less structure, such as college, or even later in life when challenges balancing multiple responsibilities become unmanageable.

Core Features of ADHD
Most of the attention given to ADHD focuses on the core textbook symptoms, eg, inattention or inability to focus, distractibility, and challenges with executive functioning and memory. These symptoms may be expressed by persons with ADHD as being easily distracted, having trouble getting started on tasks, experiencing feelings of extreme restlessness, being highly disorganized, frequently speaking or acting without thinking, experiencing frequent frustration and forgetfulness, having difficulty managing relationships, and feeling as though no one understands them.

More recently, there’s been increased focus on the deep and intense emotional symptoms experienced by persons with ADHD. Emotional dysregulation refers to the inability to modulate one’s emotional experience and expression and is characterized by extreme responses to emotions. An estimated 34% to 70% of adults with ADHD experience emotional dysregulation. For some, these emotional challenges can be far more detrimental to an individual’s sense of self-worth and well-being than are other core symptoms of ADHD. Emotional symptoms have been associated with poor global functioning, including lower quality of life, interpersonal and professional difficulties, poor prognosis, and severity of attentional and hyperactive-impulsive symptoms in adults and children.6

The importance of recognizing emotional symptoms in ADHD is not new but is frequently overlooked. In the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) diagnostic criteria, emotional symptoms were recognized as an important “associated feature” of ADHD. However, future editions, including DSM-IV and DSM-5, do not include emotional lability as a diagnostic criterion. Despite this omission, a number of experts note that emotional dysregulation is a core defining feature of ADHD as central to the disorder as hyperactivity, impulsivity, and inattention.6 And in 2019, the 10-year update of the Consensus Guidelines on Adult ADHD by European Union redefined adolescent and adult ADHD to include difficulty with emotional regulation as one of only six fundamental features in the ADHD syndrome, including inattention and hyperfocus, impulsivity, hyperactivity, emotional dysregulation, excessive mind wandering, and behavioral self-regulation.7

A significant consequence of emotional dysregulation in ADHD is rejection sensitive dysphoria (RSD). Persons with RSD experience severe physical and emotional pain when they encounter real or perceived rejection, criticism, or teasing. The emotional intensity of RSD has been described by some as having a wound, with a large number of affected persons indicating it to be the most impairing aspect of their ADHD.8

RSD may be exhibited with the following behaviors8:

• sudden short emotional outbursts (that may resolve quickly) following real or perceived criticism or rejection that can sometimes be expressed as anger and rage, as well as suicidal ideation;
• withdrawal from social situations;
• negative self-talk and thoughts of self-harm;
• avoidance of social settings in which they might fail or be criticized;
• low self-esteem and poor self-perception;
• constant harsh and negative self-talk that leads them to become “their own worst enemy”;
• rumination and perseveration; and
• relationship problems, especially feeling constantly attacked and responding defensively.

Treatment
Persons newly diagnosed with ADHD may not always be receptive to treatment for a plethora of reasons; however, the failure to be treated can be detrimental for many. It’s important for health care professionals to be able to explain the pros and cons of medication treatment as well as promote psychological treatments alone or in combination with medications that can improve coping, stress management, and organizational skills as part of an effective treatment plan.

Psychological treatment to improve coping, stress management, and organizational skills is an important part of treatment that can provide long-term benefits for those with ADHD and help address symptoms that may not respond to medication treatment. For this reason, recommended treatment may include medication, individual therapy, ADHD coaching, group therapy, or a combination of these modalities depending upon symptom severity and individual areas of functional difficulty.9

Although medication isn’t a cure, approximately 70% of persons with ADHD will benefit from such treatment, which can help reduce typical symptoms such as inattention, hyperactivity, and impulsivity.10 For most persons with ADHD, stimulants such as methylphenidate (Ritalin) and amphetamine-dextroamphetamine (Adderall) are the preferred treatment options. One of the biggest advantages of stimulants vs nonstimulants is that they often provide rapid and dramatic improvement, and for many, treatment can be life changing. With treatment, a person with ADHD will be better able to be attentive to details in all aspects of their life. Furthermore, appropriate treatment can help persons with ADHD focus and improve confidence and increase motivation to implement positive behavioral changes.

Nonstimulant medications may also be prescribed for ADHD. These generally include ADHD-specific medications (developed and approved for ADHD) such as Strattera, antidepressants including tricyclic antidepressants (eg, amitriptyline, nortriptyline) and other antidepressants (eg, bupropion, venlafaxine), and blood pressure medications such as clonidine (Catapres) and guanfacine (Tenex). Nonstimulant medications are generally not as effective as stimulants and take considerably longer to produce an effect. However, nonstimulants may be appropriate for many, especially those who do not respond sufficiently to stimulants, who experience troubling side effects (eg, weight loss, worsened anxiety in those who have a history of certain heart conditions or drug abuse, and in some persons with bipolar disorder).

Symptoms of RSD do not appear to respond well to stimulants but may be significantly improved with guanfacine and clonidine in some persons.8

Substance Abuse and ADHD
Substance abuse is a major concern for many persons with ADHD who may be considering treatment with stimulants that have the potential for abuse; however, the issue is complex. In general, persons with ADHD will respond very differently to stimulants than will persons without the disorder. Persons with ADHD suffer from reduced levels of neurotransmitters including dopamine. Stimulants are believed to help treat ADHD by normalizing levels of dopamine, which explains why they have a paradoxical calming effect in persons with ADHD. Conversely, in persons without ADHD, stimulants flood the brain with dopamine, causing a dopamine overload. Instead of a calming effect, as seen in persons with ADHD, stimulants used without a medical reason can disrupt brain communication and cause euphoria. While the sensation of euphoria may feel good at first for someone abusing stimulants, repeated use can increase blood pressure, heart rate, and body temperature, decrease appetite and sleep, and cause feelings of hostility and paranoia, while increasing a person’s risk for addiction.

While the risk of abuse from stimulants should be weighed carefully and not minimized, it’s important to recognize that the consequences of not treating ADHD is believed to greatly increase the risk of substance abuse in persons with ADHD. An analysis of health care data on 146 million people with employer-based insurance in the United States over a period of 10 years found that in people who spent periods of time on and off ADHD medications, the chance of them making an emergency department visit due to drug or alcohol use was higher during periods when they were not taking ADHD medications.11

In men managing ADHD with medication, the risk of drug abuse and addiction was 35% lower than in those not taking it. Among women, the risk was 31% lower. Thus, careful diagnosis and compliance with ADHD treatment can prevent much bigger problems.11

Similar findings have been reported from a study conducted in Sweden, with results published in 2014. The study, which used national health registers of 26,249 men and 12,504 women born between 1960 and 1998, found that ADHD medication was not associated with a higher risk of substance abuse. Furthermore, the study found that the longer the duration of compliance with ADHD treatment, the lower the rate of drug abuse and addiction.11

It is possible that stimulants not only help persons with ADHD more effectively cope with their condition but also help prevent adults with ADHD from attempting to control their symptoms by self-medicating with drugs and alcohol, which can lead to drug abuse and addiction.

The Takeaway
The consequences of undertreated ADHD can be devastating to those with the condition, causing disruption to almost every aspect of their lives. Stigmas and misunderstandings about ADHD, held by both health care professionals and laypersons, can contribute to underdiagnoses and undertreatment. By taking steps to help persons with ADHD better understand the benefits of seeking treatment, providers have an opportunity to help persons with ADHD achieve a higher quality of life.

—  Mark D. Coggins, PharmD, BCGP, FASCP, is vice president of pharmacy services and medication management for skilled nursing centers operated by Diversicare in nine states and is a past director on the board of the American Society of Consultant Pharmacists. He was nationally recognized by the Commission for Certification in Geriatric Pharmacy with the 2010 Excellence in Geriatric Pharmacy Practice Award.