ADHD in Older Adults
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
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
Failure to Recognize Symptoms
Stigmas and Myths
Core Features of ADHD
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;
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
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.
— 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.
2. Kessler RC, Adler LA, Barkley R, et al. Patterns and predictors of attention-deficit/hyperactivity disorder persistence into adulthood: results from the national comorbidity survey replication. Biol Psychiatry. 2005;57(11):1442-1451.
3. 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(4):716-723.
4. Castle L, Aubert RE, Verbrugge RR, Khalid M, Epstein RS. Trends in medication treatment for ADHD. J Atten Disord. 2007;10(4):335-342.
5. Piñeiro-Dieguez B, Balanzá-Martínez V, García-García P, Soler-López B, CAT Study Group. Psychiatric comorbidity at the time of diagnosis in adults with ADHD: the CAT study. J Atten Disord. 2016;20(12):1066-1075.
6. Rüfenacht E, Euler S, Prada P, et al. Emotion dysregulation in adults suffering from attention deficit hyperactivity disorder (ADHD), a comparison with borderline personality disorder (BPD). Borderline Personal Disord Emot Dysregul. 2019;6:11.
7. Kooij JJS, Bijlenga D, Salerno L, et al. Updated European Consensus Statement on diagnosis and treatment of adult ADHD. European Psychiatry. 2019;56:14-34.
8. Dobson W. Rejection sensitive dysphoria: new insights into rejection sensitive dysphoria. ADDitude website. https://www.additudemag.com/rejection-sensitive-dysphoria-adhd-emotional-dysregulation/. Updated August 24, 2021.
9. General information about ADHD treatment at CAPS. Purdue University Counseling & Psychological Services website. https://www.purdue.edu/caps/services/psychiatric_services/MedicationManagementofADHD.html
10. Elia J, Ambrosini PJ, Rapoport JL. Treatment of attention-deficit-hyperactivity disorder. N Engl J Med. 1999;340(10):780-788.
11. Clark M. Five ways to improve emotional regulation. Next Step 4 ADHD website. https://www.nextstep4adhd.com/five-ways-to-improve-emotional-regulation/#:~:text=Shaw%20