can develop from not treating ADHD, including job loss, suppressed income levels, low educational attainment, and difficulty maintaining relationships. Perhaps as many as have ADHD, which is highly hereditary.
Primary care physicians or family medicine clinicians are often best placed to diagnose, according to experts interviewed for this article. But first these providers need to tease out whether a patient has ADHD or another condition that is causing difficulties for these older adults.
However, clinicians may have a hard time discerning the symptoms of ADHD from that of other conditions of aging, such as. Literature is lacking on best practices for screening and treating the condition in this population, according to a published in the Expert Review of Neurotherapeutics, and a by the same authors, epidemiologists, and psychiatrists based in Europe.
“If you don’t manage it, who will? It can be very hard to get psychiatric consults, almost impossible in some cases,” said Brendan Montano, MD, an internist in Cromwell, Conn., who specializes in treating ADHD.
A critical role for primary care and family medicine
Although no formal U.S. guidelines exist on diagnosis of, Dr. Montano stressed that adults usually present with symptoms such as chronic forgetfulness, distractibility, or procrastination. Hyperactivity is more internalized as a feeling of internal restlessness in this age group, Dr. Montano said, rather than the more visible hyper behavior seen in children.
“The two big ways that people present are thinking they have it or [being] in chaos of some sort,” perhaps because they have been fired or their spouse has asked for a divorce, Dr. Montano explained.
To assess the possibility of ADHD, a clinician could give a patientthat asks questions such as how often over the previous 6 months have they had trouble completing assignments or remembering appointments. If they report difficulty in four or more of the six areas in the brief screener, clinicians can move on to a longer developed by the World Health Organization, Dr. Montano said.
To make an ADHD, however, a patient needs to report sustained difficulties in at least two aspects of life: work, home, or social situations. And they have to indicate to a clinician that these troubles began before age 12.
“You have to really sit down and paint the picture with the patient: There are no shortcuts here,” said Lenard Adler, MD, a psychiatrist who directs the Adult ADHD program at New York University. Dr. Adler helped develop the six-item screener and is currently on a committee developingin the United States.
He said that often, “ADHD cotravels with other mental health disorders like, bipolar disorders, , and substance use disorders at least half the time.”
To tease out if a patient really has ADHD, clinicians can start with a more general screening for anxiety and hone in on the possibility of the condition if the anxiety screening reveals challenges with distractibility and forgetfulness, according to Karen Smith, MD, a family physician in Raeford, N.C.
“We can’t expect patients to walk through the door with the diagnosis stamped on their foreheads,” said Dr. Smith, who is a member of the board of directors for the American Academy of Family Physicians.
But a patient’s apparent signs of ADHD could be due to another condition such asor diabetes, Dr. Smith said. The driving principle is to take enough time to figure out exactly what is going on, she said, and then to treat accordingly. “If you ask the right questions, patients will give you good answers.”
Medications areto help manage ADHD symptoms. These can include stimulants, controlled substances that include or , or nonstimulants, such as and . Dr. Montano starts his patients on a lower dose and titrates them up rapidly until they reach the optimum dose that allows them to sustain focus and feel more productive. Patients complete frequent self-reports during this process.
“Any diversion is inappropriate,” said Dr. Montano, who writes a contract with his patients saying thatmedications will not be refilled if they are used more quickly than prescribed.
For older adults, physicians should make sure that stimulants do not exacerbate any underlying cardiovascular conditions, Dr. Montano said, and consult a cardiologist when needed.
The benefits of proper ADHD treatment can be profound, Dr. Adler noted, no matter when it begins.
“Older adults have lived their lives feeling they’ve been disorganized and a burden to their significant others, and only when they’ve taken medication have they really been able to organize their days and feel effective in their social interactions and with their families,” Dr. Adler said.
Dr. Montano has reported relationships with AbbVie, Axsome, Corium, Idorsia, Intracellular, Otsuka, Supernus,/Biogen, Biohaven, Boehringer Ingelheim, Cassava, Eli Lilly, Intracellular, Janssen, Jazz, Sage, Supernus, Otsuka, and Tonix. Dr. Adler has reported relationships with Shire/Takeda Pharmaceuticals, National Football League, Major League Baseball, Corium, Otsuka, Neurocentria, Bracket/Signant, and SUNY; and is receiving royalty payments for developing adult ADHD assessments. Dr. Smith has reported no relevant financial relationships.
A version of this article appeared on.