Optimal management of ADHD in older adults

Suspected geriatric onset of attention-deficit/hyperactivity disorder in a patient with comorbid bipolar disorder

BACKGROUND

An increasing number of adults over 60 years old are presenting with requests for treatment of attention-deficit/hyperactivity disorder (ADHD). However, the prevalence of ADHD in older adults in geriatrics is unknown. Further, comorbid bipolar disorder and adult ADHD are likely underrecognized with many patients only receiving treatment for one of these conditions. The occurrence of bipolar disorder with geriatric onset ADHD is unknown.

CASE PRESENTATION

A 64-year-old Hispanic woman with a psychiatric history of bipolar I disorder (diagnosed in early adulthood) was diagnosed with ADHD suspected of geriatric onset, and able to be successfully managed on concurrent mood stabilizers and psychostimulant medication.

CONCLUSIONS

The findings of this case report emphasize the importance of appropriately recognizing and treating comorbid ADHD and bipolar disorder in any age group, including the geriatric population for which this occurrence appears to be very rare. Additionally, this case report demonstrates the safe utilization of psychostimulant medications in a geriatric patient with bipolar disorder without inducing a manic episode or other significant adverse reactions.

[Epidemiology, diagnostics and treatment of attention deficit-hyperactivity disorder (ADHD) in advanced age]

Current studies demonstrate a comparably high prevalence of attention deficit-hyperactivity disorder (ADHD) in advanced age. Older people affected by ADHD suffer from a severe burden of psychiatric and somatic comorbidities as well as substantial impairment of social functioning and subjective well-being. The diagnostic differentiation from neurodegenerative diseases is particularly difficult in this age group. This narrative review summarizes the current knowledge about the epidemiology of ADHD in advanced age and possible relationships between ADHD and the risk for neurodegeneration. Furthermore, recommendations for diagnostics and treatment options of ADHD in advanced age are presented.

The diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD) in older adults

INTRODUCTION

There is a striking knowledge gap on ADHD in older adults, and the diagnosis as well as treatment for ADHD in this age group.

AREAS COVERED

The authors first review the literature on the prevalence, functional impairment, and health comorbidities of ADHD across the lifespan. Next, they address the diagnostic criteria for ADHD in adults according to the DSM/ICD, available screening/diagnostic tools, differential diagnosis, and the validity of diagnostic criteria for ADHD in older adults. Finally, the authors focus on empirical evidence on the prevalence rates, medication response, and safety of pharmacological treatment of ADHD in older adults, and national and international clinical guidelines on the treatment of ADHD in this age group.

EXPERT OPINION

It is expected that future editions of the DSM and ICD will provide specifiers to the standard ADHD criteria, to better inform the diagnosis of ADHD in older adults. It is also expected that the increasing number of epidemiological studies will provide rigorous estimates on the prevalence, incidence, and burden of ADHD in older adults. One may expect an increasing number of RCTs assessing the efficacy/effectiveness and tolerability/safety of pharmacological as well as non-pharmacological interventions which will inform future guidelines on ADHD in older adults.

ADHD and associated psychopathology in older adults in a German community sample

Attention deficit hyperactivity disorder (ADHD) is still a neglected disorder in older adults. The aim of the present study was to examine the prevalence and symptomatology of ADHD and associated psychopathology in adults aged 40-80 years in a German community sample. We examined 539 participants in two age groups: (1) 40-59 years old (n = 256) and (2) 60-80 years old (n = 283). To assess ADHD in both childhood and adulthood as well as current psychopathological impairments, we used self-report instruments and corresponding observer reports. We examined group differences between age groups and between ADHD and non-ADHD groups. The prevalence of ADHD in the total sample was 2.6% with no significant differences between the two age groups (40-59 years: 3.1% vs. 60-80 years: 2.1%). Although differences emerged in impulsivity/emotional lability and self-concept problems, overall ADHD symptom ratings did not differ between the age groups. The ADHD group showed more psychopathological peculiarities compared to individuals without ADHD with medium-to-large effect sizes. Self-reports and observer reports showed good concordance in the assessment of ADHD and comorbid psychopathological symptoms. Regarding current ADHD symptomatology, in 92.1%, self-report was corroborated by observer's information. Our findings underline that ADHD symptoms are relevant across the lifespan. Augmenting self-reports with observer reports could increase the assessment quality of ADHD. For successful treatment, clinicians should also focus on additional psychopathological impairments and comorbidities in older adults with ADHD.

Trends in characteristics of the recipients of new prescription stimulants between years 2010 and 2020 in the United States: An observational cohort study

BACKGROUND

Stimulant prescriptions increased by 250% in the United States from 2006-2016 while diagnoses for ADHD minimally increased. There is insufficient data regarding who may be the recipients of these new stimulant prescriptions and safety of stimulants have come under scrutiny in some populations. We aim to describe trends in stimulant prescriptions across biopsychosocial patient level factors between 2010 and 2020.

METHODS

We applied a retrospective observational cohort design utilizing electronic health records from 52 healthcare organizations sourced from the TriNetX research network database in the United States. We assessed new stimulant prescriptions across biopsychosocial variables for recipients of prescriptions. We utilized linear regression to assess longitudinal trends of all participants and also conducted an age stratified logistic regression analysis.

FINDINGS

There was an increase in stimulants to people categorized as white (OR 1.24 CI 1.20-1.28), female (OR 1.28 CI 1.23-1.31), and to those with diagnosed anxiety disorders (OR 1.39 CI 1.35-1.44) as well as obesity (OR 1.34 CI 1.28-1.41). The average age of recipients increased throughout the study, and among people sixty-five and older, there was an increase in prescriptions to people with multiple cardiovascular risk factors.

INTERPRETATION

Prescription stimulant dispensing may have liberalized during the study period in some demographics as a greater number of new prescriptions were dispensed to individuals with risk of adverse outcomes (i.e. older individuals, obese individuals, and geriatric patients with CV risk factors) between 2010 and 2020. Similar trends in prescription medications were witnessed through the opioid epidemic and warrant attention given concerning trends with illicit stimulants. Additional research that investigates patient and provider motivation for stimulant prescriptions, as well as risk perception of stimulants, may be warranted.

FUNDING

This study was made possible by institutional resources at Penn State Hershey Medical Center.

Effects of Methylphenidate on Somatic Symptoms and Brain Functional Connectivity in Adolescents with Attention Deficit Hyperactivity Disorder: A Pilot Study

Objective

This study aimed to evaluate whether somatic symptoms in adolescents with attention deficit hyperactivity disorder (ADHD) are associated with a dissociative pattern of functional connectivity (FC) within the default mode network (DMN) and whether methylphenidate administration can improve clinical and somatic symptoms. We also evaluated whether the improvement of somatic symptoms is associated with increased FC within the DMN in response to methylphenidate treatment.

Methods

Fifteen male adolescents with somatic symptoms of ADHD and 15 male adolescents with ADHD without somatic symptoms were included. At baseline and after 6 months of methylphenidate treatment, all adolescents were asked to complete questionnaires for the Korean version of the Dupaul’s ADHD rating scale, the symptom checklist-90- revised-somatization subscales, the Beck Depression Inventory, and the Beck Anxiety Inventory. Additionally, a resting-state functional magnetic resonance imaging scan was conducted.

Results

Methylphenidate treatment improved clinical and somatic symptoms in adolescents with ADHD. In addition, it increased brain FC within the DMN from the posterior cingulate cortex (posterior DMN) to the middle prefrontal cortex (anterior DMN). The improvement of somatic symptoms was associated with FC within the DMN from the posterior cingulate cortex to the middle prefrontal cortex in ADHD adolescents with somatic symptoms.

Conclusion

Methylphenidate increased brain FC between the anterior and posterior DMN. The improvement of somatic symptoms in adolescents with ADHD was associated with FC within the DMN. The DMN in adolescents with ADHD seems to be associated with the severity of the clinical and somatic symptoms of ADHD.

Children and adolescents with ADHD followed up to adulthood: a systematic review of long-term outcomes

The objective is to highlight the clinical and social outcomes among adults who suffered from Attention-Deficit Hyperactivity Disorder (ADHD) in their childhood/adolescence. PubMed, PsycINFO, and Scopus databases were searched for prospective studies published during the last 5 years addressing patients with ADHD in childhood/adolescence followed-up to adulthood. We also included studies published before 2015 reported in other reviews with similar outcomes. Thousand four-hundred and eighty-five studies were identified, but only 39 were included for qualitative analysis and 27 for quantitative analysis. Overall, we found that ADHD persisted into adulthood with a mean rate of 43% and was mainly associated with both substance/alcohol use disorders and antisocial behavior and, less frequently, with anxiety and depressive disorders. The prevalence of persistent ADHD in adulthood reported by studies published after 2011 (55%) was higher than that reported by studies published previously from 1985 to 2011 (34%), suggesting a greater focus on ADHD in recent years. Our results highlight that ADHD can be considered not only a neurodevelopmental disorder, but also a persistent and complex condition, with detrimental consequences for quality of life in adulthood.

Non-mental diseases associated with ADHD across the lifespan: Fidgety Philipp and Pippi Longstocking at risk of multimorbidity?

Several non-mental diseases seem to be associated with an increased risk of ADHD and ADHD seems to be associated with increased risk for non-mental diseases. The underlying trajectories leading to such brain-body co-occurrences are often unclear - are there direct causal relationships from one disorder to the other, or does the sharing of genetic and/or environmental risk factors lead to their occurring together more frequently or both? Our goal with this narrative review was to provide a conceptual synthesis of the associations between ADHD and non-mental disease across the lifespan. We discuss potential shared pathologic mechanisms, genetic background and treatments in co-occurring diseases. For those co-occurrences for which published studies with sufficient sample sizes exist, meta-analyses have been published by others and we discuss those in detail. We conclude that non-mental diseases are common in ADHD and vice versa and add to the disease burden of the patient across the lifespan. Insufficient attention to such co-occurring conditions may result in missed diagnoses and suboptimal treatment in the affected individuals.

Assessment of Stimulant Use and Cardiovascular Event Risks Among Older Adults

IMPORTANCE

Use of stimulants continues to increase among older adults for a variety of indications. An association between stimulant use and increased risk of cardiovascular (CV) events has been established among children and young adults, but few studies have explored the risk of CV events among older patients, a group with increased baseline risk.

OBJECTIVE

To evaluate the association between stimulant use and risk of CV events among older adults.

DESIGN, SETTING, AND PARTICIPANTS

This propensity score-matched cohort study, with 4 nonusers per 1 user, was conducted from July 1, 2017, to June 27, 2019, using data from population-based health care databases from Ontario, Canada, from January 1, 2002, to December 31, 2016. Included individuals were outpatients aged 66 years or older.

EXPOSURES

Initiation of a prescription stimulant.

MAIN OUTCOMES AND MEASURES

The primary outcome was a CV event, defined as a composite of emergency department visit or hospitalization for myocardial infarction, stroke or transient ischemic attack (TIA), or ventricular arrhythmia. Risk of CV event was assessed at 30 days, 180 days, and 365 days after initiation of stimulants from Cox proportional hazard models. A secondary analysis assessed each component of the primary outcome separately.

RESULTS

Among 6457 older adults who initiated a prescription stimulant (ie, the exposed group) and 24 853 older adults who did not initiate such treatment (ie, the unexposed group), the distribution of baseline patient characteristics was well balanced after matching (sex: 3173 [49.1%] men vs 12 112 [48.7%] men; standardized difference, 0.01; median [IQR] age: 74 [69-80] years vs 74 [69-80] years; standardized difference, 0.01). Within this cohort, there were 932 CV events during the 365-day follow-up (5.11 events per 100 person-years among individuals who initiated stimulants). In the primary analysis, stimulant initiation was associated with increased risk of CV events at 30 days (hazard ratio [HR], 1.4; 95% CI, 1.1-1.8) but not at 180 days (HR, 1.2; 95% CI, 0.9-1.6) or 365 days (HR, 1.0; 95% CI, 0.6 to 1.8). In the secondary analysis, stimulant initiation was associated with increased risk of ventricular arrhythmias (HR, 3.0; 95% CI, 1.1-8.7) and stroke or TIA (HR, 1.6; 95% CI, 1.1-2.1) at 30 days.

CONCLUSIONS AND RELEVANCE

This cohort study found that stimulant use was associated with an early increase in CV events among older adults with no association for long-term use.

Obstructive Sleep Apnea: Cognitive Outcomes

There is a strong association between obstructive sleep apnea (OSA) and cognitive dysfunction. Executive function, attention, verbal/visual long-term memory, visuospatial/constructional ability, and information processing are more likely to be affected, whereas language, psychomotor function, and short-term memory are less likely to be affected. Increased accumulation of Aß₂-amyloid in the brain, episodic hypoxemia, oxidative stress, vascular inflammation, and systemic comorbidities may contribute to the pathogenesis. Patients with OSA should have cognitive screening or formal testing, and patients with cognitive decline should have testing for OSA. Treatment with continuous positive airway pressure may improve cognitive symptoms in the patient with OSA.

Being Different but Striving to Seem Normal: The Lived Experiences of People Aged 50+ with ADHD

This qualitative study explored the day-to-day life of people aged 50+ diagnosed with ADHD. A phenomenological-hermeneutical method was chosen for the analysis. Two themes including sub-themes were revealed. The first theme, Being different and trying to handle my inner self, concerned emotional self-regulation, emotional resilience, social skills, and personal resource management. The second theme, Trying to adapt to fit in with people around me, concerned relationships, work, and personal finances. The comprehensive understanding was interpreted as Being different but striving to seem normal.

The Positive Aspects of Attention-Deficit/Hyperactivity Disorder among Famous People

OBJECTIVE

The shortage of clinical data regarding adult patients with often results in adults with ADHD being stigmatized and being inadequately treated. In this paper, famous people who potentially have ADHD were analyzed to understand better, the life-long progression of ADHD.

METHODS

131 people were analyzed as potential candidates for ADHD. A grading system for the candidates was developed: class 1, compatible with ADHD; class 2, likely; class 3, less likely; class 4, uncertain with a shortage of data; and class 5, not compatible. Initially, 39 subjects in class 4 and 12 in class 5 were excluded from the analysis. Finally, 80 subjects (30 in class 1, 33 in class 2, and 17 in class 3) were analyzed for sociodemographic data and psychiatric comorbidities.

RESULTS

88.8% were men and 47.5% of the subjects were married once. In terms of occupation, 45.0% of the subjects were cultural professionals and 25.0% were chief executives. Narcissistic personality disorder was the most frequently noted comorbidity, followed by substance-related and addictive disorder.

CONCLUSION

Famous people with ADHD in this study revealed high skill levels in occupation, offering positive aspects of ADHD in adults.

ADHD with Comorbid Bipolar Disorders: A Systematic Review of Neurobiological, Clinical and Pharmacological Aspects Across the Lifespan

BACKGROUND

Attention deficit hyperactivity (ADHD) disorder is a neurodevelopmental disorder characterized by inattention, hyperactivity, disruptive behaviour, and impulsivity. Despite considered typical of children for a long time, the persistence of ADHD symptoms in adulthood gained increasing interest during the last decades. Indeed, its diagnosis, albeit controversial, is rarely carried out even because ADHD is often comorbid with several other psychiatric diosrders, in particular with bipolar disorders (BDs), a condition that complicates the clinical picture, assessment and treatment.

AIMS

The aim of this paper was to systematically review the scientific literature on the neurobiological, clinical features and current pharmacological management of ADHD comorbid with BDs across the entire lifespan, with a major focus on the adulthood.

DISCUSSION

The pharmacology of ADHD-BD in adults is still empirical and influenced by the individual experience of the clinicians. Stimulants are endowed of a prompt efficacy and safety, whilst non-stimulants are useful when a substance abuse history is detected, although they require some weeks in order to be fully effective. In any case, an in-depth diagnostic and clinical evaluation of the single individual is mandatory.

CONCLUSION

The comorbidity of ADHD with BD is still a controversial matter, as it is the notion of adult ADHD as a distinct nosological category. Indeed, some findings highlighted the presence of common neurobiological mechanisms and overlapping clinical features, although disagreement does exist. In any case, while expecting to disentangle this crucial question, a correct management of this comorbidity is essential, which requires the co-administration of mood stabilizers. Further controlled clinical studies in large samples of adult ADHD-BD patients appear extremely urgent in order to better define possible therapeutic guidelines, as well as alternative approaches for this potentially invalidating condition.

Risks and Benefits of Attention-Deficit/Hyperactivity Disorder Medication on Behavioral and Neuropsychiatric Outcomes: A Qualitative Review of Pharmacoepidemiology Studies Using Linked Prescription Databases

Attention-deficit/hyperactivity disorder (ADHD) medication is one of the most commonly prescribed medication classes in child and adolescent psychiatry, and its use is increasing rapidly in adult psychiatry. However, major questions and concerns remain regarding the benefits and risks of ADHD medication, especially in real-world settings. We conducted a qualitative systematic review of studies that investigated the effects of ADHD medication on behavioral and neuropsychiatric outcomes using linked prescription databases from the last 10 years and identified 40 studies from Europe, North America, and Asia. Among them, 18 used within-individual designs to account for confounding by indication. These studies suggested short-term beneficial effects of ADHD medication on several behavioral or neuropsychiatric outcomes (i.e., injuries, motor vehicle accidents, education, substance use disorder), with estimates suggesting relative risk reduction of 9% to 58% for these outcomes. The within-individual studies found no evidence of increased risks for suicidality and seizures. Replication studies are needed for several other important outcomes (i.e., criminality, depression, mania, psychosis). The available evidence from pharmacoepidemiology studies on long-term effects of ADHD medication was less clear. We discuss time-varying confounding and other limitations that should be considered when interpreting results from pharmacoepidemiology studies. Furthermore, we highlight several knowledge gaps to be addressed in future research and implications for research on mechanisms of outcomes of ADHD medications.

Diagnosis and treatment of attention deficit hyperactivity disorder

Attention-deficit hyperactivity disorder (ADHD) is a neurobehavioral disorder characterized by signs and symptoms of inattention, hyperactivity, and impulsivity that typically begin in childhood. ADHD can persist into adulthood, causing impairments in occupational performance and peer and family relationships. This article reviews the epidemiology, diagnosis, and treatment of ADHD.

Midlife ADHD in women: any relevance to menopause?

Recently, there has been a growing interest in better understanding of the adult-type attention deficit hyperactive disorder (ADHD). It is now accepted that many children with ADHD continue to have symptoms later in life, although the characteristics of the disease may change substantially in adults. Data are emerging on ADHD in midlife and old age and some studies analyze gender differences and co-morbidities during the lifespan of ADHD patients. This short communication discusses the possible resemblance of certain menopausal symptoms and those of adult ADHD and the potential contribution of the female hormonal environment. Further, there might be a promising role for psychostimulants, the mainstay of ADHD management, as treatment of impairment of some executive function domains in menopausal women.