Is it Alzheimer’s , or A.D.H.D.?

by Judith Berck

The 73-year-old widow came to see Dr. David Goodman, an assistant professor in the psychiatry and behavioral sciences department at Johns Hopkins School of Medicine, after her daughter had urged her to “see somebody” for her increasing forgetfulness. She was often losing her pocketbook and keys and had trouble following conversations, and 15 minutes later couldn’t remember much of what was said.

But he did not think she had early Alzheimer’s disease. The woman’s daughter and granddaughter had both been given a diagnosis of A.D.H.D. a few years earlier, and Dr. Goodman, who is also the director of a private adult A.D.H.D. clinical and research center outside of Baltimore, asked about her school days as a teenager.
“She told me: ‘I would doodle because I couldn’t pay attention to the teacher, and I wouldn’t know what was going on. The teacher would move me to the front of the class,’ ” Dr. Goodman said,

After interviewing her extensively, noting the presence of patterns of impairment that spanned the decades, Dr. Goodman diagnosed A.D.H.D. He prescribed Vyvanse, a short-acting stimulant of the central nervous system.

A few weeks later, the difference was remarkable. “She said: ‘I’m surprised, because I’m not misplacing my keys now, and I can remember things better. My mind isn’t wandering off, and I can stay in a conversation. I can do something until I finish it,’ ” Dr. Goodman said.

Once seen as a disorder affecting mainly children and young adults, attention deficit hyperactivity disorder is increasingly understood to last throughout one’s lifetime.

In 2012, in one of the only epidemiological studies done on A.D.H.D. in older adults, a large Dutch population study found the condition in close to 3 percent of people over 60.

Yet we know little about how A.D.H.D. affects older people, or even who has it.

“We hardly have any literature,” said Dr. Thomas Brown, associate director of the Yale Clinic for Attention and Related Disorders at the Yale School of Medicine. Almost none of the clinical trials and epidemiological studies on A.D.H.D. have included people over 50. “But I see quite a few people turning up in my office with these complaints. It’s reasonable to assume that a lot of elderly people have A.D.H.D.”

Heightened awareness of A.D.H.D. is bringing increased referrals of elderly adults to specialty clinics. “A child had been treated, then a parent, then everyone started looking at Grandpa, and saying, ‘Oh my gosh,’ and they would bring him in,” said Dr. Martin Wetzel, associate clinical professor of psychiatry at the University of Nebraska Medical Center.

Yet many general practitioners and mental health experts mistake symptoms like impaired short-term memory or an inability to stay focused on a task as something else.

“We do a horrible job of training health care professionals about adult A.D.H.D.,” Dr. Wetzel said.

Dr. Brown said, “Most doctors are not thinking of A.D.H.D. as a characteristic of somebody who is 60 or over.” Hence, the condition may be overlooked in the 80-year-old who has trouble staying engaged at the senior center, despite a lifelong history of inattention. “They figure it’s just cognitive decline from aging” or diagnose depression or anxiety in such patients, which may or may not be the case, he said.

Until about three years ago, most geriatric cognitive and memory studies did not include any people with A.D.H.D., at least not knowingly.

“Deeply hidden in all the studies about mild cognitive impairment and early Alzheimer’s are significant numbers of people with A.D.H.D.,” Dr. Wetzel said. “We have no idea who in those studies had it or didn’t have it, because nobody was asking the question.”

Screening for A.D.H.D. is not simple. No blood test or imaging study can make a definitive distinction; A.D.H.D. is basically a clinical diagnosis. “Unless you ask questions and do a comprehensive assessment, nobody’s ever going to know,” Dr. Wetzel said.

Dr. Goodman said: “This is where it gets difficult in aging patients. One has to distinguish between the longitudinal A.D.H.D. symptoms and the overlap of age-related cognitive decline. You can have both simultaneously.”

Dr. Lenard Adler, director of the Adult A.D.H.D. Program at the NYU Langone School of Medicine, and past president of the American Professional Society of A.D.H.D. and Related Disorders, said, “The key issue is to get the diagnosis correct, get the right medication into the individuals who need it and to be sure that older adults have the appropriate medical clearance prior to treatment.”

Older adults with A.D.H.D. are typically treated with the same drugs given to children, stimulants like Adderall or Ritalin, but these medications pose distinctive challenges for older patients.

“If they have cardiac or blood pressure issues, the doctor would first have to pay attention to getting the heart issues or hypertension resolved or under control and then possibly come in with a stimulant,” said Dr. Brown, who added that he had successfully treated a number of people in their early and mid-70s with stimulants.

Why treat people at an advanced age for something they have had their entire life?

“Let’s say you’ve spent your whole life not functioning at a level that you could, and you believed that was an outgrowth of you as a person, and all of a sudden you received a diagnosis and medication that showed you that all of the criticism from the environment wasn’t because of who you were, it was because of what you had,” Dr. Goodman said. “That it is a very liberating experience, even if you’re 65, 72 or 83.”


Does Excercise Change Your Brain?

by Gretche3n Reynolds
At the age of 93, Olga Kotelko — one of the most successful and acclaimed nonagenarian track-and-field athletes in history — traveled to the University of Illinois to let scientists study her brain.

Ms. Kotelko held a number of world records and had won hundreds of gold medals in masters events. But she was of particular interest to the scientific community because she hadn’t begun serious athletic training until age 77. So scanning her brain could potentially show scientists what late-life exercise might do for brains.

Ms. Kotelko died last year at the age of 95, but the results of that summer brain scan were published last month in Neurocase.

And indeed, Ms. Kotelko’s brain looked quite different from those of other volunteers aged 90-plus who participated in the study, the scans showed. The white matter of her brain — the cells that connect neurons and help to transmit messages from one part of the brain to another — showed fewer abnormalities than the brains of other people her age. And her hippocampus, a portion of the brain involved in memory, was larger than that of similarly aged volunteers (although it was somewhat shrunken in comparison to the brains of volunteers decades younger than her).

Over all, her brain seemed younger than her age.

But because the scientists didn’t have a scan showing Ms. Kotelko’s brain before she began training, it’s impossible to know whether becoming an athlete late in life improved her brain’s health or whether her naturally healthy brain allowed her to become a stellar masters athlete.

And that distinction matters. Before scientists can recommend exercise to forestall cognitive decline, they need to establish that exercise does in fact slow cognitive decline.

So far, much of the available evidence has been weak. Many epidemiological studies show that physically active older people perform better on cognitive tests than their sedentary counterparts. But those studies were associational and leave many questions unanswered.

A new experiment by the same group of researchers who scanned Ms. Kotelko’s brain, however, bolsters the idea that exercise makes a difference in aging brains.

In the study, published last month in PLOS One, Agnieszka Burzynska, now an assistant professor of human development at Colorado State University in Fort Collins, and colleagues at the Beckman Institute for Advanced Science and Technology at the University of Illinois in Urbana scanned the brains of older men and women, aged 60 and 80, using a technique that tracks oxygen delivery to cells to determine brain activity. The researchers also measured their volunteers’ aerobic capacity and asked them to wear an activity monitor for a week to determine how much and how intensely they moved each day.

Notably, the most physically active elderly volunteers, according to their activity tracker data, had better oxygenation and healthier patterns of brain activity than the more sedentary volunteers — especially in parts of the brain, including the hippocampus, that are known to be involved in improved memory and cognition, and in connecting different brain areas to one another. Earlier brain scan experiments by Dr. Burzynska and her colleagues had established that similar brain activity in elderly people is associated with higher scores on cognitive tests.

Interestingly, as Dr. Burzynska points out, none of these volunteers were athletes, as Ms. Kotelko was. In fact, none of them formally exercised at all. But those who walked, gardened and simply moved more each day had brains that appeared to be in better shape than those of the other volunteers.

Of course, while this research offers tantalizing clues as to why exercise may be good for the brain, the study, like Ms. Kotelko’s scan, cannot prove cause and effect.

So, fundamentally, we still do not know whether and how physical activity changes our minds — a confusion that most likely was intensified for many of us by the results of a well-publicized study published last month in JAMA. In it, researchers from the Wake Forest School of Medicine in Winston-Salem, N.C., and other universities asked sedentary, elderly men and women, between the ages of 70 and 89, to start walking and doing light resistance training while other volunteers joined a health education program to serve as a control group.

To measure whether exercise made a difference in brain health, all of the participants completed cognitive testing at the beginning and the end of the study.

On the surface, the results were discouraging. The scores for the people in the exercise group were unchanged after two years and about the same as the scores for the group that attended health classes, intimating that exercise had had no effect.

But look deeper and there is another, intriguing inference. The cognitive performance of the volunteers in both groups remained stable, instead of declining, as might have been expected at their ages. So it may be that exercise did keep the volunteers’ minds sharp — and so did getting out and attending classes and engaging socially with the world.

“There are so many things that may impact brain aging,” Dr. Burzynska said, “and so much that we don’t yet understand about the process.”

Scientists need to scan people’s brains before and after long-term exercise programs, she said, and parse how exercise affects the many different varieties of thinking. In the JAMA study, for instance, there were some small improvements among the oldest exercising volunteers in their working memory and attention, but not other cognitive skills.

But even in advance of more studies, it “seems very likely,” Dr. Burzynska said, that exercise enables our brains to age better, even if, like Ms. Kotelko, we get started a little later in life.