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.”

http://well.blogs.nytimes.com/2015/09/28/is-it-alzheimers-or-a-d-h-d/?ref=health&_r=0

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