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3 Feb 2021

Sibley MH. Am J Geriatr Psychiatry 2020; Epub ahead of print

Older adults with ADHD may evade clinical attention for over 50 years. It is possible that when these adults were children or adolescents, ADHD was not identified as a medical disorder. Moreover, when these adults were aged 30–40 years, persistence of ADHD into adulthood was not recognised (Sharma et al, 2020). Nevertheless, older adults with ADHD would most likely have experienced symptoms of ADHD at some point in their life. Due to the chronicity of ADHD, symptoms may be more identifiable in older adults with ADHD compared with younger adults, as they will have a longer track record of behaviour, which may aid diagnosis.

Presently, there are no data surrounding the validity of self-reported ADHD symptoms in older adults with ADHD. However, when younger adults are being assessed for an ADHD diagnosis, collection of information from an informant is advised (Sibley et al, 2016). Therefore, it could be advised that an informant may be used to collect information surrounding an older adult’s ADHD symptom history.

Current diagnostic guidelines for ADHD require 6 months of ongoing symptoms to make a diagnosis. An older adult with ADHD may not have experienced functional impairment for many years; however, 6 months of ADHD-like symptoms may instead be attributed to age-related cognitive decline, depression, dementia or another medical-related issue (Goodman et al, 2016). Future research could determine what degree of symptom chronicity is required to optimise diagnostic sensitivity and specificity in older adults with ADHD. Additionally, older adults may have experienced non-ADHD sources of long-term cognitive dysfunction (e.g. chronic depression, medication side effects and traumatic brain injuries). Therefore, a possible step towards providing a first-time diagnosis of ADHD in an older adult could be ensuring that symptoms are not better explained by another source of dysfunction.

An additional consideration for diagnosis in older adults is the age of ADHD onset (Sharma et al, 2020). It is recommended that age of ADHD onset should be considered when diagnosing older adults with ADHD but may be waived when: (1) a stable pattern of ADHD-like behaviour across a lifetime can still be shown; or (2) childhood information is clinically unreliable.

It should be noted that the recommendations provided in this article are those of one author and are based on speculation. Studies on older populations are required to test these hypotheses regarding optimal diagnostic processes for ADHD in older adults.

In the author’s opinion, the most critical future research steps for diagnosing older adults with ADHD are: (1) examining the validity of self versus informant symptom reports; (2) determining how to establish chronicity; and (3) investigating the additional value of incorporating information surrounding an older adult’s functioning capabilities during childhood when assessing them for ADHD.

Read more about diagnosing ADHD in older adults here

Goodman DW, Mitchell S, Rhodewalt L, et al. Clinical presentation, diagnosis and treatment of attention-deficit hyperactivity disorder (ADHD) in older adults: a review of the evidence and its implications for clinical care. Drugs Aging 2016; 33: 27-36.

Sharma MJ, Lavoie S, Callahan BL. A call for research on the validity of the age-of-onset criterion application in older adults being evaluated for ADHD: a review of the literature in clinical and cognitive psychology. Am J Geriatr 2020; Epub ahead of print.

Sibley MH, Swanson JM, Arnold LE, et al. Defining ADHD symptom persistence in adulthood: optimizing sensitivity and specificity. J Child Psychol Psychiatry 2016; 58: 655-662.

Sibley MH. Diagnosing ADHD in older adults: critical next steps for research. Am J Geriatr Psychiatry 2020; Epub ahead of print.

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