Phillip Ruppert, PhD Assistant Professor Department of Psychiatry and Behavioral Neuroscience
Noam Grysman, MD Department of Psychiatry and Behavioral Neuroscience
George Grossberg, MD Samuel W. Fordyce Professor Director, Geriatric Psychiatry
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Saint Louis University School of Medicine St. Louis, Missouri
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Medications for ADHD symptoms are thought to act via catecholaminergic mechanisms.21 As a result, adverse effects of stimulants can include headache, appetite suppression, nausea, difficulty sleeping, tremor, blurred vision, agitation, psychosis, increased heart rate, arrhythmia, and hypertension.22,27,32-34 Especially in older adults, adverse effects such as reduced appetite, disrupted sleep, or increased blood pressure or heart rate may be harmful.21,23 Using caffeine or pseudoephedrine can exacerbate these adverse effects.21 Atomoxetine’s adverse effects include appetite suppression, insomnia, dizziness, anxiety, agitation, fatigue, dry mouth, constipation, nausea, vomiting, dyspepsia, and increased heart rate or blood pressure.27,32,35 Genitourinary adverse effects have also been reported, including priapism (rare), decreased libido, and urinary hesitancy and retention.26,32 Before any medication is initiated, it is important to conduct a physical and neurologic examination and a detailed clinical interview.
Before starting medication, as with any medical treatment, conduct a risk vs benefit analysis. Record baseline values for the patient’s heart rate, blood pressure, and weight.23,26,27,31 During the interview, screen for family and personal cardiovascular conditions,27,33 and obtain an electrocardiogram for any patient with cardiovascular risks.23,26,27,31 Once the patient is deemed to be an appropriate candidate for pharmacologic treatment, begin with low doses and titrate the medication slowly until reaching a therapeutic level.23,48
Medications should be combined with psychotherapy (eg, cognitive-behavioral therapy or dialectical behavioral therapy) and other lifestyle changes (exercise, mindfulness, support groups).18,22,23,27,31,49 Psychotherapy can help patients come to terms with receiving an ADHD diagnosis later in life and help with organization and socialization.12,50 Pharmacologic treatments are thought to be helpful with attention challenges and emotional instability.50 Taken together, medications and behavioral interventions can help individuals experience an improved quality of life.
Future directions
Given the relatively recent interest in ADHD in older adults, there are several areas that need further research. For future editions of DSM, it may be prudent to consider establishing ADHD criteria specific to older adults. Research has also shown the need for clear diagnostic and validated tools for older adults.8 Few analyses have been undertaken regarding pharmacotherapy for this population. Randomized controlled clinical trials are needed.23,37,48 More research about the relative utility of psychotherapy and behavioral interventions would also be useful, given their potential to improve the quality of life for older adults with ADHD.
Bottom Line
Although generally thought of as a disorder of childhood, attention-deficit/ hyperactivity disorder (ADHD) has substantial effects in older adults. When the condition is appropriately diagnosed, pharmacologic treatment and psychotherapy are associated with improved quality of life for older patients with ADHD.
