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ADHD in Old Age
Taina Guldberg-Kjär Ph.D.
Department of Psychology, University of Gothenburg
Post doc Gillberg Neuropsychiatry Center,
Sahlgrenska akademin, University of Gothenburg
Picture Inge Löök ©
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Year
Author
Concept/Diagnosis
1770
Melchior Adam Weikard
First description of attention disorder in
medical literature: ”bacchanal”, ”flighty”,
”careless”, and ”mercurial”.
1798 Sir Alexander Crichton ”On Attention and its Diseases” - The incapacity of attending with a necessary
degree of consistency to any one object. 1844 Heinrich Hoffmann Fidgety Phil (”Zappelphillipp”) in
”Struwwelpeter”. 1902 Sir George Frederic Still Defect of Moral control, The Goulstonian
lectures. 1908 Tredgold et al Postencephalitic behavior disorder. 1932 Franz Kramer & Hans Pollnow Hyperkinetic disorder of infancy. 1930s and 1940s Minimal brain damage. 1960s Minimal brain dysfunction. DSM 1968 DSM-II Hyperkinetic reaction of childhood. 1980 DSM-III Attention deficit disorder: with and without
hyperactivity. 1987 DSM-III, revision Attention deficit hyperactivity disorder 1994 DSM-IV Attention deficit hyperactivity disorder 2000 DSM-IV-TR Attention deficit hyperactivity disorder 2013 DSM-5 Attention deficit hyperactivity disorder
ICD 1992 ICD-10 Hyperkinetic disorder Scheduled release 2015 ICD-11
Hyperkinetic disorder
Conceptual and Diagnostic History of ADHD
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JAD, 2006
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”Fidgety Phil”
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IMAGINE HAVING ADHD … in old age
• Your GP now really starts laughing when you ask for diagnostic assessment, although your daughter and granddaughter were recently diagnosed with ADHD, and successfully treated … you really thought there was still some hope for you as well, but you find out that innovative new knowledge is usually very reluctantly implemented in mental health care
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Impairment in adult ADHD ~ bagage to old age
In clinical as well as epidemiological samples compared to NCs: • Learning problems (60%) • Less graduated • Lower education • Lower income • Less employed, more sickness leave • More job changes (longest job 5 yrs) • More often arrested, divorced and more social problems • More driving accidents, teenage pregnancies, suicide attempts • Higher (mental) health care costs → Nega&ve excperiences, feeling le2 outside and poor selfconfidence a2er years of failures… casts shadows over your old age
Biederman 2006; Kooij 2001, 2005; Barkley 2002; Manor, 2010
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Clinical picture of ADHD
Lifetime symptoms of Attention-Deficit/Hyperactivity Disorder: • Inattention: distracted, chaotic, forgetful, late, difficulty making decisions, organising and planning, no sense of time, procrastination
• Hyperactive: (inner) restlessness, tense, talkative, busy; coping by: excessive sporting/alcohol abuse/avoiding meetings
• Impulsive: acting before thinking, impatient, difficulty awaiting turn, jobhopping, binge eating, sensation seeking
In addition in 90% of adults, lifetime: • Moodswings (5x/day) and Anger outbursts
APA 1994; Kooij 2001, 2012; Conners 1996; Wender 1995; Asherson UKAAN 2011
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Intryck från den kliniska vardagen -‐ kvarvarande problem:
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Reglering av känslor, energinivå, motorik och beteende
-‐ Sortera och organisera. -‐ Komma igång med och avsluta
uppgifter. -‐ Prioritera och hushålla med tiden, göra en sak i taget. -‐ Fokusera och avgränsa sig, begränsa sig.
Ökad stresskänslighet och att man lever utan marginaler Minnet (relaterat till uppmärksamhets- och arbetsminnesproblem?)
-‐ Komma ihåg vad man ska göra, när och var.
Perceptuell överkänslighet (ljud, ljus etc.) ADL-förmågor
-‐ Man har svårt att utföra det man vet att man borde göra.
-‐ Organisera och genomföra: matlagning, disk, städning, tvätt, strykning m.m.
-‐ Hålla ordning: veta var sakerna finns -‐ Att inte störa grannar. -‐ Komma ihåg att stänga av plattor,
strykjärn m.m. -‐ Ta hand om sig själv när det gäller
kost, motion, sömn, egenvård m.m.
Försämrad koncentrationsförmåga Rastlöshet
-‐ Framför allt en stark inre oro. -‐ Känsla av ständig stress.
Impulsivitet -‐ Till exempel impulsköp. -‐ Byter läkare ofta. -‐ Impulsiva kommentarer.
Tidsuppfattning -‐ Passa tider och beräkna
tidsåtgång. Social isolering
-‐ Självcentrering. -‐ Hamnar lätt i konflikter. -‐ Orken minskar ytterligare. -‐ Misstänksamhet.
Sömnsvårigheter Depression Ångest Ekonomi
-‐ Sortera räkningar och betala dem i tid.
-‐ Veta hur mycket pengar man har att spendera.
-‐ Impulsköp.
Inte ett konstant tillstånd – variation beroende på motivation i stunden, krav och stress.
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Comorbidity in ADHD ADHD comes seldom alone: 75% has at least one other disorder Mean: 3 comorbid disorders • Depression (60% SAD) 20-‐55% • Bipolar Disorder (88% BP II) 10% • Anxiety Disorders 20-‐30% • Substance Use Disorders 25-‐45% • Smoking 40% • Cluster B Pers. Disorders 6-‐25% • Sleeping Problems (DSPS) 78% • Muscle, joint, neck-‐ and backpain ??
Biederman 1991,1993, 2002; Weiss 1985; Wilens 1994; Kooij 2001, 2004; van Veen 2010; Amons 2006; Gillberg 2004
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Why an interest in ADHD in older adults? • Starting point Summer 2002 – An older patient referred to an assessment
for potential dementia with an untypical symptomatology and life history.
• New questions emerged:
– Can ADHD persist into old age ?
– If so, how prevalent is ADHD in an elderly population ?
– How can we identify ADHD in old age ?
– What about expressions/symptomatolgy and burden of ADHD across the life-span
– What about the perspectives from those affected?
I could not find answers to these questions…..
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Sweden 31/12 2013 (SCB) 1 872207 individuals ≥65 år (19.4% of the total population) Hypothetic prevalence: 1%: 18 722 1,5%: 28 083 5%:93 610 3%: 56 166 In 2060 25% of the Swedish population is estimated to be 65 years or older !!! – how many with ADHD ?
Socialdepartementet LEV
Källa: Human Mortality Database. University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany), SCB.
Age
Number
Number of deaths at various ages, Sweden 1751-2110
Socialdepartementet LEV
Number
Age Källa: Human Mortality Database. University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany), SCB.
Number of deaths at various ages, Sweden 1751-2110
Socialdepartementet LEV
Number
Age Källa: Human Mortality Database. University of California, Berkeley (USA), and Max Planck Institute for Demographic Research (Germany), SCB.
Number of deaths at various ages, Sweden 1751-2110
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Thesis September 20, 2013 The first thesis about ADHD in Old Age in the world - Can be downloaded from: hSp://hdl.handle.net/2077/33241
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Aim: to estimate the prevalence of childhood ADHD symptoms in a population-
based sample of persons aged 65-80.
Participants and Methods: 2 500 persons aged 65-80 years in Hässleholm municipal were randomly selected
to participate in Study I.
1 599 (64%) participated in the study. We used the 25-item Wender Utah Rating
Scale (WURS) to estimate self-rated childhood ADHD symptoms. Demographics, self-ratings of problems in childhood, current health and memory were also investigated.
Taina - ADHD – Bridging the Gap Wednesday March 5, 2014, Copenhagen
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Main finding
• The prevalence rate of retrospectively reported childhood ADHD symptoms in old age in our sample is 3.3% (using cut-off 36 for WURS). The mean WURS score in this sample was 12.14 (median=10.00, SD=10.48, range=0-82).
• Individuals, who scored higher on the WURS scale, and especially those
above the cut-off level may constitute survivors of those who actually exhibited childhood ADHD.
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• more childhood problems • more jobs (> 5) • more men • worse current health, worse current memory • more divorce/no relationship (34 vs 12%)
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Aim: to examine the persistence of ADHD symptomatology across the lifespan by
comparing older individuals self-reports about current ADHD symptoms and symptoms in childhood.
Participants and Methods: Two sub-samples, each with 30 individuals (30 with WURS score <36 and 30 with WURS score ≥36) were followed-up by the Wender Riktad ADHD Symtom Skala (WRASS), a Swedish version of the Targeted Attention deficit Disorder Rating Scale (TADDS).
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Main finding
• Among those with a WURS score of 36 or more, 16 (53.3%) individuals scored 70 or more (the clinical cut-off used in Sweden). None of the individuals with a WURS score below 36 scored higher than 70 on the WRASS.
• Our findings in Study II support the idea of a significant persistence of ADHD symptoms from childhood to old age.
• The results thus, encourage further studies of ADHD using a lifespan perspective.
.
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• Among those with the WURS score 36 or more, 16 (53.3%) individuals rated 70 points or more (clinical cut-off in Sweden). None of the individuals with the WURS score below 36 rated 70 points or more on the WRASS.
Guldberg-Kjär, T., Sehlin, S., and Johansson, B. (2013). ADHD Symptoms across the Lifespan in a Population-Based Swedish Sample Aged 65 to 80.
International Psychogeriatrics. 2013 Vol 25 (5), 667-675.
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Aim: to compare different scales capturing ADHD symptoms for self-reports about childhood and current ADHD symptomatology and to relate these reports to the DSM-IV ADHD criteria.
Participants and Methods: Two sub-samples, each with 30 individuals were drawn based on their WURS scores (30 with WURS score <36 and 30 with WURS score ≥36) and studied using the WRASS, Barkley Childhood Symptoms Scale (CSS-Child Recall), Barkley Current Symptoms Scale (CSS) and assessed using DSM-IV ADHD criteria.
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ADHD Burden Over the Lifespan: Clinical information from a Population-Based Swedish
Sample Aged 65 to 80
Aim: to explore problems in daily functioning, past psychiatric history, family psychiatric history, and overall health history in elderly individuals reporting childhood ADHD symptomatology
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Main finding
• Significantly more self-reported problems in daily life across the life span among those who reported more childhood ADHD symptoms. Furthermore, those who exhibited childhood ADHD symptoms also reported more past psychiatric history; depression, anxiety and suicidal thoughts being those most frequently reported.
• Heart problems and diabetes in past adulthood and currently were more common among those who reported more childhood ADHD symptoms and generally worse current self-rated health
In family: • More ADHD (symptoms) • More bipolar disorder
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Meaning of diagnosis and treatment
• N=3 clinical patients were more extensively interviewed about daily functioning, and treated with stimulants
• All were alone, divorced or never married • All showed the negative impact of lifetime ADHD on
financial, social and emotional wellbeing • The general picture of living with ADHD is that of a
hard life with many difficulties and little help… • All were still looking for help and reduction of suffering
at old age • All were treated, though medication did not bring the
expected benefit
Prevalence of ADHD through the lifespan
Children: USA 4 - 8% % persisting ADHD 50 - 60%
Adults: USA 4 - 5%
10 countries (mean) 3.4% Older people:
Sweden 3.3% Netherlands 2.8 - 4.2%
Faraone 2003; Kessler 2006; Murphy & Barkley, 1996; Kooij 2005; Fayyad 2007; Guldberg 2013; Michielsen 2012
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Marieke Michielsen & Evert Semeijn
Presenting their posters in Berlin, ADHD Congress, 2011
Symposium Chairs: Marieke & Taina, IPA Congress, Seoul, Oct. 2013
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• Semeijn EJ, et al.(2013). Journal of the American Geriatrics Society.
Summary
Older adults with ADHD reported: higher levels of depressive symptoms
higher levels of anxiety symptoms over several years AND
lower self esteem lower self-‐efficacy lower sense of mastery higher levels of neuro\cism higher levels of social inadequacy
than older adults without ADHD
Mastery and self-‐esteem partly mediated the rela\onship between ADHD severity and depressive symptoms. • Michielsen et al. (2012),Journal of Affective Disorders.
Rela;onship to normal aging process ? Important to control diminishing exeku;ve func;ons (i.e. compared
to inaSen\on and poor working memory) • Recent research: ”Older adults show deficits in emo;onal/
cogni;ve integra;on as well as in execu;ve func;on”(E. Baena et.al/Neuropsychologia 48 (2010) 319-‐333)
-‐ dorsolateral prefrontal cortex (DLPFC) -‐ ventromedial prefrontal cortex (VMPFC) • DESR (Deficient Emo;onal Self-‐Regula;on) even worse emo\onal self-‐regula\on in eldery with ADHD ? (frontal-‐striatal, frontal-‐cerebellar, frontal-‐limbic) -‐BARKLEY art
2010!!!! • Ques\ons have also been raised about the effects of hormonal
changes in later life on individuals with ADHD (Nadeau&Quinn, 2002)
How is to grow old with ADHD, for better and worse?
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ADHD and dementia
Some recent studies have, interestingly shown an association between ADHD and the development of dementia with Lewy bodies (Golimstock et al., 2010) and between childhood symptoms of ADHD and the development of Parkinson’s disease (Walitza et al., 2007).
references: -‐ Golimstock, A., Rojas, J.I., Zurni, M.C., Doctorovich, D., & Cris\ano, E. (2010). Previous adult aSen\on-‐deficit and hyperac\vity disorder symptoms and risk of demen\a with Lewy bodies: a case-‐control study. Eur J Neurol, 18 (1): 78-‐84.
-‐ Walitza, S., Melfsen, S., Herhaus, G., Scheuerpflug, P., Warnke, A., Muller, T., et al. (2007). Associa\on of Parkinson's disease with symptoms of aSen\on deficit hyperac\vity disorder in childhood. J Neural Transm Suppl(72), 311-‐315.
-‐ Vascular demen;a:? -‐ Alzheimers disease: ? - Questions have also been raised about the effects of hormonal changes
in later life on individuals with ADHD (Nadeau & Quinn, 2002).
Does it really ma>er, ADHD in old age?
? • Think about the demography in our society…can we
afford not to care ? • The most important thing is to find reliable methods for
iden\fying earlier unrecognised ADHD symptomathology among older adults.
• …so that we can provide this group of elderly individuals correct diagnosis and hopefully adequate treatment.
• Ideal: -‐ Focus in a life-‐span perspec;ve with co-‐work between
child-‐adult-‐geriatric psychiatry
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assessed for Emma, 86 år (dementia/adhd) Risto, 72 år (dementia) Lars, 71 år (dementia) Karin, 70 år (dementia/adhd) Berit, 68 år (adhd) Mats, 66 år (adhd) Maria, 66 år (adhd, earlier dementia) Thorbjörn, 54 år (dementia) Katarina, 53 år (dementia) Douglas, 50 år (dementia) Måns, 48 år (dementia) Anki, 54 år (dementia) Ebba, 71 år (adhd, earlier dementia)
ADHD clinical cases
Not their real names
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January 9, 2012 Jacob Klompstra: "Looking back at my youth, I can see now that my father must have suffered from the same condition as I have: ADHD. And in the family there were others with ADHD too. With parents who encountered tremendous problems with me and a especially a father who was so chaotic that he was incapable of dealing with the problems I caused. As a result my childhood was indescribably difficult. At school I always fell behind in class and 'bad grades' was my middle name. Besides ADHD I also have difficulties reading (dyslexic) and arithmetic (dyscalculia). Both were not recognised at that time. 'You'll never achieve anything', I was told constantly. Well, they should take a look at me now and see what I've achieved despite all obstacles." How did Jacob manage to survive in a world that didn't understand him? What kept him going, learning, living, loving and becoming a father, not knowing why he was so different from other people? How did his creative brain make him successful, finding solutions to problems others didn't even think about. What changed when he was finally diagnosed ADHD at age 58?
”Fireworks on the Brain”
Malmö 2012-06-07
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www.adhdfund.com
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• Building bridges
• between generations
• professions
• …and regions
The ADHD Bridge
Join the Closed Facebook Group: ADHD-bron / The ADHD Bridge
Life span clinic ? Three genera\ons women with med ADHD
! APen;on nr5/2012
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Clinical implications
• Finding methods for identifying and understanding ADHD among elderly persons to improve treatment
• In a differential diagnostic perspective important to distinguish from dementia, other psychiatric conditions for experienced problems related to ADHD.
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…and what happened to Emil ?
• ” The fact that that boy became a chair man in his municipal when he became an adult is one of the miracles that can happen but that did really happen and he was the finest man in the entire Lönneberga. Think, this teaches us that the worst little children can grow up into something really beautiful and that is wonderful to think about.” (Astrid Lindgren)
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