Old Age Psychiatrist (2014) 58

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1 in Older People: An Evidence Based Perspective Dr. Shalini Agrawal, Consultant in Old Age Psychiatry South Essex Partnership University NHS Foundation Trust Aim To review the current literature for evidence in relation to Attention Deficit Hyperactivity Disorder () in older people, focussing on prevalence, clinical characteristics, diagnostic criteria, treatment and prognosis. Method Literature search of various databases including Cochrane, Google Scholar, PubMed, PsychINFO, Medline and NHS Database. Keywords, elderly, older adults, Hyperactivity Disorder, diagnosis, diagnostic tools, Attention Deficit Hyperactivity Disorder. Background begins in childhood and can persist throughout life. It can have serious consequences. For example, Barkley et al 1 found increased rates of comorbid substance abuse disorder, anxiety disorder, mood disorder, personality disorders, and disruptive behaviour disorders among adults with that had persisted from childhood into adulthood. They found this rate to be 84.3%. remains a controversial diagnostic entity. There are disagreements on its cause, research methodology and even whether it should be classified as a mental disorder 2. So far, most studies in adulthood concern young or middle-aged adults. Less is known about in old age. What is? is a treatable neuropsychiatric disorder characterized by core symptoms of inattention, hyperactivity and impulsivity, which is pervasive and impairs functioning and is not explained by any other medical or psychiatric condition (DSM IV) 3. The ICD 10 diagnostic criteria for Hyperkinetic Disorder (F 90) 4 are very similar to the DSM IV criteria in terms of inattention, hyperactivity and impulsivity along with the pervasive nature of the presentation and onset before seven years of age with clinically significant distress. Gene-environment interaction is predominantly a genetic disorder with environmental factors contributing 1

2 to its aetiology. Low birth weight, traumatic brain injury during childhood, exposure to infections, use of tobacco and alcohol pre-natally, can predispose to development of. Individuals with exhibit differences in the size and function of certain areas of brain, particularly the inhibitory centres in the frontal region. There is also an inherited deficit in dopaminergic function that makes it more difficult for individuals with to control their impulses and filter out distractions 5. The symptoms Individuals with present a mix of symptoms of hyperactivity, impulsivity and distractibility. Some individuals exhibit significant impulsivity and hyperactivity, while others primarily exhibit distractibility and disorganisation 5. has a profound impact on the lives of adults. They may exhibit problems with inattention, which manifests as disorganisation, forgetfulness, unreliability, difficulty in planning and/or completing tasks. Older adults with primarily exhibit symptoms of distractibility and disorganisation at home and in work-related areas 5. For example, they may forget to pay bills, miss appointments or tasks, lose items, and exhibit carelessness whilst driving. Difficulties in relationships with peers and family members can be evident in the form of marital discord, inconsistent relationships and few friends. The diagnosis Various diagnostic systems exist. However, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) 3 requires the presence of symptoms prior to seven years of age. The current diagnostic tools ICD-10 and DSM-IV-TR are orientated towards diagnosing in children. However, in older people there are no similarly validated tools. The consensus approach towards diagnosis of in older adults is a clinical decision based on unstructured interview to gather a comprehensive history along with collateral information about development, school and work performance, relationships, psychiatric history and family history. Diagnosis can be complicated because of the varying nature of symptoms, comorbidities like depression, anxiety, substance abuse, personality disorders and major life events (e.g. divorce or loss of job). In older people, diagnosis can be further complicated by the presence of cognitive impairment. 2

3 How prevalent is among older adults? According to a Dutch study 6, almost 3% of over 60s have ; the disorder does not fade away in adulthood. This study found that 2.8% of the 231 participants had syndromatic (6 or more symptoms of inattention and/or hyperactivityimpulsivity in a 6 month period) while 4.2% presented with symptomatic (at least 4 symptoms of inattention and/or hyperactivity-impulsivity in 6 months). Literature search There are very few studies and informal articles that mention in older people. Most studies are based on children or adults and one study that mentions the elderly has a study sample with a mean age of 66 years. My literature search yielded the following studies: Study/Article 1. Guldberg-Kjar and Boo Johansson (2009) Old people reporting childhood AD/HD symptoms: Retrospectively selfrated AD/HD symptoms in a population-based Swedish sample aged Golimstok et al (2011) Previous adult attentiondeficit and hyperactivity disorder symptoms and risk of Dementia with Lewy Bodies (DLB): a case-control study 8 Diagnostic criteria used to identify patients 25-item Wender Utah Rating Scale (WURS) was administered The DSM-IV criteria adapted for the identification of adult patients with and validated to Spanish Wender Utah Rating Scale were used to identify individuals with preceding symptoms during their adult life Comments/findings The Wender Utah Rating Scale was developed to assess adults' retrospective account of the childhood occurrence of symptoms associated with. The prevalence of selfrated childhood AD/HD symptoms was 3.3% The frequency of preceding symptoms in DLB cases was 47.8% as compared to Alzheimer s Disease 15.2% and 15.1% in the control group. The prevalence of symptoms in DLB cases was significantly higher. 3

4 3. Fischer et al (2012) The Identification and Assessment of Late-Life in Memory Clinics 9 4. Brod et al (2011) burden of illness in older adults: a life course perspective Michielsen et al (2012) Prevalence of in older adults in the Netherlands 6 Questionnaire to Memory Clinics to ascertain whether they identified in Memory Clinics to any extent. No mention of diagnostic criteria 1. Screening questionnaire by Barkley et al 2. Diagnostic Interview for in Adults, second edition (Diagnostisch Interview Voor bij volwassenen, DIVA 2.0) a modified structured interview Half the memory clinics that responded reported seeing patients, either identifying previously diagnosed cases and/or newly diagnosing. One fifth of clinics reported screening regularly for. Few clinics described accessing collateral informants to establish the diagnosis. Older adults Quality of Life measured by accumulative negative impact of symptoms/impairments on their professional, economic, social, and emotional well-being years. Tools not validated for older adults. Estimated prevalence rates in older adults: syndromatic, 2.8%; symptomatic, 4.2%. People aged years reported significantly more symptoms than those aged years. Treatment symptoms in adults show the same responsiveness to stimulant and nonstimulant medications as that seen in children 11, 12. However, no studies could be found regarding treatment options for specifically in older people. 4

5 For an elderly person with, how successful will treatment be? We know from research that stimulant medications appear to be the most helpful for treating. However, patients with cardiac conditions like severe arrhythmias, hypertension and cardiomyopathy are not suitable for this treatment. Early research indicates that methylphenidate, a drug prescribed for adult, may help prevent falls in older people and in patients with Parkinson's disease 13. Although this study was too small to warrant the widespread prescription of methylphenidate, results suggest that treating cognitive defects associated with ageing and diseases like may decrease falls in the elderly 13. Prognosis Little evidence based data exists. is associated with cognitive impairment 14 and this may compound other cognitive impairments like difficulty with working memory, executive function and other aspects of cognition which develop in older people. The combination may have worse prognosis than either alone. Discussion Diagnosing is more complex in older people for several reasons. While there is general agreement that can be reliably diagnosed in children through the use of the formal diagnostic criteria, validity of specific diagnostic tools in elderly people is reduced 15. symptoms may diminish over time 16 and the clinical profile may increase in heterogeneity with age, rendering it harder to recognise in older patients 17. It requires careful consideration of differential diagnoses such as depression, bipolar disorder, generalised anxiety disorder, personality disorder, substance misuse and dementia. Typical sources of collateral information may be unavailable for older people e.g. school reports. Symptoms may also be misattributed to age-related cognitive decline 18. Conclusion in older people may be associated with psychiatric co-morbidities and therefore it is possible that social and economic costs of caring for this population may increase. does not disappear in adulthood and thus, there is a need to understand the presentation and impact of in later life. This should include developing age-appropriate approaches and assessment tools to aid diagnosis and treatment. 5

6 References 1. Barkley RA, Murphy KR, Fischer M. in Adults: What the Science Says. (New York: Guilford; 2008) 2. Controversy about. Accessed 20 July American Psychiatry Association, Diagnostic and Statistical Manual of Mental Disorders 4th Edition (1994) 4. World Health Organization, ICD-10 Classification of Mental and Behavioural Disorders (1992) 5. Kapalka G. in older adults Accessed 20 July Michielsen M, et al. Prevalence of attention-deficit hyperactivity disorder in older adults in The Netherlands. Br J Psychiatry (2012) 1 8. doi: /bjp.bp Guldberg-Kjär T, Johansson B. Old people reporting childhood AD/HD symptoms: Retrospectively self-rated AD/HD symptoms in a population-based Swedish sample aged Nord J Psychiatry (2009) 63: Golimstok A, et al. Previous adult attention-deficit and hyperactivity disorder symptoms and risk of dementia with Lewy bodies: a case-control study. European Journal of Neurology (2011) 18: 1, Fischer BL, et al. The identification and assessment of late-life in memory clinics. Journal of Attention Disorders (2012) 16: Brod M, et al. burden of illness in older adults: a life course perspective. Quality of Life Research (2012) 21: 5, Faraone SV, et al. Meta-analysis of the efficacy of methylphenidate for treating adult attention-deficit/hyperactivity disorder. Journal of Clinical Psychopharmacology (2004) 24: Simpson D, Plosker GL. Atomoxetine: a review of its use in adults with attention deficit hyperactivity disorder. Drugs (2004) 64: Hausdorff J. Alleviating the Fear of Falling. University of Tel Aviv (2008) 6

7 14. Nigg J. Cognitive Impairments Found With Attention-Deficit/Hyperactivity Disorder (2009) Accessed 20 July Simon V, et al. Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Br J Psychiatry (2009) 194: Halperin JM, Healey DM. The Influences of Environmental Enrichment, Cognitive Enhancement, and Physical Exercise on Brain Development: Can we Alter the Developmental Trajectory of? Neurosciences Biobehaviour Review (2011) 35: Schmidt S, Petermann F. Developmental psychopathology: Attention Deficit Hyperactivity Disorder BMC Psychiatry (2009) 9: 58. Published online Smith G, Rush B. Normal aging and mild cognitive impairment. In: Geriatric Neuropsychology ed. D. Attix, K. Welsh-Bohmer (New York: Guilford; 2006) 7

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