Katherine Quinn, Ph.D. interviewed Dr. Kathleen Nadeau on May 3, 2022 as a tease prior to the release of her book in September, “Still Distracted After All These Years,” where she reported the results of interviews of older adult individuals with ADHD and their functioning in later life. Dr. Quinn’s interview questions presented below were based on Dr. Nadeau’s presentations and writings as well as highlights of her findings from her interviews for her book.
The first of two parts of Dr. Quinn’s interview of Dr. Nadeau was presented in the July issue of Age in Action. The second is presented below.
Katherine Quinn, Ph.D. is a clinical psychologist in private practice. She is a Past President and Fellow of SDPA. She was also previously Editor of the San Diego Psychologist.
ADHD – ONE OF THE FOUR MOST COMMON PSYCHIATRIC DISORDERS – SUBTYPES AND MEDICATION
Q – Talk about some of the ADHD subtypes: the inattentive type versus the hyperactive type. It sounds like there still can be a lot of activity, especially motor activity, with the older adult. And can you comment on the use of medication for this group? You have also discussed co-occurring diagnoses and so maybe there is also some anxiety and depression going on too. How would you refer someone for medication?
Well, there is precious little education of psychiatrists on adult ADHD at all, and even less on older ADHD adults. Dr. David Goodman, who is a friend and colleague of mine here in the Washington, D.C. area, specializes as a psychiatrist in working with adults with ADHD, and he’s done a good bit of lecturing.
Dr. Goodman says that adult ADHD is one of the four most common adult psychiatric disorders. And yet the amount of time spent on training adult psychiatrists during their residency is limited. Because of this, it is not treated as one of the most common psychiatric disorders that we really need to know how to diagnose and treat. And that is the reason that I have done so much research on it and written my book. I really want to educate mental health professionals that this is a common disorder.
Q – I hear that the approach to assessment and medication needs to be done carefully, in order to appropriately look at medication treatment and see what might be helpful.
Yes and an important point is that older adults respond to stimulant medication just as well as younger adults and children do. Yet there is real misapprehension that it’s dangerous and there is a general reluctance to prescribe to them.
For example, they may be on blood thinners, or they might be on cholesterol medications, etc. Doctors don’t want to complicate things by giving them a stimulant. Still, this is so ironic because among geriatric psychiatrists treating very old people in nursing home settings, the prescription of stimulant medication is actually very common. And still these people are more vulnerable and older and sicker than those who have not entered nursing care yet. And typically in nursing homes, stimulants are prescribed for depression and lethargy. At least that’s what doctors think they’re treating for. And yet for people, a decade younger, the younger old ADHD group, there’s a lack of knowledge and therefore a reluctance to prescribe stimulant medication.
Q – What more does Dr. Goodman report?
Interestingly, Dr. Goodman indicates that in his survey of older adults recently, he gave an online talk and asked how many had difficulty getting stimulants prescribed for their ADHD. He found that many more of them have been able to get stimulant medication prescribed by their primary care physician, as long as they have a letter from a psychologist, or from a psychiatrist saying, “Yes, we recommend this and we’ve diagnosed ADHD.” So there’s a dawning of awareness about the needs of older adults in this regard. And they respond well to the same medications, the same dosages, and can be tremendously helped.
In my upcoming book, in the medication chapter, I’ve got a long list of verbatim quotes from many of the adults that I interviewed. They talked about how life changing for them and how helpful it has been for them to start taking stimulant medication. We are really doing them a disservice to ignore or misdiagnose their ADHD. Sadly, Dr. Goodman reports, after he surveyed memory clinics across the US, among those that responded, only one in five clinics mentioned even occasionally considering the possibility of adult ADHD. If someone came in talking about forgetfulness, the clinics were tuned in to dementia, and prescribed for that.
ADHD AND DEMENTIA – IS THERE A HIGHER RISK?
Q – You just brought up the topic of dementia. Talk about the relationship between ADHD and the dementias including Alzheimer’s dementia. What do we know about the relationship?
We don’t know very much yet because we really haven’t been studying older adults that much. Several years ago, the only connection between dementia and ADHD was some research that showed a slight connection between dementia with Lewy bodies (DLB) and ADHD. I came across an article very recently that linked ADHD with a slightly higher risk for Alzheimer’s, but it is not a huge risk factor. You are not hugely more likely to develop dementia because you have ADHD.
ADHD IN OLDER ADULTS AND COEXISTING CONDITIONS
Q – What are some of the most common coexisting conditions with ADHD and older adults?
They’re exactly the same ones that we find in middle aged adults. Anxiety and depression are among them, but we are much less concerned with learning disorders.
And the other thing that I think is important to understand about my research is that in no way can I say that the adults I studied are a representative sample of adults across the whole spectrum. The reason I say that is I advertised for adults to interview in Attitude magazine, a British gay life style magazine read by many in the UK. And many of the people that read that and responded to me are among the very highest functioning adults. Readers were much more likely to be college educated and to be the parent or grandparent of someone with ADHD. And so they were very informed about it. I think the statistics that I gathered, in terms of co-morbidities, is not an accurate reflection. For example, I did not find a high level of reported substance use issues. And, I think that they certainly exist in the older ADHD population as they do in every other age group. But I think I was just interviewing a more functional group of people.
EXECUTIVE FUNCTIONING IN OLDER ADULTS
Q – There is some contradictory information in the research around whether or not older adults have less executive functioning concerns with age. What are you finding?
I don’t think that’s accurate. I’ll tell you an analogy. If you had a disability that limited your mobility, you could say that if you suddenly started living in a one floor, you didn’t have to worry about stairs. That doesn’t mean your disability has changed at all. It means that you’ve accommodated your disability. And so the analogy I use is when people are retired, they’re not working, not raising children, and have less demand placed on their executive functioning abilities, which makes life easier. But I can guarantee you that if life ramped back up, if suddenly they had to start raising grandchildren, et cetera, their executive functioning problems would pop right back up. It’s just that for some life gets simpler as they age.
WOMEN AND ADHD
Q – In your 2018 presentation at the American Professional Society of ADHD and Related Disorders, you talked about women and ADHD and aging and their specific concerns. Women in their forties and fifties, premenopausal and menopausal women, need to start looking out for changes regarding their ADHD. Say more about this.
Well, by the time you get to the age of the people that I interviewed, they are well beyond menopause but I can say, in a very general way, that women’s ADHD is hugely impacted by their estrogen levels. And so the lower our estrogen levels, the more impacted they are in many ways, and ADHD is one of them. Recently I had a consult with and was asked a question by an older woman who was diagnosed with breast cancer that was not advanced. She was not going to have to go through radiation or significant surgery, but she was going to take a medication for the rest of her life. She wondered if it would make her ADHD worse. And there is no research on that because there’s almost no research on older adults with ADHD. But I spoke to one of my physician colleagues who is very interested in the impact of hormonal fluctuations on women with ADHD. She indicated that, in general, the medicine would likely make the ADHD symptoms worse because it would lower her estrogen levels.
ADHD AND RETIREMENT AND SOCIAL ISOLATION
Q – In your takeaway presentation in 2018 about the parallels between children and older adults with ADHD, you talked about the parallel challenges between these groups. What are they?
Both groups are on parallel paths in that older teenagers and young adults leaving home are both leaving behind an enormous amount of structure and support that has helped them to function. Young adults are moving away from parents and tutors and, in many cases, teachers and going out into the adult world. And so there’s a great deal more demand on their own ability to self-regulate, to manage what they eat, how much they sleep when they sleep, if they exercise, and are they able to pay their bills? Can they find and keep a job? Can they regulate their lives? And there’s a huge learning curve and challenge in that process. And I have found that for some adults and certainly not all of them, they go through this same process as children and young adults. When the older adult leaves the world of work, they don’t have a place to go in the morning, a time schedule. They don’t have colleagues at work to interact with or a focus or a purpose for their day. Some adults make a wonderful pivot toward other activities and say,” this is the best time in my life.” That is not the majority of people. I did talk to people who were very involved in their community and involved in doing something that engaged them and that mattered to them. This gave them people to interact with. And they were doing well. But I found many more people that were not doing so well. And we know the divorce rate is higher among people with ADHD. We know that women with or without ADHD are more likely to live alone in their later years simply because women live longer than men. And that people that are living entirely alone don’t function very well. Many of them would comment, “I don’t even get dressed all day long. I stay in my pajamas. I don’t eat regular meals. I stand in front of the refrigerator and snack. It is such a pain to cook for one person and I don’t have much of a social life. My friends have moved away or some of them have died and my house is such a mess. I would never invite anyone over.” These people just sink into increasing social isolation. And as we know, loneliness literally can kill. I read more and more articles about the loneliness epidemic here in the U.S. and that people are living their lives online, and the only contact they have is by Zoom or just surfing the internet and social media. So, one of the analogies I use is I think for many older adults with ADHD, they are likely to thrive more in a community designed for older adults that has lots of built in social connection and activity so that they don’t get so socially isolated.
I was talking to a woman, who has ADHD and lives in a place in Florida called The Villages, which is the fastest growing community in the United States. And this woman shared that her community is so fast growing because it is an affordable community. And there are some very wealthy people there, but most people are just middle class and live in modest two-bedroom houses. But The Villages is designed to provide just almost an infinite amount of activities and social interactions that are hard to come by for people that stay in their houses in their community as they age.
I’m currently noticing the lack of social interaction and activities where my husband and I live. The community where we live is not the same as the one where we raised our children. Still, we have lived in this community for 16 years. And even here, I’ve noticed that many of the people our age have either died or moved away because the houses they lived in were too large. And so my current community is younger than I am.
What this means is that we don’t have that much in common. We don’t have kids in school. I don’t have kids on the swim team, you know, all the things that connect people to younger parents. And so even though many older adults state that they would prefer to age in place, I think really what they’re stating is it just feels like an overwhelming proposition, a frightening proposition, to leave a house that they have been in for so many years. It is such a project to move. People have accumulated stuff for 40 or 50 years. And I don’t know where else I would go live anyway, and neither do most people. So, it is just easier to just stay. But sadly, that decision to just stay usually entails a lot of social isolation.
ADHD AND WHO IS DOING BETTER AS AN OLDER ADULT
Q – An important question you were seeking an answer to was “What ADHD individuals were doing better as they age and which ones were doing worse.” So, what have you found?
One finding relates to social isolation and the impact on regulation. Human beings are social animals and we are typically much better regulated when we live with other human beings. For example, when people live alone often there is no regular bedtime or getting up time. There is no regular meal time or anything time.
Another important point regarding regulation is that people with ADHD of all ages have a big struggle structuring themselves. When there is no structure surrounding them, they don’t do as well. So, creating and maintaining structure is the mantra that it is important to teach people, especially when people live alone where they are less likely to have it.
EDUCATION OF THOSE WHO DIAGNOSE AND TREAT ADHD
Q – You have discussed that medical doctors don’t understand about ADHD, but psychologists, we’re the ones assessing and treating these people, and we don’t have many psychologists that are educated. What would you tell psychologists so that they can do a better job in diagnoses and treatment?
Well, because statistically we now know that ADHD is one of the four most common adult disorders, it should be something on the mind of every psychologist regarding every adult that walks into their consulting room. As a profession, we tend to be so over focused and trained for screening for anxiety and depression that we tend to overlook the ADHD screening.
We need to look for dysregulated sleep in these individuals and notice that they are always arriving late for their appointments. And that lateness doesn’t necessarily mean they are resisting therapy. It more likely means they have ADHD and can’t manage to get themselves out the door on time to be at their appointment on time and that should be on the psychologist’s radar. The other thing I would say to psychologists is that you really need to know how to treat the ADHD and not just the more psychosocial or psychological issues that we’re all so familiar with.
And that’s sort of our default position. As psychologists we are going to talk to you about your marriage, your self-esteem, your anxiety, your whatever, but probably not whether or not you might have ADHD and that you might function better if you were on stimulant medication and get your living environment in better order. People can’t be organized and focused when they are living in physical chaos; still many older adults live this way.
Q – So, it sounds like what I hear you saying and what one of the things our Association is thinking of is to develop and provide presentations on educating psychologists about the assessment treatment process for ADHD in adults. Say more about that.
Yes, it is so important to do that. And you can take this amazing statistic back to your association psychologists. Because we are living longer, by 2030, there will be more people with ADHD over the age of 65 than under the age of 18. And so that’s really telling us that all those years ago we started off thinking that this is a disorder of childhood. However, there will continue to be many more adults on this planet than children with ADHD.
And I asked in my interview, “What are your struggles related to ADHD as an older adult?” And the number one answer was that people say they just can’t seem to accomplish anything.
They will say, “I will set out intending to pay my bills or work on a project or whatever, and I just don’t ever seem to finish it.”
And many people said to me, “I had so many dreams of what I would do in my retirement when I had lots of time, but I’m not doing any of them. I can’t get a focus and stay focused and be productive, even on things that I really thought I wanted to do. And it is just me, myself, and I.”
I tell them, “If you want to write that memoir, you need to join a memoir writing group which will give you more structure and support. If you want to paint, join a painting group. We need each other.” A colleague of mine and I offered a support group for older ADHD adults at the very beginning of the pandemic to assist in providing structure to them weekly.
And as far as I know, it was the first ever support group for older adults with ADHD. And they became an incredibly tightly knit group. And when I said, “we can no longer support this group, but we hope you’ll continue, they continued and it is the highlight of the week for most of the women in that group. The feeling was, “I am in with my tribe.” And I think that support groups of this type are something that is so critical for us to be aware of and, yes, and to offer as mental health professionals.
REMAINING TAKES FROM THE BOOK
Q – What have we not talked about that wasn’t in my list of questions to you?
Let me go through the other top challenges because this will tell your crew what to look for. The number one challenge that I already talked some about for older ADHD adults was not getting anything done. The number two challenge was emotional dysregulation.
And we’ve only really very recently started thinking of emotional dysregulation issues as a core element of ADHD. You won’t find that in the DSM, but I think you will at some point in the future. And that was definitely the number two complaint. And so, people said things like “I feel overly irritable. I have emotional meltdowns. I get angry easily. I feel overwhelmed, anxious, and impatient. I feel a lot of sadness and regret for all the things I might have accomplished if I’d been diagnosed with ADHD a long time ago.” And so, people report a lot of emotional issues as they get older.
And poor time management is a number three challenge. “I don’t know where the time goes. I don’t seem to get much done. I’m always running late. I don’t have a schedule and it is just harder to manage my time.”
And number four, I called this one. I call it remnants of hyperactivity. Some people said, “I just feel continually restless. I have random thoughts swirling in my head all the time. I talk too much. I can’t seem to relax. I just need to keep going and doing. And I constantly take on too many things.” And then of course they don’t finish them.
And the last of the top five were difficulties with interpersonal relationships. Those social skills challenges of the early years continue on. People would say, “I feel misunderstood. I feel judged by other adults. I need to learn to be a better listener. I use the wrong tone of voice sometimes and don’t mean it. I say the wrong thing. I miss social cues. And I just generally don’t feel like I fit into most social groups easily.” And those things are really things that a teenager might say if they had the self-awareness to say it. In other words, older adults do not necessarily have new issues. Their issues are very similar to the younger aged groups.
Q – Speaking of providing educational opportunities to psychologists, would you have any interest in coming to the West Coast to present to our Association?
That certainty interests me; however, I am also learning not to over commit. My book is coming out in October and I think I am going to be involved in publicity around that. But certainly, if I’m out on the West Coast, I would be happy to let you know that and possibly we could organize something around that.