Living on the Spectrum — ADHD in Older Adults
In this episode, Aaron and Jamie look at a topic they feel gets far too little attention: ADHD in later life. Drawing on three ADDitude pieces — Linda Roggli's "Inside the Aging ADHD Brain" and two articles by psychiatrist David Goodman — they work through why diagnoses are climbing among people in their sixties and beyond, how clinicians tell ADHD apart from ordinary cognitive aging and early dementia, what the research does and does not say about medication safety, and why an evaluation at 60 or 70 can still matter.
Inside the Aging ADHD Brain
Diagnoses are rising steadily among people in their sixties, seventies and older — cohorts born in the 1940s, 50s and 60s, when ADHD was rarely identified in children. Clinicians report a steady stream of testing requests at ages 40, 50, 60 and beyond. The article profiles Zophia, who was 63 in 2006 when a television talk show prompted her evaluation after more than 40 years of therapy that never reached the underlying issue, and John Washbush, diagnosed at 70, who took his first dose of Ritalin on his 72nd birthday and said that within 20 minutes he knew he was "on a path to discovering the real me."
A central clarification: there is no adult-onset ADHD. ADHD begins in childhood and continues through life. What changes are the demands placed on the person and the coping resources available to them. Normal aging adds overlap of its own — processing speed begins slowing from the mid-30s, and working memory and selective attention decline with age — which complicates the question of whether new forgetfulness reflects ADHD, typical aging, or both.
Diagnosis in this age group is difficult. There is no blood test or brain scan; clinicians rely on in-depth intake interviews and behavioral markers. The DSM-5 requires six impairing symptoms for those 17 and under and five for adults over 17, but most diagnostic criteria and questionnaires were developed for children. Psychiatrist William Dodson notes that an adult meeting purely child-based criteria would essentially have to function like an elementary-school-age child with untreated ADHD. Some researchers have proposed fewer symptoms for people over 40, but the hosts stressed this remains a research suggestion rather than established practice.
Mild cognitive impairment and early dementia can look similar on the surface. Kathleen Nadeau observes that symptoms involving memory, routines and executive function in older adults are more often read as MCI or dementia than as ADHD. Anthony Rostain of the University of Pennsylvania frames the key distinction as: is this someone who never had ADHD symptoms and is now newly forgetful, or someone who has always been distracted and is only now being recognized? Goodman uses a practical version of that question in his practice — "If I interviewed you 10, 20, or 30 years ago, would you have been talking about these symptoms?" The hosts noted that only about 20 percent of memory clinics report screening regularly for ADHD, meaning many clinics may attribute ADHD-like symptoms to age-related decline without considering ADHD as a premorbid baseline.
Neuropsychological testing, which listeners might expect to settle the question, is not reliable for diagnosing ADHD in older adults and can be expensive. Goodman cites a study of more than 300 Alzheimer's center patients aged 62 to 91, in which about 4.5 percent met ADHD criteria on a rating scale, yet neuropsychological testing found no significant differences between those with and without ADHD. He reserves such testing for examining other aspects of cognitive ability, and treats the clinical interview as the gold standard.
On driving, a 2023 cohort study led by researchers at Columbia University's Mailman School of Public Health and published in JAMA Network Open followed adults aged 65 to 79. Compared with same-age drivers without ADHD, those with ADHD were 74 percent more likely to have car crashes, 102 percent more likely to receive traffic tickets and 7 percent more likely to show hard-braking events. The hosts were careful to frame this as an association from a cohort study rather than evidence of causation, and noted the article's own caution that higher accident rates in older adults have also been attributed to normal aging, dementia, poor vision, medical problems and medications.
On treatment, a November 2022 meta-analysis in JAMA Network Open pooled 19 observational studies from the previous 15 years, covering 3.9 million participants across the US, South Korea, Canada, Denmark, Spain and Hong Kong, and found no statistically significant association between ADHD medications and cardiovascular disease, including among middle-aged and older adults. The hosts emphasized the limits: this is observational evidence, and there are no controlled research trials of ADHD medications in people over 65, partly because trials tend to exclude people taking other medications or with other medical conditions. Any stimulant prescription for ADHD over 65 is therefore technically off-label, and no research to date addresses non-stimulants in adults over 65. Polypharmacy is a real consideration — about 76 percent of adults over 50 with ADHD report ongoing treatment for other conditions. Dodson says first-line stimulants and the alpha-agonists clonidine and guanfacine can generally be taken alongside most commonly prescribed medications, though monitoring matters: stimulants can raise heart rate and blood pressure, and patients with conditions such as atrial fibrillation should consult a cardiologist. Goodman's bottom line was quoted directly: "Cardiac illness should not be the absolute contraindication to taking medication because untreated ADHD can significantly reduce quality of life" — a position that requires individualized consultation with cardiologists and prescribers rather than self-directed treatment.
The article also devotes a section to hormones. Developmental pediatrician Patricia Quinn explains that estrogen supports neural receptors that improve connections between norepinephrine and dopamine, the neurotransmitters involved in alertness, focus and motivation; when estrogen drops, dopamine and norepinephrine drop with it. Perimenopause can therefore make ADHD symptoms suddenly much more visible, and Quinn reports many women being diagnosed in their late 30s and 40s at that stage. For women over 40 also navigating sandwich-generation caregiving, divorce or bereavement, and new health problems, the question "ADHD or menopause?" becomes immediate. Rostain notes that twice as many men as women come to his clinic seeking a possible diagnosis, and that male hormone change is less dramatic — estrogen stays relatively constant until about 70, while testosterone decreases gradually, which can bring mood swings and sleep disturbances. Quinn mentions estrogen therapy as potentially helpful for ADHD symptoms at menopause, with cautions: a progestin should be added at regular intervals to protect against uterine cancer, and women with vascular problems or a cancer history should consult their doctors. Both she and Rostain recommend maintaining ADHD treatment alongside estrogen therapy if it is chosen, and the hosts stressed this is firmly a matter of individual medical decisions.
On comorbidity, studies of adults with ADHD over 50 report psychiatric comorbidities in roughly half of participants — about 36 percent depression, 26 percent anxiety and 25 percent bipolar disorder. The article suggests earlier diagnoses of those conditions in older ADHD adults were likely accurate but incomplete, in that ADHD coexisted without being identified.
Finally, the article's practical answer to the question Arnold asked at 73 — whether evaluation is worth it at that age — is that value depends on life circumstances, but age should never be a deterrent. A diagnosis is required for medication and for insurance coverage of testing, medication, psychotherapy and behavioral interventions.
ADHD in Older Adults: Distinct Diagnostic & Treatment Considerations
Goodman's diagnostic piece underlines how much the standard toolkit was built for children. The DSM-5 symptom thresholds — six for those 17 and under, five for adults over 17 — were validated in younger populations, and Dodson argues that applying child-based criteria literally to an adult would imply functioning at the level of an elementary-school child with untreated ADHD. The suggestion that older adults might warrant fewer symptoms remains untested as clinical practice.
The hosts highlighted the practical interview question Goodman uses to establish whether ADHD is lifelong: "If I interviewed you 10, 20, or 30 years ago, would you have been talking about these symptoms?" Rostain's framing — whether someone is newly forgetful with no prior history, or has always been distracted and is now finally recognized — makes the same point. The differential with mild cognitive impairment and dementia is a live concern, and Nadeau's observation that memory, routine and executive-function symptoms in this age group tend to be attributed to cognitive decline rather than ADHD suggests a systematic gap in recognition.
On testing, Goodman cites the Alzheimer's center study of more than 300 patients aged 62 to 91: about 4.5 percent screened positive for ADHD on a rating scale, but neuropsychological testing did not distinguish them from the rest of the group. He treats the in-depth clinical interview as the primary diagnostic instrument and reserves neuropsychological testing for other questions, in part because of cost.
On treatment, the piece sets out both the reassuring findings and their boundaries. The 2022 meta-analysis of 19 observational studies and 3.9 million participants found no statistically significant link between ADHD medication and cardiovascular disease, but the absence of randomized controlled trials in people over 65 — and the exclusion criteria that keep such trials small — means stimulant prescribing in this group is off-label, and non-stimulants are unstudied in adults over 65. With roughly 76 percent of adults over 50 on treatment for other conditions, Dodson's account of generally manageable interactions with clonidine and guanfacine comes with the caveat that monitoring is essential, particularly given stimulant effects on heart rate and blood pressure. Goodman's framing of cardiac illness as something to weigh rather than an absolute contraindication was presented as a risk–benefit judgment that belongs to cardiologists and prescribers, not patients acting alone.
Does ADHD Get Worse with Age? Persistent Symptoms and Smart Treatment in Older Adults
Goodman's second piece anchors the persistent-symptom question in data. A study following more than 109,000 participants over 17 years found that people with ADHD had a 2.77 times greater risk of dementia than those without, even after adjustment for factors including obesity and diabetes. The same study found participants exposed to stimulant medication had less dementia risk than those unexposed. The hosts were explicit about what this does and does not show: it is an association, not evidence that treating ADHD prevents dementia, and Goodman himself says much more research is needed to understand the ADHD–dementia link.
On the "smart treatment" side, the discussion returned to individualized care — medication decisions shaped by cardiovascular status, interacting prescriptions and personal medical history rather than age alone.
The hosts also emphasized what a late diagnosis can mean beyond medication access. Goodman describes late diagnosis as frequently liberating for older adults, and points to an often overlooked benefit of psychotherapy in this group: improved self-esteem and self-concept after decades of assuming one was fundamentally flawed. Given that roughly half of adults over 50 with ADHD report psychiatric comorbidities — about 36 percent depression, 26 percent anxiety, 25 percent bipolar disorder — recognizing ADHD can also reframe earlier diagnoses as accurate but incomplete.
For listeners considering evaluation, the hosts suggested that if a clinician dismisses the possibility because of age, bringing research studies to the appointment and seeking a second opinion from someone experienced in adult ADHD are reasonable steps. Goodman's remark that "It's easier to educate the uninformed than it is to educate the misinformed" speaks to how clinician training has historically lagged on ADHD in older adults. As always, the hosts reminded listeners that nothing in the episode replaces professional medical advice, and that diagnosis and treatment decisions belong with qualified professionals.
Sources
- ADDitude — Inside the Aging ADHD Brain (Linda Roggli)
- ADDitude — ADHD in Older Adults: Distinct Diagnostic & Treatment Considerations
- ADDitude — Does ADHD Get Worse with Age? Persistent Symptoms and Smart Treatment in Older Adults
Podcast Transcript
Aaron: Welcome to Living on the Spectrum. I'm Aaron.
Jamie: And I'm Jamie.
Aaron: Today we're talking about something that doesn't come up nearly often enough — ADHD in older adults. There's a fascinating piece in ADDitude by Linda Roggli called "Inside the Aging ADHD Brain," and it really opened my eyes. Jamie, where do we start?
Jamie: I think the headline finding is that diagnoses are climbing steadily among people in their sixties, seventies, and beyond — people who grew up in the 1940s, 50s, and 60s, when ADHD was rarely recognized in children, let alone adults. Clinicians are now seeing a steady stream of requests for testing at ages 40, 50, 60, and older.
Aaron: That makes so much sense to me. If you were born in 1955, no one was looking for ADHD in your elementary school. So you spent decades thinking you were just disorganized or lazy. The article profiles a woman named Zophia who was 63 in 2006 when a TV talk show prompted her to get evaluated, after more than 40 years of therapy that never quite got to the root of it. And a man named John Washbush, diagnosed at 70, who took his first dose of Ritalin on his 72nd birthday and said within 20 minutes he knew he was "on a path to discovering the real me."
Jamie: Those personal accounts are striking, but it's important to say clearly: there's no adult-onset ADHD. ADHD starts at birth and continues, largely unchanged, through life. What changes are the demands placed on the person and the coping resources available. So the older adult who suddenly feels more forgetful is facing a different question than the one who always felt scattered.
Aaron: Right, and that's where it gets tricky, isn't it? Because normal aging itself causes some overlap — processing speed slows starting in the mid-30s, working memory and selective attention decline with age. How does a clinician untangle ADHD from what's just normal cognitive aging?
Jamie: There's no blood test or brain scan. Diagnosis relies on behavioral markers gathered through in-depth intake interviews. The DSM-5 requires six impairing symptoms for children and adolescents 17 and under, and five for adults over 17. But here's the nuance: most diagnostic criteria and questionnaires were designed for children. William Dodson, a psychiatrist quoted in the article, points out that an adult meeting purely child-based criteria would essentially have to function at the level of an elementary-school-age child with untreated ADHD. Some researchers have suggested that fewer symptoms might be appropriate for people over 40, but that remains a research suggestion, not established practice.
Aaron: That's a really important distinction. So the tools we have are imperfect for this population. And there's another layer — mild cognitive impairment and early dementia can look similar on the surface. The article quotes Kathleen Nadeau saying that older adults' symptoms involving memory, routines, and executive functioning are more often interpreted as MCI or dementia than as ADHD.
Jamie: Exactly. Anthony Rostain, from the University of Pennsylvania, frames it as a key distinction: is this someone who never had ADHD symptoms and is now newly forgetful, or someone who has always been distracted and is just now getting recognized? That question — has this been lifelong? — is central. Dr. David Goodman, a psychiatrist who wrote two of the ADDitude pieces we're drawing on, uses a revealing question in his practice: "If I interviewed you 10, 20, or 30 years ago, would you have been talking about these symptoms?"
Aaron: I love that question. It's so practical. And it connects to something the article says about memory clinics — only about 20 percent reported screening regularly for ADHD. That means most clinics might see ADHD-like symptoms and attribute them to age-related decline without ever considering ADHD as a premorbid baseline.
Jamie: That's a significant gap. And neuropsychological testing, which people might assume would help, isn't reliable for diagnosing ADHD in older adults. Goodman cites a study of more than 300 Alzheimer's center patients aged 62 to 91, where about 4.5 percent met ADHD criteria on a rating scale, but neuropsychological testing found no significant differences between those with and without ADHD. Testing can also be expensive. He reserves it for examining other elements of cognitive ability, not for ADHD diagnosis itself.
Aaron: So the clinical interview is really the gold standard. That's good to know. Now, there's a driving study in the article that caught my attention — a 2023 cohort study led by researchers at Columbia University's Mailman School of Public Health.
Jamie: Right, published in JAMA Network Open. Among adults aged 65 to 79 with ADHD, car crashes were 74 percent more likely, traffic tickets 102 percent more likely, and hard-braking events 7 percent more likely compared with drivers of the same age without ADHD.
Aaron: Those are striking numbers. But I want to be careful here — that's an association, not causation, right?
Jamie: Correct. The article itself notes that higher accident rates among older adults have been attributed to normal aging, dementia, poor vision, medical problems, and medications — not solely ADHD. It's an association from a cohort study, and individual circumstances vary widely.
Aaron: That's the kind of nuance I want our listeners to hold onto. Now let's shift to treatment, because the medication picture for older adults raises some important questions.
Jamie: There's good news and important caveats. A November 2022 meta-analysis, also in JAMA Network Open, looked at 19 observational studies from the previous 15 years, including 3.9 million participants, and found no statistically significant association between ADHD medications and cardiovascular disease — even among middle-aged and older adults. It included patients from the US, South Korea, Canada, Denmark, Spain, and Hong Kong.
Aaron: That's a big sample. Does that mean stimulants are completely risk-free for older adults?
Jamie: Not exactly. It means the meta-analysis didn't find a statistically significant association. But there are no controlled research trials of ADHD medications in people over 65, partly because trials tend to exclude people on other medications or with other medical conditions. So technically, any stimulant prescription for ADHD over 65 is off-label. There's also no research to date on non-stimulants for adults over 65.
Aaron: So the evidence base is observational, not from randomized controlled trials in this age group. That's a meaningful distinction. And polypharmacy is a real concern — the article notes that about 76 percent of adults over 50 with ADHD report ongoing drug treatment for other conditions.
Jamie: Right, and drug interactions matter. Dodson says first-line stimulants and the alpha-agonists clonidine and guanfacine — a related class of medications sometimes used for ADHD — can generally be taken with most commonly prescribed medications, but monitoring is key. Stimulants can raise heart rate and blood pressure, so patients with conditions like atrial fibrillation should consult a cardiologist. The approach is individualized — not a blanket yes or no.
Aaron: Goodman's bottom line on cardiac risk is worth quoting: "Cardiac illness should not be the absolute contraindication to taking medication because untreated ADHD can significantly reduce quality of life." He's clearly saying it's about weighing risks and benefits per person, not about avoiding medication by default.
Jamie: And he's explicit that this requires consultation with cardiologists and prescribers — it's not a green light for self-directed treatment. Now, there's an interesting finding from a 2023 study that Goodman discusses in a separate ADDitude piece.
Aaron: The dementia study?
Jamie: Yes. It followed more than 109,000 participants for 17 years and found that people with ADHD had a 2.77 times greater risk of dementia than those without, even after adjusting for risk factors like obesity and diabetes. Importantly, the study also found that participants treated with stimulant medication had less dementia risk than those unexposed to medication.
Aaron: So the association isn't that ADHD medication causes dementia — if anything, the direction went the other way in that study.
Jamie: That's what the data showed. But Goodman himself says much more research is needed to understand the ADHD-dementia link. It's an association, not a conclusion that treating ADHD prevents dementia. We should be precise about that.
Aaron: Absolutely. Now, I want to bring in the hormone angle, because the article has a whole section on estrogen and ADHD in women.
Jamie: Patricia Quinn, a developmental pediatrician, explains that estrogen supports neural receptors to improve connections between norepinephrine and dopamine — neurotransmitters that maintain alertness, focus, and motivation. When estrogen drops, dopamine and norepinephrine drop too, and cognitive function follows.
Aaron: So perimenopause — the years before menopause when estrogen becomes erratic — could be a time when ADHD symptoms suddenly become much more visible.
Jamie: Quinn reports that many women are diagnosed in their late 30s or 40s during perimenopause. For women over 40 who are also dealing with sandwich-generation caregiving, divorce or loss of a spouse, and new health problems, the question "ADHD or menopause?" becomes very real.
Aaron: And Rostain makes an interesting point about men — he says twice as many men as women come to his clinic seeking a possible ADHD diagnosis. He also notes that male hormone changes are less dramatic: estrogen stays relatively constant until about 70, while testosterone gradually decreases, which can lead to mood swings and sleep disturbances.
Jamie: Quinn does mention estrogen therapy as potentially helpful for ADHD symptoms at menopause, but with clear cautions — women should add a progestin at regular intervals to protect against uterine cancer, and those with vascular problems or a cancer history should consult their doctors. She and Rostain both recommend maintaining ADHD treatment alongside estrogen therapy if chosen. This is firmly in the realm of individual medical decisions.
Aaron: That feels like a good place to turn practical. For someone listening who's in their 60s or 70s wondering, "Is it even worth getting evaluated?" — Arnold in the article asked exactly that at 73.
Jamie: And the article's answer is that the value depends on life circumstances, but age should never be a deterrent. A diagnosis is necessary for medication, and for insurance coverage of testing, medication, psychotherapy, and behavioral interventions. Goodman emphasizes that late diagnosis can be genuinely liberating — he frames it as a positive, life-changing revelation for many older adults.
Aaron: There's also the self-esteem angle. Goodman's article notes that psychotherapy has a critical, often overlooked benefit for older adults diagnosed late: improved self-esteem and self-concept. If you've spent decades thinking you were fundamentally flawed, that's a lot to unpack.
Jamie: And that connects back to the comorbidity data. In studies of adults with ADHD over 50, roughly half reported psychiatric comorbidities — about 36 percent depression, 26 percent anxiety, 25 percent bipolar disorder. The article notes that for older ADHD adults, earlier diagnoses of other conditions were probably accurate but incomplete — ADHD coexisted but wasn't identified.
Aaron: So the takeaway for me is: if you're an older adult who's always struggled with focus, organization, or follow-through, it's worth exploring whether ADHD is part of the picture. And if a clinician dismisses you because of your age, Goodman suggests bringing research studies to the appointment and, if needed, seeking a second opinion from someone experienced in adult ADHD.
Jamie: His phrase — "It's easier to educate the uninformed than it is to educate the misinformed" — captures something real about how clinician training has historically lagged on ADHD in older adults.
Aaron: Well said. We should also remind everyone that nothing in today's episode replaces professional medical advice. Individual diagnosis and treatment decisions belong with qualified professionals.
Jamie: Absolutely.
Aaron: That wraps up today's conversation. Full article summaries and original links are on our episode page.
Jamie: Thanks for listening, and we'll see you next time.