612- Poor Memory & Attention Late in Life: Is It ADHD or Dementia?

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0:33Welcome to the Attention Deficit Disorder Expert Podcast Series by Attitude Magazine.

0:43I'm Carol Fleck, and on behalf of the Attitude team, I'm delighted to welcome you to today's ADHD experts presentation titled, Poor Memory and Attention Late in Life. Is it ADHD or dementia? Leading today's presentation is Dr. David Goodman. We're so excited to welcome him back. Dr. Goodman presented in 2024 on clinical guidance and implications for older adults. You can listen to it by searching AttitudeMag.com for podcast 499 or by subscribing to the ADHD Experts podcast on most streaming platforms. Dr. Goodman is an internationally recognized expert and speaker on ADHD in adults. He has presented over 750 lectures to healthcare specialists, authored some 40 peer-reviewed scientific papers, conducted clinical research on several of the ADHD medications now on the market, and serves as a consultant to the NFL and the World Anti-Doping Agency.

1:49Dr. Goodman served on the American Professional Society for ADHD and Related Disorders Steering Committee, which is developing for publication the first U.S. guidelines for the diagnosis and treatment of ADHD in adults. He is also the lead author of the American Society for Clinical Psychopharmacology Task Force on an expert consensus recommendation for the deprescribing of stimulants for adults with ADHD. Raise your hand if you're often flustered because you can't think of the word you're trying to say in the middle of a conversation, or you can't remember your appointments and you show up on the wrong day, or you can't recall your neighbor's name and they've been living across the street for years.

2:36Sometimes it's hard to tease apart the symptoms of ADHD from aging-related cognitive impairment or decline, or even early signs of dementia. How do we differentiate between these conditions when they share overlapping symptoms? Today, Dr. Goodman will explain the diagnostic considerations and clinical differences for dementia and ADHD in older adults, and he will explain treatment options that take safety and other factors into consideration. So without further ado, I'm so pleased to welcome Dr. David Goodman. Thank you so much for joining us today.

3:11David W. Goodman, M.D.: Thanks, Carol. That was a wonderful introduction and a great endorsement of what Attitude is doing for everyone in this community. My talk today is really going to be focused on ADHD and its occurrence in older adults, and also how to distinguish those cognitive changes that result from ADHD versus those cognitive changes that occur with normal aging or the development of early Alzheimer's. The point here, though, is that the diagnosis is not it's ADHD or dementia. it actually can be both disorders co-occurring and it becomes very complex to sort this out. In regards to clinicians who may be ignoring you or dismissing you over the age of 50 with ADHD, while it's easy to call it gaslighting, I would prefer to say that your clinicians are not aware, haven't been educated, and don't know how to address your concerns.

4:20David W. Goodman, M.D.: And in that regard, if you're dismissed and you believe that you do have a history of ADHD that went undiagnosed, then it's best to see someone who has the training and the experience in order to differentiate normal aging perimenopausal changes or ADHD. So with that, let me move forward. This is my disclosures. The one thing you'll notice as you read on the left, I have no relationships with pharmaceutical companies or any company that has a commercial product in the ADHD arena. That means that everything I say is an outgrowth of my understanding of the research, my contribution to research, and 40 years of direct patient care.

5:07David W. Goodman, M.D.: So isn't this a great picture for all of us who are old enough to remember Peter Fonda and Dennis Hopper and that actor that made his debut in Easy Rider, Jack Nicholson. Here's my idea of what it means to have ADHD as an older adult. So the learning objectives today, we're going to identify ADHD in older adults and evaluation of cognitive symptoms. Understand the complexity of what's called the differential diagnosis for cognitive complaints, and that is what might it be and what is it clearly not. Be able to sort out concurrent medical and psychiatric comorbidities because 70 to 80 percent of adults with ADHD have another psychiatric disorder.

5:56David W. Goodman, M.D.: 50 percent have two psychiatric conditions. And if you're older, we have to overlay medical illnesses and medications that may also contribute to soft cognitive changes. And then we're going to help distinguish some of the clinical similarities and differences between ADHD in older adults and what's called mild cognitive impairment that then leads into dementia for about 40 % of individuals. So this slide is what I'm known for amongst my colleagues. And this basically is a picture, a very funny picture. But if you look at this picture, your guess of what happened, what's the diagnosis, is purely speculation.

6:47David W. Goodman, M.D.: And this is what an evaluation is if you're only looking at the present symptoms. So I don't know whether this gentleman got psychotic believing he was James Bond and the truck was going to turn into a submarine, or whether he's getting divorced and he said over my dead body, is she getting my truck? And the point here is that we don't make a diagnosis of ADHD solely based on a single snapshot of presenting symptoms. It really is based on the trajectory of symptoms, the chronicity of symptoms that developed in childhood and have persisted virtually lifelong with impairments. So a couple of fun facts about the population.

7:38David W. Goodman, M.D.: One out of six people in the U.S., one out of six, is now 65 or older. And by 2034, for the first time in U.S. history, adults aged 65 and older will outnumber adults or adolescents under the age of 18. That's going to make for a very top-heavy population. And you can only imagine what the economic issues are going to be for the federal government. But needless to say, the older adults are going to have particular political power as we all age into that category. So there's a lot of data, a lot of information. I've chosen, though, to focus our discussion on a particular case. Now, this is a patient of mine who came to see me.

8:34David W. Goodman, M.D.: I'm going to show you what he presented with. I'm going to interface some research information, but we're going to walk through this case, and I'm going to show you how I make a differentiation between what is ADHD and what are other factors for cognitive changes. So this is a 62-year-old white married male, a very successful academic physician who came to see me because his cognitive symptoms have worsened over the past two years. He was more forgetful, losing his keys, items, and appointments. He had less cognitive stamina during the day. He had difficulty finding words. He was losing his train of thought quickly, difficulty remembering names that he would otherwise have known, spelling errors, poor ability to shift his attention from one task to another, and difficulty holding variables in his head.

9:27David W. Goodman, M.D.: It became so problematic that he resigned from some leadership positions. He stopped doing public presentations and he was working less and less to the point where he almost gave up work except for a couple of days a week. And so this is how he comes to see me. He had already seen a neurologist. He had already seen a neuropsychologist that did a battery of tests, all of which I will show you as we progress through this. This is the prevalence rate of ADHD in the United States. So adult ADHD is about 4.4 percent you see in the gold bar. older adults OA, ADHD, in the pink is 3 % in the general population.

10:19David W. Goodman, M.D.: This is only second then to major depression, which is about 8.3%. And you can see the other psychiatric disorders. The point here is that adult ADHD is the second most prevalent psychiatric disorder, and yet the focus in professional training programs, whether it's psychiatric, residencies, PhD, psychology, physician assistant, nurse practitioner, etc., is almost negligible. It has gotten better in the last 10 years, but a lot of people, a lot of clinicians in the field are learning this in the field with their patients and not a result of formal training. Thank you. is 3.1 % in placebo arm. Rx only.

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11:37David W. Goodman, M.D.: If you look at the international research prevalence rate, it's about 2.5%. Let me say something about prevalence rate. This is the prevalence rate in the general population. However, if you're a clinician in your practice, seeing people with mental health concerns and challenges and distress, the prevalence rate of ADHD in the clinical population is eight to nine times higher. So you have to imagine that the prevalence rate in a clinical population is a probably easily 25%. And so if you're a clinician who isn't looking for ADHD in your patients and clients who come in with mental health issues, then you may be missing the diagnosis of something that's relatively easily identified and treated.

12:33So what's the difference between childhood diagnosis and adults? Well, the obvious, adults are older, and so they may not have been diagnosed as a child because those that were identified in the 50s and 60s and 70s were the who were really hyperactive and extremely disruptive. 75 % of adults with ADHD were never diagnosed as children. So you don't need to have a diagnosis of ADHD as a child in order to be diagnosed as an adult. And in a very small survey years ago of older adults over the age of 60, 100 % were never diagnosed as children, and they were diagnosed much later in life. So it's not that there's some expiration on getting diagnosed, after which you can't get

13:26David W. Goodman, M.D.: diagnosed and you wouldn't have it. ADHD, for most people, becomes a lifelong challenge. So what are the issues with clinicians when they are unable to identify? Well, I wrote a paper with two of the leading researchers in the world about the failure of identifying patients, diagnosing patients, and treating patients. And so this goes back to the gas sliding issue that Carol raised earlier. And I want to mention why clinicians are unable to recognize this. The first is clinical blindness. They just don't know what they're looking at. The second is clinical prejudice. They just believe that ADHD is a childhood disorder and doesn't exist in adulthood.

14:15David W. Goodman, M.D.: Or it's clinical experience. There's very limited training on ADHD in older adults. And again, they don't know what they're looking at or how to evaluate it. There's diagnostic challenges because there's a lot of overlap between the cognitive decline of aging or perimenopause, and also cognitive declines that occur because of psychiatric comorbidities, major depression, severe anxiety disorders. The other is clinical complexity, and it's not as if you have one diagnosis or the other. It may be that you have two diagnoses simultaneously and the medical illnesses. Some cause soft cognitive problems, so that makes making the diagnosis of ADHD that much more difficult.

15:06And also treatment hesitancy. A lot of clinicians simply do not want to write stimulants for older adults because of the risk of high blood pressure or their fear of stroke and heart attack, which is relatively absent as a risk. But we've all been taught decades ago that these are dangerous medicines for older adults.

15:30David W. Goodman, M.D.: So keep that in mind when your clinician, your provider, either dismisses you or looks puzzled or doesn't know how to address it. It's not that they don't want to treat you. It's just that they don't know what it is, how to identify it, being sure of the diagnosis, and comfort with the medication that's often used. Now, just because you get a diagnosis doesn't mean you have to be on medication and you can be referred to someone who does organizational and time management skills as well. The other issue is on diagnostic confusion. Some people will say, well, I'm not sure what's going on with this 62-year-old man I just presented.

16:12Maybe I'll send them for neuropsychological testing and that'll sort it out. The problem with that is it really actually doesn't do that. there is a Swedish study that looked at 160 participants. They compared older adults with ADHD with younger adults with ADHD. And what they found on neuropsychological testing, you're looking at three sets of bars where there's no deficits, single deficits, and multiple deficits. The younger are the blue, the older are the light purple. And you'll see multiple deficits are actually higher in the younger ADHD individuals than in the older ADHD individuals. So unless you have a very skilled neuropsychologist who understands how to sort out normal aging from ADHD, neuropsychological tests, which can run approximately$3 ,000, is not going to be able to provide an accurate diagnosis.

17:09In fact, the neuropsychological testing may come back reflecting that they don't have ADHD, but understand the test results tell you about deficits. They do not tell you what the diagnosis is. You need to be able to interpret those results in a clinical history and setting. So let me move on to differential diagnosis. And this is how a clinician or provider thinks through the presentation of the patient's psychological experiences and symptoms in order to determine what would be the most appropriate and hopefully accurate diagnosis, because it's the accuracy of the diagnosis that then determines what treatment options you consider.

17:55If you get the diagnosis wrong and you institute treatments as a function of that inaccurate diagnosis, then the patient simply doesn't get well as much as if the diagnosis was accurate and the treatment was appropriate. So this is the timeline over aging. And historically, you have symptoms in childhood and those symptoms cause impairment. And that brings the person to be identified and diagnosed with ADHD. But if the impairments don't show up until later in life, because you had good support, you had overseeing parents, you had a good teacher to student ratio in school, you are especially bright, then those impairments don't occur until later in life when the demands of each developmental phase in life starts to exceed your ability to compensate.

18:53So going to college is a developmental phase, going to your first job, getting married and working with somebody else, having children and coordinating all of that, getting a raise. All of those are different developmental phases. And then somebody alerts the person or they have read an article in Attitude magazine that says, maybe you have these symptoms. But if you're older, the other considerations are, are there medical illnesses that are causing cognitive difficulty or are you on medications or several medications, medical medications, that may be causing some cognitive difficulties? Or are you somebody who's been drinking habitually over the course of years or has been using THC and vaping or using cannabis that does cause cognitive difficulties over time?

19:48So that becomes part of the consideration. The other is an old term called pseudodementia of depression. And this is where the person is apathetic and confused, but they don't say they're sad or depressed. But in fact, we consider them depressed and treat them that way. You also have age-related cognitive changes. So after the age of in your late 50s and 60s, you'll start to notice that your cognitive ability is slightly changing. And perimenopause also causes cognitive changes as a result of declining estrogen.

20:23David W. Goodman, M.D.: there's a disorder called mild cognitive impairment which are significant cognitive changes although it doesn't greatly affect your functioning during the day but we know if we follow mci patients out that they can develop early dementia and so that becomes a harbinger And as I said before, it's not the differential here is not you have ADHD or you have MCI. It's you have ADHD and you may have MCI or early dementia, which again is going to lead us back to the patient case that I highlighted earlier. Now, this is a very long list of medical considerations when seeing an older adult who has cognitive complaints.

21:15David W. Goodman, M.D.: and one word of caution is that older adults will come in and say i have problems and they've worsened over the last two or three years if you use that temporal metric in isolation then you'll think that the worsening is a function of age or age-related medical issues and not look for pre-existing ADHD. You really do have to go looking for the pre-existing ADHD because older adults don't come in saying, I have ADHD. MCI, I talked about, perimenopause, I have mentioned. Dementia is also part of this. Now that we have biomarkers for Alzheimer's, it's a lot easier to make the differentiation between pre-existing ADHD and the development of Alzheimer's.

22:07There are other dementias that are considered, and Lewy body dementia actually is particularly relevant because it has a very high association with ADHD. Parkinson's disease, there are a variety of medical issues, infections, bladder infections can cause confusion in older patients. You'll notice I refrain from using the word elderly. Once I've reached this age category, I no longer consider elderly an appropriate term, and so I refer to us as older adults. Increasing polypharmacy, a lot of patients are on three, four, five, six medications, a combination of which can cause soft cognitive difficulties.

22:54And also sleep disturbance, specifically sleep apnea. I routinely ask about sleep apnea in initial evaluations. Just make sure that we're not missing something that's going to contribute to the cognitive difficulties. Rubrik is the security and AI operations company built for what happens after an attack hits. Not just the moment before. AI has turned the threat landscape into quicksand, moving too fast for any human to fully predict. That's why an agentic cyber resilience platform matters. Automated recovery. Clean data. A business that keeps moving no matter what hits. One platform, not a patchwork of stitched together tools and gaps.

23:34Don't wait for the next attack. Secure and accelerate your business at rubric.com. Again, rubric.com. The differentiation though for ADHD is ADHD is a childhood, early adolescent onset that continues rather chronically, pervasively with impairment over the course of one's life. Most of what you're looking at here on the differential are related to an onset that occurs in adulthood. So that becomes one very important diagnostic marker to differentiate ADHD from all of these differentials that you're seeing here. But again, you can have somebody who has ADHD, and if they've had repetitive concussive injuries from a sport in their late adolescence and college, that can compound the cognitive difficulties of ADHD.

24:34So when I think about this, thinking about just the diagnostic categories, first I mentioned the differential diagnosis, which we talked about, also coexisting psychiatric disorders. So you can have ADHD and a severe anxiety disorder. You can to have ADHD and bipolar disorder or major depression, and you can have ADHD with other medical diagnosis. EDS is Ehlers-Danlos syndrome, which is a connective tissue disorder. PCOS has

25:07David W. Goodman, M.D.: been renamed polycystic ovary syndrome and MCI. I mentioned all of these have soft cognitive difficulties that can appear as if they're ADHD, but they're independent medical considerations. Under the differential, though, you have what are the psychological stressors, what are the psychiatric disorders, and what are the medical disorders and how to sort this out. So let's go back to our 62-year-old. Let's talk about the history here. The history is such where he talks about symptoms in childhood. The second grade report card needs to pay attention more, talk less, and be neater. Now, I use symptom rating scales in childhood.

25:55David W. Goodman, M.D.: The patient fills out on the best of their recollections. And you'll notice two of nine and four of nine. You need to really have five or six of nine to be diagnostic. But you don't need to fill the diagnostic symptom count in order to get an adult diagnosis. And I'm going to show you how these scores change by the patient's recollection. Most importantly, I go on the description of what the patient remembers their ability was in class. So he describes himself as frequently forgetting and misplacing items. And I'm not going to read everything on the slide. What I'm looking for is the patient's recollection of childhood symptoms and whether or not there was an environmental response.

26:41David W. Goodman, M.D.: Did teachers recognize that you were struggling and were making allowances for you? That means the environment recognized that your impairments were such they needed to make accommodations, just even informal. So now he's in college. He's procrastinating. He's putting assignments off. He was disorganized in high school, procrastinating and not getting things done on time. and his rating symptoms of adult symptoms now starts to increase. Four of nine, five of nine. Now he's reaching diagnostic criteria. His sister said, you need to go into academia because you could be an absent-minded professor.

27:27His wife said he was, first wife said he was sloppy and forgetful. And again, I'm relying on the patient's discussion of what others had reported to him were their observations. The symptom rating scale is changing here, which is why I don't want to be inflexibly

27:49David W. Goodman, M.D.: adherent to a diagnostic symptom category of five of nine inattentive symptoms or five of nine hyperactive impulsive symptoms, which is the diagnostic symptom count threshold. Psychiatric history has a history of major depression. He's been on antidepressants. When he comes to see me, he's on bortioxetine, lorazepam, and zolpidem. Lorazepam is an anxiety antidepressant, self-adam is a sleep medication. So he's had off and on major depression for which he's been on antidepressants. This is the symptom rating scale. I'm not sure it's showing up very well. It's the nine symptoms of inattention. The red marks, oh, there's some missing here.

28:40I'm sorry. There are some red marks missing, but there should have been more red marks in the red circle. and this is his endorsement of symptoms. But the one thing I want to point out here is that there's a little yellow checkmark by his wife where he doesn't recognize in the red, scored at two, and she scores it at four. Again, the spouse's observation or someone who's been in one's life for a long period time is really important because the patient may not recognize some symptoms where an observer may say, wow, that's as evident as any symptom I've seen. So if I had included all the red marks, he would fulfill diagnostic criteria.

29:30And the yellow is the wife and the red is the patient. So this is the nine symptoms out of hyperactive impulsive symptoms. And again, it's always very helpful to have the wife and the patient score these together.

29:53But what's particularly important is how to differentiate in a clinical evaluation the cognitive deficits that are ADHD and those that are not ADHD. And so this is from a review article I published in November in Psychiatric Times, along with Brandy Callahan, who's an excellent neuropsychologist in Canada. And you are really seeing state of the art because there are no research articles differentiating age-related cognitive decline, mild cognitive impairment, and ADHD. But those that are not related to ADHD, difficulty finding words, misspelling, word substitution, using a generic descriptor like things or stuff because of word finding difficulty.

30:50Difficulty following conversations. You're hearing the conversation. You're just not processing the information. Difficulty remembering recent events or conversations. Visual spatial skills. Difficulty recognizing objects or judging distance. And these specific cognitive deficits are worsening. These are not ADHD. If you have ADHD and this has been recently developing over the last year or two or three, then there's a second process here that needs to be evaluated by a neurologist, internal medicine doc, and get a workup for this.

31:36So mild cognitive impairment, just to be specific, it's memory complaints usually observed by an by an informant or observer. There's an objective memory impairment. That is, the patient says that I'm having difficulty remembering things. General cognitive function is okay, and it doesn't

31:57David W. Goodman, M.D.: interfere with their activities during the day. The patient is not demented. So this is a bit more than age-related, and it's worsening at a pace that's greater than age-related changes. Just to show you the age categories and the prevalence rate in the general population, you can see as you get older from age 60 onward, then the prevalence rate of MCI starts to increase. the conversion of mci to dementia is about 40 percent at five years so not everybody with mci develops dementia but it certainly is something to be aware of so that planning your life the quality of life the circumstances and environment of your life can be developed to accommodate your function and cognitive change.

32:59And the question then becomes, we know there's a risk of adult ADHD for dementias. It's Alzheimer's, it's Lewy body's dementia. And so the question is, well, is this adult ADHD the cause and preamble to dementia? Is this adult ADHD who's been on medication and the medication is making things worse? Is it a combination of both, or are there other factors that are contributing to neurodegeneration in the presence of ADHD? And this is the state of the art and the questions. Now, it gets even more complicated. The risk here, is it associated with having ADHD? Is it associated with the lifestyle choices and the medical illnesses that arise, like diabetes?

33:58Is it the medical issues that are associated with ADHD, like obesity?

34:05David W. Goodman, M.D.: Is it ADHD genotype? That means, are the genes for ADHD, which don't cause ADHD, but are present in individuals, do those genes contribute in some way to neurodegeneration 60, 70 years later? There is some recent research that suggests genotype may be a risk factor for neurodegeneration independent of having ADHD itself. So let's go back to the patient. So he had a MRA brain scan that showed some scattered punctate hyperintensities. That simply means that he had some microvascular changes, probably very, very small strokes that were clinically irrelevant. This is seen in an aging brain, and it didn't reflect the particular clinical presentation the patient was complaining of.

35:12He had a Doppler ultrasound that's on your neck. So these are the large vessels that run into your head and brain in order to see if there are any plaques that are obstructing flow. And there really wasn't anything there to speak of. So he had neuropsychological testing. And it did show that measures of attention, memory, and language were weaker. And he had impaired name tasks. These are specific neuropsychological tests. So he had some specific deficits, and the conclusion here was mostly consistent with

35:51David W. Goodman, M.D.: a gnomic aphasia. That means difficulty naming and pulling words. And the conclusion was he had what's called amnestic mild cognitive impairment. So difficulty recalling and remembering words and events causing the diagnosis of mild cognitive impairment. nowhere in this neuropsychological evaluation was any mention of adhd

36:20so he has a history of traumatic brain injury that the neurologist thought was contributing to neurodegeneration 35 years later he had what's called progressive primary progressive aphasia as a result of the traumatic brain injury he had mild cognitive impairment by the neuropsychologist He had a history of major depression that I told you about. And then he came to see me and I concluded that he also had ADHD. But remember I said there were some deficits that weren't consistent with ADHD.

36:59So hold that thought. I mentioned the risk of ADHD and dementia. So there's three published studies that looked at this. and as i mentioned there's up to a five-fold higher risk for lewy body dementia in a 17-year follow-up study the risk of dementia in adult adhd was 2.7 fold higher even when adjusting for cofactors like medical illnesses there's no increased risk of dementia with prescription stimulant medication this was looked at and in fact the risk of adhd and dementia is higher if you have not been on medication than if you were on stimulant medication so stimulant medication is not leading to neurodegeneration and this is the meta-analysis and it's just part of the research you'll notice you'll see stimulant unexposed, the farther you are over to the right, the greater the risk of developing dementia.

38:11So let's go back for a moment to the patient. I mentioned that I thought the deficits that he was having were different than what I would expect with ADHD. So he was diagnosed with ADHD. I put him on medication, Vyvanse. We dosed the medication upward and he got better. He got significantly better. Both he and his wife said he was 70 % better. He was so much better that his confidence went up. He resumed some of the leadership positions. He went back to his research and is now working five days a week from home. However, even with the Vyvanse, He was still complaining of word finding, spelling, difficulty recalling conversations, interruptions in his sentence because he was looking for the next word or the thought, or he would lose his train of thought.

39:13Patient goes back to the neurologist and says, my psychiatrist thinks something else is going on. I want to get biomarkers for Alzheimer's. So he goes to the neurologist. The neurologist says, fine. You do a lumbar puncture. And it turns out, based on his biomarkers, that he also has early Alzheimer's. And in the biomarkers, without going into the specifics, you measure amyloid and you measure phosphorylated tau, P tau for short. And if the P tau is high, then you have early Alzheimer's. And this is just showing the lab results that I showed to physicians and clinicians when we're making this determination.

40:06So these were the diagnosis that I made. We started him on the Vyvanse. We took him off as antidepressant because his mood had not changed over the past two months on the medicine. We stopped the bupropion that somebody had added because they thought it might be helpful for cognition and mood. We started the lisdxamphetamine, which you know as Vyvanse, and titrated it up to 70 milligrams. He said 70 was a little too much and too activating, so he's now on 60 milligrams. And that effect lasts for about 10 hours during the course of the day. So what do you do with a patient who has multiple psychiatric disorders?

40:49There is something called diagnostic prioritization, and that is if you have somebody with several psychiatric conditions, which do you treat first, second, and third? And the object here is to treat one without making the others worse. generally we want to get the severe alcohol and substance abuse under control and in recovery treatment then treat the severe mood disorders like bipolar disorder and major depression the severe anxiety disorders third ADHD and then cognitive decline related to age or MCI the reason we do this is because the cognitive changes you see in ADHD can actually occur in the other untreated psychiatric disorders.

41:37And the medication, namely stimulants used for ADHD, run the risk of making the other psychiatric conditions worse if they are not treated and stabilized. So this is the current diagnostic prioritization. Now, there's emerging research that suggests rather than doing this in sequence, that alcohol and substance abuse with ADHD get treated concurrently. That is, you put the person on medication for ADHD while they are in their recovery program. And that research suggests the patients are far less likely to relapse at 90 days if their ADHD is treated versus their ADHD is not treated while they're in recovery.

42:23So what's the outcome? I mentioned his wife and the patient reported a 60, even 70 percent improvement in cognition. At that time, he resumed work three days a week and progressed up to five days a week working at home because he needed an environment that didn't have a lot of noise and distractions. He resumed some of his positions that he had suspended. He was pleased with his progress and less discouraged by the Alzheimer's diagnosis because he saw that he was now going to have a few more years of functioning with the treatment of his ADHD in spite of the presence of Alzheimer's. He decided to forego getting the anti-amyloid treatment for Alzheimer's because his review of the literature, he didn't want to take on the risks of brain swelling.

43:14His wife is relieved that he continues to work, leaving him in a better state of mind, and everybody who's been married or living with someone, if your partner is in a better state of mind, your relationship is probably in a better state of mind. So the summary here is screening for ADHD is important for cognitive complaints, especially in older adults, because you have the opportunity to identify a very treatable condition and then modify the environment or other aspects of their medical care. Cognitive complaints in older adults should not be easily discounted as age-related decline or neurodegeneration.

43:59Medical etiology of cognitive complaints usually have their onset in adulthood, not childhood, as ADHD, and that becomes the distinguishing factor. It's the temporal relationship of the onset of symptoms. ADHD It's a childhood, early adolescent disorder. You do not develop ADHD at 25 or 37 or 45. Impairments are persistent. So the diagnosis here rests not only on symptoms, but how do these symptoms affect you during the course of your day? How does it impair your ability to get things done? And what observations do your partner, your spouse, or others notice about your ability to execute dependably and consistently.

44:49ADHD treatment is effective for improving cognition and daily functioning. It shouldn't be discounted. If you hear your provider say, well, even if you've had ADHD, you've had it your whole life, why bother treating it now? I will tell you, having treated people in their 60s, 70s, and even early 80s, that they are grateful to realize that they had a disorder that could have been treated. There is a psychotherapy of grief about the loss of opportunities during the course of one's life, but there's also a resurrection of self-image because you come to realize the difference between who you are and what you have.

45:32so mci and adhd and alzheimer's can coexist it's not one or the other sometimes it can be both simultaneously and it really is never too late to treat adhd regardless of how old you are And I think with that, I've come to the end. Thank you very much. I do oversee a charitable foundation that supports my work in this area. The QR code is there. If you wish to contribute, that would be great. I appreciate that. I think at this point, I'm going to turn it back to Carol and answer whatever pressing questions everybody has. I appreciate everybody's attendance and hopefully this was time well spent for you.

46:19Thank you so much for that wonderful presentation, Dr. Goodman. I'm convinced I have all the above. Now to your questions. Does ADHD get worse as you get older?

46:34David W. Goodman, M.D.: So the answer is no. The ADHD should not get worse. The experience of ADHD may be worse if the demands start to increase and exceed your ability to compensate. So as we get older, we have more and more paperwork to take care of. If you're on Medicare, you get bills, you see doctors, you get a variety of bills. I can tell you my experience getting older is I can't imagine, I couldn't imagine how much paperwork it takes to take care of my life with my wife. but adhd doesn't get worse it's the demands that exceed your ability to compensate and your experience of your adhd is worse now the other side of that is if you're having cognitive changes that are beyond the scope of your adhd now you have two uh neurologic processes going on and it may be getting worse because you have a second neurosciences neurological process that needs to be evaluated.

47:41Could ADHD medication mask symptoms of mild cognitive impairment? That's a great question. So there is very, very limited research on stimulants in MCI. My clinical impression is that stimulants likely help MCI, but do not take that as an endorsement to seek treatment for MCI with stimulants. There's no literature on that. There is emerging research that has not yet been published. The follow-up question on that is, if you have ADHD and you have MCI, will treating the ADHD delay the development of MCI or Alzheimer's? Great question. No research for me to answer that question. If this were me, I'd be treating my ADHD, keeping my fingers crossed and appreciating the fact that the quality of my life is higher on medicine than it would be without my ADHD treated.

48:44Yeah. Okay. We had, as you might imagine, quite a few questions around hormonal changes for perimenopause and menopause leading to cognitive function issues. and how to really separate which deficits are from hormonal changes and which might be signs of mild cognitive impairment or early dementia. So again, great questions, insightful questions. This is similar and dissimilar to the concurrence of ADHD and MCI. So for ADHD and MCI, I can point to clinical differences on cognitive deficits that help me differentiate one from the other. In perimenopause, cognitive difficulties in ADHD, that, A, hasn't been looked at in neuropsychological testing that I'm aware of.

49:38And also, the cognitive deficits you get from a decline in estrogen will not be the result of neurodegeneration. it's simply the effect of declining estrogen that has an effect on cognition but the specific deficits that are related to the estrogen decline haven't been well differentiated from adhd so if you have pre-existing adhd and you go into menopause you may experience the cognitive difficulties getting worse and saying my ADHD is getting worse, but it's not the ADHD, it's the declining estrogen. If you didn't have ADHD and you go into perimenopause and have cognitive changes, then it's the direct result of the estrogen decline.

50:31And then you'll say, well, okay, what do I do about it? Well, again, go to the literature and there's no clinical guidance. so heretofore uh hormone replacement therapy got um got a ding because it alleged to increase risk for breast cancer and other medical illnesses that has now been refuted and so if i have a woman who's 50 years old who says look for the past two years i've had cognitive decline the person had adhd before then the question is do i increase their stimulant medication or do I put them on hormone replacement therapy? I am inclined at that point to put you on hormone replacement therapy.

51:15Now, when I say I recommend that you see the GYN, you go on hormonal replacement therapy for three months. The stimulant medication remains at the same dose. And then you see what the qualitative change is in your cognitive functioning. If it improves on HRT, then the question is, do you stay on HRT for some extended period of time along with the stimulant medication? If the HRT doesn't work or you can't take HRT for medical reasons, then I might increase the stimulant medication to see if we can't overcome the perimenopausal changes from the estrogen decline. But again, everything I'm saying is clinical experience for which there is a paucity of research for clinical guidance.

52:07And it's just really, in my opinion, appalling that we don't have more research for clinical guidance here. Yes, yes. Someone asks, do the effects of years of chronic stress lead to dementia? Oh, that's a good question. So chronic stress will have an impact on the brain. The person who does a lot of this work is Cynthia Monroe. She's a neuropsychologist at Hopkins who looks at stress and dementia.

52:43David W. Goodman, M.D.: Cynthia Monroe, M-U-N-R-O. So if you pull up her work, you might find some impact on there. So that's as far as I could go with that. But the answer to that is, yes, chronic stress will have an impact on your brain, even to a morphologic degree. It shrinks the brain. Chronic stress will shrink your brain.

53:12Wow. Could signs of a B12 deficiency be mistaken for dementia? Yes. So there are a number of medical issues. It's a long list. Folate deficiency, which is B12 deficiency, hypothyroidism.

53:29David W. Goodman, M.D.: Again, your internist, your primary care physician will know the preliminary medical disorders and illnesses to rule out with the physical exam and blood tests. okay um we've had a number of questions about people have trouble sleeping either falling asleep or staying asleep um we know that sleep is an issue for people with adhd does that does a lack of sleep or insufficient sleep chronically could that lead to mild cognitive impairment or is the cognitive functioning deficits you're seeing just simply a result of poor sleep? Right. It's a chicken or an egg question, and it depends on the particular patient.

54:22David W. Goodman, M.D.: So you can have early dementia, which will affect your sleep. And in that regard, the disorder is causing sleep disruption. if you have chronic sleep apnea that goes untreated that will leave you with sleep deprivation and soft cognitive problems if you have chronic sleep difficulties not associated with sleep apnea and you're chronically sleep deprived that will also slow your cognitive abilities as well. So you can hear as I think through these issues, I walk through a decision tree in my head, try to prioritize the presentations of the symptoms. What would be the disorders that would explain that?

55:15And then going through a decision tree of how to sort out what treatment to start first, second, and third in order to figure it out over the course of time.

55:28okay um we have two similar questions one is how should an older adult go about finding a competent clinician who specializes in adhd in older adults and what do i say to clinicians who claim that old people can't have adhd excuse me right okay so the first thing you can do is I was the lead author on the first literature review on this published in 2015. If you go to pubmed.gov, P-U-B-M-E-D dot G-O-V, that is the repository of all scientific publications. of publications. Type in ADHD and older adults, and you'll have some articles come up. Look for mine. You're going to get the abstract. You can print out the abstract and take it with you to your clinician and say, actually, I've been doing some research, and there's this guy, Dr.

56:37Goodman, who's published in this area, and there's a lot of research. you can also go to the psychiatric times and see if you can find my article again just do a google search or an ai search on it it's older adults with adhd attitude magazine i've written articles for attitude so there are articles on attitudes website about this the point here is one educating

57:03David W. Goodman, M.D.: yourself the second point is bringing some of this information to a clinician who might be receptive but not knowledgeable. Be careful when you bring it. If the clinician recoils, this is somebody who's not going to be receptive to pursuing this with you and you need to see somebody else. In regards to finding somebody who's qualified, I would look for an adult psychiatrist. And the easiest way to do this is to, if you have a large academic center, you can call the child psychiatry department and ask who they refer to for adult adhd the other is you can do a google search type in uh adult adhd psychiatrist with your zip code and see who comes up and then start doing some research on the credentials um i don't know does attitude magazine have a directory of individuals who treat ADHD.

58:05Not psychiatrists, no. Okay. So that's the way to do it. Call a major academic center and talk to child psychiatry because the adult psychiatry department unlikely has an expert. It's the child psychiatry people who are referring to the adult psychiatrists in the community

58:22David W. Goodman, M.D.: and or punch in your adult ADHD psychiatrist and then your zip code and see what comes up. That's great information. Thank you. That has to be our last question because we're out of time. Thank you so much, Dr. Goodman, for joining us today and sharing your expertise with our ADHD community. We appreciate you. Thank you for coming back. Thank you for inviting me. Thank you, Carol. And thank you to everyone here today. If your question wasn't answered during the webinar, we do share audience questions with our experts and yours may appear in a future edition of Attitude Magazine's Ask the Advisor column.

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59:51Thanks, everyone. For more Attitude Podcast and information on living well with attention deficit, visit AttitudeMag.com. That's A-D-D-I-T-U-D-E-M-A-G.com.