Jay D Tarnow, M.D.
This article is a follow-up from my previous Psychopharmacology Newsletter on the physiological, psychological, and social changes in middle age and beyond. As previously noted, there are a number of changes that occur naturally as we age that can mimic ADHD. The aging process affects us cognitively, some people more than others. ADHD, however, is not associated with any increase of Alzheimers, Dementia, or Parkinson’s Disorders. The normal Mild Cognitive Disorder of older age may have a greater impact because of the difficulty with organizing, working memory, and distractibility of ADHD. The long-term effects of alcohol and drug use can also lead to similar impairments.
Vitamins and nutrition
The use of certain vitamins and nutrients have been shown to improve cognition as we age. Some people seem to need extra “methylated” forms of vitamin B12 and folic acid. A special enzyme is needed to methylate the folic acid and vitamin B12, enabling them to pass over the Blood Brain Barrier into the brain, so that neurotransmitters can be made. Some people do not make enough of the enzyme genetically, or this enzyme may wear out causing the person to lose their cognitive capabilities or becomes depressed.
Omega 3, which is high in fish oils, flax seeds, and nuts, is necessary for normal brain function. It increases the speed of transmission of signals in the brain. Some research has shown that taking these oils will improve cognition, ADHD, and working memory. However, do they reach the brain? The use of a phospholipid serine improves the flow into the brain. I have used Vayacog to improve memory and Vayarin to improve ADHD symptoms. The use of Aricept or Memantadine has had mixed results in Mild Cognitive Impairment, but have not shown to improve ADHD symptoms in this age group. There is minimal evidence that these medicines help Mild Cognitive Impairment.
Medicine for older adult ADHD
The medicines we use for childhood ADHD are still effective in this age group; however, some risks need to be monitored. As you can imagine, telling someone with ADHD to monitor anything can be frustrating, but must be done nevertheless.
While stimulants are still the most effective treatment for symptoms of distractibility, disorganization, and poor detailing, careful monitoring is required in the older population because adults are more susceptible to rising blood pressure and pulse rate. Not surprisingly, members of this age group are starting to have cardiovascular symptoms as these medicines cause vasoconstriction and can worsen hypertension, poor circulation, and chest pain.
Stimulants also can decrease sleep, which is often already a problem in middle to old age. It would not be a good idea to use a benzodiazepine for this problem since it is associated with dementia in later life. Therefore, I suggest a trial of Melatonin. Loss of appetite is another problem for the older generation and can often lead to a vitamin or protein deficiency.
Guanfacine or Clonidine will help with ADHD symptoms and lower blood pressure. These are particularly helpful when anxiety is present. Intuniv is a long-acting guanfacine that can be very helpful since it can be given at night, thus, minimizing daytime sedation. I will use these agents in combination with stimulants to control high blood pressure caused by the stimulants.
There are also antidepressants, which have been shown to have positive effects on ADHD symptoms. They work on a 24-hour basis and need three weeks to build up. Bupropion has been shown to be helpful in ADHD to a minor degree in adults. It is a dopamine reuptake inhibitor and a norepinephrine reuptake inhibitor. I also use Imipramine, Desipramine, or Amitryptilline, all of which can cause sedation. These have multiple effects on neurotransmitters.
Depression and Anxiety Disorders are common conditions in this age period and can mimic the symptoms of ADHD. So antidepressants may have an advantage in this area as well.
In summary, when one reaches middle age, the need for ADHD meds may be greater, but can be more complicated by medical conditions. For further information on this topic, please contact the Tarnow Center.