Is It Aging, or Is It ADHD? A Growing Number of Adults Seek Answers
Realizing that your brain is slowing down can be unsettling. After age 45, many people begin to experience forgetfulness, misplacing items, or difficulty concentrating, often prompting a visit to a doctor to rule out age-related cognitive decline. However, an increasing number of Americans are asking a different question, according to providers: Am I just getting old, or do I have ADHD?
Awareness of Attention-Deficit/Hyperactivity Disorder has risen dramatically in recent years. CDC estimates from 2020 to 2022 indicated that roughly 11 percent of American children aged 5 to 17 had received a diagnosis. Now, many adults in midlife and beyond are questioning whether their cognitive challenges are simply a symptom of aging, or something more. For some, the answer may be that they have undiagnosed ADHD, with symptoms becoming prominent enough to significantly impact their lives. In other cases, the answer may be “both.”
Historically, ADHD was largely associated with hyperactive boys. However, studies suggest that approximately 3 percent of people over 50 – roughly 3.6 million Americans – are expected to have ADHD, according to David Goodman, an expert on adult ADHD at Johns Hopkins University. While debate continues regarding whether ADHD is generally overdiagnosed or underdiagnosed, diagnoses are increasing among populations previously overlooked. The CDC reported a “substantial” increase in stimulant prescriptions among people in midlife from 2020 to 2021.
Diagnosing ADHD in midlife can be complex. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) only directly addressed adult ADHD in 2013, and the condition receives limited attention in medical school curricula. This means many healthcare providers may not consider ADHD as a potential explanation for a patient’s worsening cognitive function, Goodman explained. Existing clinical guidelines focus solely on childhood diagnosis, and the presentation of ADHD can change significantly across the lifespan. For example, physical hyperactivity in childhood may evolve into internal restlessness in adulthood.
The potential causes of cognitive decline in midlife are numerous and often interconnected. Normal aging is associated with the natural shrinkage of the brain and a decrease in neuronal connections. Psychiatric conditions common in midlife, such as depression and anxiety, can also mimic ADHD symptoms. Mild neurocognitive disorder, prevalent in individuals 65 and older, shares symptoms with ADHD, including missing appointments and losing things. However, unlike those with ADHD, individuals with mild neurocognitive disorder tend to forget words and how to spell them. In some cases, early-onset dementia or Alzheimer’s disease may be the underlying cause. Caregiving responsibilities, physical ailments, and increased work demands – all common in midlife – can exacerbate cognitive issues stemming from any of these factors.
Middle-aged women, in particular, face diagnostic challenges. Girls are less frequently diagnosed with ADHD than boys, meaning many women live their entire lives unaware they have the condition. Perimenopause, with its associated cognitive changes like brain fog, difficulty concentrating, and forgetfulness, can complicate diagnosis. Fluctuations in hormone levels during perimenopause can also worsen ADHD symptoms by interfering with dopamine signaling in the brain, according to Brandy Callahan, a neuropsychologist at the University of Calgary.
Increased awareness of adult ADHD, fueled in part by social media, has prompted more women to seek help. Stimulant prescriptions have risen sharply among women aged 50 to 54. However, the combination of unclear diagnostic criteria and overlapping symptoms means many older Americans with ADHD likely remain undiagnosed, and untreated. A first-time diagnosis in midlife can significantly improve quality of life, providing validation during a period of major life changes and offering relief from challenges like maintaining relationships, managing finances, and performing at work. Stimulant medication can improve attention, impulse control, and hyperactivity in individuals with ADHD.
A diagnosis also has implications for future brain health. ADHD is associated with neurodegenerative disorders such as Alzheimer’s disease, Parkinson’s disease, and certain types of dementia, though the reasons for this association are not yet fully understood. One possibility is that individuals with ADHD struggle with habits that promote brain health, such as managing stress and prioritizing sleep and exercise. Research also suggests that ADHD brains may have abnormal white matter, potentially making them less resilient to age-related diseases.
While research is ongoing, prescribing ADHD medications to older adults can be done safely. However, most ADHD drugs are FDA-approved only for individuals up to age 55 or 65 due to a lack of testing in older populations and limited Medicare coverage. Stimulants can also raise blood pressure and heart rate, posing risks for individuals with cardiovascular disease or obesity. Despite these concerns, evidence is growing that supports the safe use of ADHD medications in older adults, highlighting the importance of accurate diagnosis.
The American Professional Society of ADHD and Related Disorders (APSARD) is expected to release the first clinical guidelines for adult ADHD this year, aiming to establish a clearer understanding of treatment approaches. While it remains to be seen whether these guidelines will specifically address middle-aged and older adults, the increasing prevalence of adult ADHD diagnoses underscores the need to refine our understanding of what constitutes normal aging. While cognitive decline is inevitable with age, some individuals may have more opportunities to maintain their cognitive edge.
