ADHD in Older Adults: The Science, Signs, and Strategies

By Katie Linz, OT
Occupational Therapist, Maryland

My dad has demonstrated signs and symptoms of ADHD, attention deficit hyperactivity disorder, for as long as I can remember. In fact, an elementary school friend’s parent diagnosed him while she was driving us home because my dad had lost track of time and forgotten to pick my sister and me up from school, again. But at the time, I was not educated on ADHD nor had I ever associated it with anyone over the age of ten. However, after my mom died when I was in college, I became even more aware of his difficulty/boredom in handling daily tasks. 

But it was not until I was treating a woman in her 80s with poor time management, high distractibility, organized clutter, and poor medication management that I had the epiphany regarding my own aging father. Since elementary school, I have accumulated vast knowledge regarding ADHD in adults through my roles as both an occupational therapist and as a daughter. Keep reading as I share some digestible science, how to detect signs and symptoms of ADHD in older adults and three strategies to improve their participation in daily activities. 

The Science Behind ADHD

Here is the scientific answer to the question “Why does my patient/parent/friend have a hard time focusing on the task?” and “Why do they lose track of time so much?” 

According to ADHD 2.0 by Doctors Ned Hallowell and John Ratey, our brains have two networks important to this conversation. The “task-positive network” (TPN) fosters our ability to do something without wasting time. The “default mode network” (DMN) fosters our daydreaming and creative thinking. In brains with ADHD, the toggle that switches between them is disabled. Thus explaining “hyperfixation” when a person becomes stuck in TPN. On the other hand, they can get stuck in the DMN, constantly thinking of new ideas/hobbies to pursue creating new ambitions but without the motivation from the TPN. 

Further research from Katya Rubia finds:

Meta-analyses of fMRI studies of executive functions (EFs) show that ADHD patients have cognitive-domain dissociated complex multisystem impairments in several right and left hemispheric dorsal, ventral, and medial fronto-cingulo-striato-thalamic and fronto-parieto-cerebellar networks that mediate cognitive control, attention, timing and working memory (WM). There is furthermore emerging evidence for abnormalities in orbital and ventromedial prefrontal and limbic areas that mediate motivation and emotion control.

Do they have a mild cognitive decline or just an attention deficit? It’s tricky because in some cases the answer can be both. Most physicians don’t receive extensive training on the issue in school and the majority they do receive is pediatrics-focused. It was not until 2013 that the Diagnostic Statistical Manual was modified to include descriptors for adults with ADHD (Hallowell & Radley, 2021). 

Signs of ADHD in Older Adults

There are 3 types of ADHD presentations: predominantly inattentive, predominantly hyperactive/impulsive, and a combination (Hallowell & Radley, 2021). Some signs that you may begin to notice include:

• Difficulty maintaining clean spaces
  • Home is best described as “organized chaos”
  • Can’t seem to keep space tidy despite best efforts
• Misplacing items
  • Where are my keys? Oh, where did I put that cane?
• Interrupting others or difficulty following conversation 
  • Can be hyperverbal
  • May try to finish your sentence for you
• Trouble sticking to a routine/poor time mgmt 
  • Need more sessions/practice doing home exercise programs than most
• Have there been lifelong signs?
  • My dad got in trouble at school all the time. Is regarded as the absent-minded professor now and my uncle had “to-do” lists everywhere

3 Strategies for Addressing ADHD in Older Adults

Once you’ve read over the signs above, you can attempt some of the following non-pharmaceutical strategies to see if they help your productivity levels.

1. Body Doubling

You know that saying “the best thing you can do is just be there for them”? That statement, when taken literally, is one of the best strategies you can use to help someone with ADHD complete their tasks. 

It is not evidence-based yet, but it is highly regarded in anecdotal evidence. Per Hallowell & Ratey, boredom is the kryptonite of people with ADHD. If a task, like paying bills, is understimulating, you may find them fidgeting simultaneously or avoiding the task altogether. With someone else present, body doubling, ideally modeling task productivity (does not have to be the same task), the chore becomes more fun and the body double also acts as an external trigger to flip the person’s toggle from DMN to TPN. 

For example, one of my clients struggled with performing their home exercise jogging program despite their ambition and ability to complete it. Upon his partner’s agreement to body double for him 1x/week, the client was capable of lacing up his shoes, initiating the homework, and enjoying the completion while also reaping the benefits of social participation. Try a coffee shop or library. If in-person body doubling is not an option at this time, try doing it virtually. Get that person on Facetime.

2. Reduce Visual and Auditory Clutter

A common phenomenon of ADHD is an inability to organize personal spaces (car interiors, bedrooms, offices), often regarded as “organized chaos.” To eliminate this barrier to their performance of daily activities, transition the person from singular cleaning attempts to atomic habits. PRO TIP: Read Atomic Habits by James Clear. 

Occupational therapists can facilitate behavior change to support routine organization. By habit stacking and designating spaces, a person with ADHD can become more efficient in daily activities. Clear explains that “habit stacking” is the act of piggybacking the new task on a regularly performed task. For example, if the person would benefit from wiping their counters daily, have them perform it directly after breakfast. 

Stacking habits can be applied to home exercise programs as well. After the regular task and the new task, add a reward; “rewards work much better for the ADHD mind than do consequences” (Hallowell & Radley, 2021). For example, my client now brushes her teeth (old habit), cleans the sink and counters (new habit), and then rewards herself with her morning coffee. People with ADHD already struggle with high distractibility internally, we need to reduce the distractions externally.

A key strategy for organization is designating spaces for commonly used items. Use a color-coded labeled file system for paperwork. Designate a “key bowl” and keep it in the same spot. For those with comorbidity dementia, tape a picture of a key on the bowl to visually cue them. By having a specific space for each thing, the person does not have to worry about making a decision and can develop a good habit. 

Remove the auditory clutter while you’re at it, too. If you want to talk to a person with attention deficits, attempt a conversation away from crowds and televisions so the person does not have to multitask filtering out the background conversations and piecing together your conversation. Or add screen panels and headphones to reduce auditory input.

3. Stress and Time Management

Over 33% of adults with ADHD suffer from depression, higher risk of addictions, and have higher rates of divorce (Adamou, et al., 2021). To increase their self-efficacy, provide social connection, and ensure success in needed occupations like paying bills, planning meals, and completing exercises. 

According to the Grant study, “love is the single most important factor in predicting health, longevity, occupational success, income, leadership ability, general happiness” and the MacArthur Foundation study on aging showed that “joining and attending group meetings and frequency of visits with friends as the two factors most associated with long life” (Hallowell and Radley, 2021). Occupational therapists can educate persons and caregivers on emotional regulation; promoting recognition of calm alert state vs. over/under-alert states. 

Keep in mind that boredom is kryptonite in this population so time management is a huge key to stress management. To ensure success in needed occupations, Hallowell recommends “spending more time on a single thing. You can do it, imagine it as distracting yourself” (2021). From an occupational therapist’s standpoint, the process looks like establishing priority occupation, planning out the day, making sure to include rest breaks, setting up an auditory cue like a timer, and initiating the occupation. Once initiated, the task becomes easier. Regular breaks allow for proprioceptive input to shift a person back into a calm alert state for optimal performance. 

Clinicians Need to Be Involved

Deficits in the executive functions of planning, sequencing, monitoring, and using cognitive flexibility to change steps based on situational demands to perform tasks are well documented in ADHD. 

As a clinician treating the geriatric population, it is important to me to introduce the above coping strategies in order to reduce the long-term detrimental health consequences for this population that already receives reduced social support. Someone can only be negative-symptom-free for so long if they forget to take their blood pressure medications. Keep in mind that the strategies above are modifying the task or environment; it is recommended to take a compensatory approach vs. a rehabilitative approach, attempting to change or punish the person.