CGPR: Dr. Goodman, please tell us about your work and how you became interested in ADHD in older adults.
Dr. Goodman: I’m an adult psychiatrist with decades of clinical experience in private practice and research on early ADHD medications. My focus has long been recognizing and treating adults with ADHD, a challenge because most clinicians were never formally trained on it. Over the past two decades, my work has increasingly centered on older adults. Many of my patients have aged with me, and I’ve seen firsthand that ADHD persists across the lifespan.

CGPR: What prevents clinicians from recognizing ADHD in older adults?
Dr. Goodman: Four things get in the way: 1) clinical blindness, 2) inexperience, 3) diagnostic complexity, and 4) safety concerns. Many clinicians don’t include ADHD in the differential diagnosis for older adults with cognitive complaints. Others lack experience managing psychiatric illness and stimulants alongside medical comorbidities such as hypertension or cardiac disease. Differentiating ADHD from other psychiatric and medical conditions can also be challenging, discouraging clinicians from pursuing this diagnosis. Finally, concerns about stimulant safety or misuse in older adults add another barrier.

CGPR: Why is it so difficult to make the ADHD diagnosis in late life?
Dr. Goodman: The main challenge is differentiating ADHD from age-related cognitive decline. Older adults who report distractibility or forgetfulness are often labeled as having age-related cognitive changes or mild cognitive impairment. Without a careful evaluation that includes ADHD in the differential, clinicians miss opportunities to identify a lifelong disorder. In the psychiatric differential, you’re also looking for anxiety disorders, mood disorders, and post-traumatic stress disorders. In the medical arena, you’re looking for a history of traumatic brain injury, repetitive concussive injuries, history of a stroke, or other conditions that may now lead to neurodegeneration. ADHD may also coexist with mild cognitive impairment or dementia, further complicating the picture. Most older adults with ADHD were never diagnosed in childhood, so the absence of an earlier diagnosis should not rule it out (Sharma MJ et al, Am J Geriatr Psychiatry 2021;29(7):669–678).

CGPR: What clues suggest ADHD rather than another psychiatric illness?
Dr. Goodman: ADHD begins in childhood or adolescence and follows a chronic, lifelong course. By DSM-5-TR criteria, new-onset cognitive problems later in life are not ADHD. The chronic nature of ADHD distinguishes it from mood disorders, which tend to be episodic. Anxiety can worsen attention, but anxious patients emphasize worry and rumination, whereas patients with ADHD describe anxiety tied to performance failures, such as being late, forgetting tasks, or missing details. Remember that childhood onset of ADHD symptoms and impairment is the anchor to the diagnosis.

CGPR: How can clinicians distinguish worsening ADHD from a developing neurodegenerative process?
Dr. Goodman: ADHD symptoms are relatively stable over time, although longitudinal data suggest some variability (Sibley MH et al, Am J Psychiatry 2022;179(2):142–151). New-onset progressive language changes, such as worsening word-finding difficulty, semantic substitutions, or emerging spelling errors in someone without a lifelong history, suggest a second process, such as mild cognitive impairment or early Alzheimer’s disease (AD). Spelling errors alone are nonspecific and may reflect ADHD-related inattention or long-standing learning disorders (such as dyslexia), but a progressive decline in written or spoken language should raise concern for neurodegeneration. ADHD symptoms typically fluctuate with attention, fatigue, and environmental demands, whereas neurodegenerative changes are progressive in later life. A similar distinction applies to executive functioning: In ADHD, executive difficulties are variable and context-dependent, often improving with structure or treatment, while executive dysfunction due to neurodegenerative disease is typically progressive, less responsive to scaffolding, and accompanied by broader cognitive decline across domains. When cognitive complaints persist despite stable attention and optimized ADHD treatment, neurologic evaluation and biomarker testing might be warranted.

CGPR: Many older patients have multiple medical or psychiatric problems. How do you disentangle ADHD from comorbidities?
Dr. Goodman: ADHD rarely occurs alone. Approximately 70% of adults with ADHD have at least one psychiatric comorbidity, and many have multiple. These comorbidities exacerbate attentional impairment and are associated with reduced treatment response (Fu X et al, Front Psychiatry 2025;16:1597559). A systematic assessment is essential, including mood, anxiety, trauma-related, and substance use disorders, as well as medical contributors such as prior brain injury or stroke.

CGPR: What are your key elements of this comprehensive assessment?
Dr. Goodman: It starts with developmental history, focusing on symptoms before age 12, and continues through academic, occupational, and relationship functioning. Collateral about childhood functioning (eg, parents or school records) is often unavailable in older adults, but input from spouses or adult children can still help clarify long-standing patterns of inattention and functional impairment. In the absence of early collateral, I rely on contextual cues and ask how teachers or peers responded to attention or performance concerns: “Were you moved to the front of class for inattention? Did you need reminders for assignments?” These clues help confirm early impairment. I also probe for compensatory strategies, caregiver scaffolding, and comorbid conditions.

“Impairment isn’t just about outward performance;
it’s also about the internal effort required to sustain it.”

David W. Goodman, MD

CGPR: How do you raise ADHD as a possibility with older patients?
Dr. Goodman: Some patients come in already wondering about ADHD, but many do not. More commonly, they present with lifelong struggles that feel increasingly unmanageable. I focus on long-term patterns over current symptoms, asking whether attention or organization problems have been present as long as they can remember. I also ask about compensatory systems and what happens when structure is removed. When I raise ADHD, I present it as one possible explanation among several, normalizing late recognition of a lifelong condition without presuming a diagnosis.

CGPR: Some patients appear to lose their ADHD symptoms in structured adulthood, then relapse later. What’s happening?
Dr. Goodman: ADHD symptoms wax and wane with environmental and cognitive demands (Sibley MH et al, J Clin Psychiatry 2024;85(4):24m15395). Structure and external supports can mask deficits, while transitions such as retirement, bereavement, or job loss can unmask them. New attentional complaints, however, do not automatically indicate ADHD relapse. Stress, grief, and depression can produce similar symptoms, so continuity from childhood must be confirmed.

CGPR: What about those with strong childhood symptoms who functioned well for decades? Are they still considered impaired?
Dr. Goodman: Impairment isn’t just about outward performance; it’s also about the internal effort required to sustain it. High-IQ or externally structured individuals may appear successful yet expend enormous mental energy to stay organized. A CEO with a dedicated assistant may appear to perform well but still have ADHD. The key is assessing mental fatigue, compensatory strategies, and reliance on external supports. When success requires disproportionate effort or constant external support, that’s impairment, even if performance looks intact.

CGPR: What diagnostic tools or rating scales are useful in older adults?
Dr. Goodman: There is only one validated ADHD scale for adults over 65: the Barkley Adult ADHD Rating Scale, which is proprietary and rarely used in clinical practice. Most tools were developed in younger populations, and few randomized trials include older adults (Dobrosavljevic M et al, Expert Rev Neurother 2023;23(10):883–893). That’s largely due to safety concerns about placing controlled drugs in older adults with multiple medical issues.

CGPR: Should clinicians use screening tools like the Adult ADHD Self-Report Scale (ASRS) in older adults?
Dr. Goodman: Screening tools are designed to flag possible cases, not confirm diagnoses. Their positive predictive value is low in older adults with overlapping medical or cognitive issues. They should supplement, not replace, a comprehensive clinical evaluation. I use the ASRS at baseline and longitudinally to track symptom change. Because it maps onto the 18 DSM-5 symptoms and rates frequency, it’s helpful for monitoring trends. Functioning matters as much as symptoms: You can have a patient with only a few symptoms who’s constantly missing deadlines and losing jobs, and another who checks off half the list but functions well. Treatment should aim to improve both symptoms and real-world functioning, not just lower the symptom score.

CGPR: How do you decide when a more comprehensive reassessment is needed?
Dr. Goodman: I reassess more fully when something changes, such as new cognitive complaints, mood symptoms, or medical issues. In older adults, DSM-5 symptoms still apply but often look different: Hyperactivity becomes inner restlessness, impulsivity is less overt, and inattention is easily mistaken for aging or depression (Editor’s note: For more on how ADHD symptoms present differently in older adults, visit: www.thecarlatreport.com/ADHDSymptomsinOlderAdults).

CGPR: When should clinicians refer to neuropsychological testing?
Dr. Goodman: Rarely for ADHD alone. ADHD remains a clinical diagnosis, and test results may be normal even when ADHD is present. I reserve testing for complex cases, such as coexisting learning disorders or suspected neurodegenerative disease, where understanding specific cognitive domains informs diagnosis and management. Otherwise, it’s an expensive tool with limited diagnostic value for ADHD.

CGPR: Why is confirming a formal ADHD diagnosis important rather than simply treating symptoms?
Dr. Goodman: Response to stimulant medication does not confirm ADHD. Stimulants can improve focus in people without ADHD, so prescribing based on symptom relief alone risks inappropriate use. Diagnosis ensures we’re treating a legitimate psychiatric disorder, not using stimulants as performance enhancers. It’s important for clinicians to document their rationale clearly, especially since prescription rates have increased sharply over the last few years (Huskamp HA et al, Psychiatr Serv 2025;76(9):782–787).

CGPR: Has increased ADHD awareness in older adults improved diagnosis or created problems?
Dr. Goodman: Both. Public awareness and pharmaceutical marketing have expanded recognition of adult ADHD, but they’ve also led to overdiagnosis and casual prescribing. When I started in the late 1980s, colleagues doubted adult ADHD even existed. Now, prescriptions have exploded, often written by nonpsychiatrists. Awareness is good, but rigor must match it. We need thorough evaluations, not quick checklists that can drive inaccurate diagnosis and inappropriate prescribing.

CGPR: Many evaluations happen in primary care. What’s realistic for nonspecialists?
Dr. Goodman: Primary care clinicians can initiate screening, but accurate diagnosis takes time. A full ADHD evaluation usually takes 60–90 minutes and can’t be done in a brief visit. In primary care, it’s reasonable to screen with the ASRS and ask a few targeted follow-up questions, but the diagnosis requires establishing a lifelong pattern of symptoms and impairment. A first-degree relative with ADHD also makes the diagnosis more likely.

CGPR: Why treat ADHD in someone aged 65 or older?
Dr. Goodman: Treatment can be life changing. It helps patients understand lifelong struggles as symptoms of a disorder rather than personal failure and can significantly improve quality of life. ADHD may also increase dementia risk, making identification and longitudinal monitoring especially important in older adults (Levine SZ et al, JAMA Netw Open 2023;6(10):e2338088). Older adults deserve the same functional recovery we aim for in younger patients.

CGPR: What recommendations do you have for stimulant use in older adults with or without ADHD?
Dr. Goodman: Stimulants are sometimes used off-label for conditions such as traumatic brain injury, sleep apnea, or apathy in AD (Mintzer J et al, JAMA Neurol 2021;78(11):1324–1332). When used, clinicians should document their rationale carefully and weigh cardiovascular risks, including hypertension, arrhythmias, and underlying structural heart disease. For ADHD, stimulant treatment should rest on verified childhood onset and clinically meaningful impairment.

CGPR: Can you share a case when treating ADHD in late life changed outcomes?
Dr. Goodman: A physician in his early 60s presented with a two-year history of cognitive decline and long-standing but undiagnosed ADHD. After initiating ADHD treatment, his functioning improved enough for him to continue working. Biomarker testing later confirmed coexisting early AD. There is little guidance in the literature for managing this overlap, but treating his ADHD meaningfully improved quality of life for two to three years. That benefit matters.

CGPR: What would you most want clinicians to remember about ADHD in late life?
Dr. Goodman: Please include ADHD in the differential when evaluating older adults with cognitive complaints. Don’t dismiss attention problems as “just aging.” Use a structured clinical interview, confirm childhood onset, assess comorbidities, and document the trajectory of symptoms and impairment over time. If you identify ADHD, treat it like any chronic disorder: carefully, compassionately, and in collaboration with the patient’s broader medical team. These patients experience remarkable improvement once lifelong symptoms are finally understood and addressed. Successful treatment helps patients distinguish a treatable disorder from their identity, often restoring confidence and self-efficacy.

CGPR: Thank you for your time, Dr. Goodman.