Geriatric Onset of Attention-Deficit/Hyperactivity Disorder in a Patient with Comorbid Bipolar Disorder

doi:10.21203/rs.3.rs-2762725/v1

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Case Report

Geriatric Onset of Attention-Deficit/Hyperactivity Disorder in a Patient with Comorbid Bipolar Disorder

https://doi.org/10.21203/rs.3.rs-2762725/v1

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Journal Publication

published 05 Mar, 2024

Read the published version in BMC Geriatrics →

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Background

An increasing number of adults over 60 years old are presenting with requests for treatment of attention-deficit/hyperactivity disorder (ADHD). However, the prevalence of ADHD in older adults in geriatrics is unknown. Further, comorbid bipolar disorder and adult ADHD are likely underrecognized with many patients only receiving treatment for one of these conditions. The occurrence of bipolar disorder with geriatric onset ADHD is unknown.

Case Presentation

A 64-year-old Hispanic woman with a psychiatric history of bipolar I disorder (diagnosed in early adulthood) was diagnosed with geriatric onset ADHD, and able to be successfully managed on concurrent mood stabilizers and psychostimulant medication.

Conclusions

The findings of this case report emphasize the importance of appropriately recognizing and treating comorbid ADHD and bipolar disorder in any age group, including the geriatric population for which this occurrence appears to be very rare. Additionally, this case report demonstrates the safe utilization of psychostimulant medications in a geriatric patient with bipolar disorder without inducing a manic episode or other significant adverse reactions.

ADHD

psychostimulants

geriatric psychiatry

bipolar disorder

An increasing number of adults over 50 years old are presenting with requests for treatment of attention-deficit/hyperactivity disorder (ADHD) [1]. However, the exact prevalence of ADHD in older adults in geriatrics is unknown. The prevalence of ADHD is generally accepted among psychiatrists to decrease with age, but there are limited controlled studies that investigate using ADHD medications in adults over 50 years old [1]. There are estimates that childhood ADHD may persist into adulthood at age 25 between 15–65% of cases [2]; however, older adults and geriatrics with ADHD are an even less studied population with estimates generally below 5% of the population [3, 4].

Although ADHD and bipolar disorders are common mental health conditions, the degree of their comorbid occurrence in adulthood, and especially geriatric age, remains unclear. There are estimates of ADHD and adult bipolar disorder occurring comorbidly in as many as 1 in 13 patients; however, many of these cases may be unrecognized and untreated [5]. The under-recognition of both disorders when they occur comorbidly is likely due to some symptomatology overlap, as well as the similar impacts that each condition has on major life area functioning for patients [6]. Still, appropriate recognition and treatment of both conditions are optimal, and the effective management of both conditions is likely to result in improved quality of life and functioning [1, 6].

A 64-year-old Hispanic woman with a psychiatric history of bipolar I disorder (diagnosed in early adulthood) presented in the outpatient setting for the continuation of psychiatric care after moving to the area. Her prior uncontrolled symptoms included pressured speech, rapid ideas of importance, and insomnia. She also reported new short-term memory problems. Her psychiatric management included amitriptyline (25mg daily), valproic acid extended release (1500mg nightly), and quetiapine (50mg twice daily).

On continued follow-up, she complained of forgetfulness and dropping items which led to feelings of sadness and frustration. A neurologic exam revealed no focal deficits at that time. She was prescribed donepezil (titrated to 10mg daily) for treatment of possible dementia. Over the following year, her symptoms continued, and the patient relapsed into a major depressive episode. Neurology was consulted for continued concerns of dementia, with laboratory studies returning within normal limits (TSH, T4, T3 total, erythrocyte sedimentation rate, c-reactive protein, vitamin B12, RPR). Electroencephalogram (EEG) demonstrated mild generalized slowing, with no focal slowing or seizure activity. Computed tomography (CT) scan and magnetic resonance imaging (MRI) were unremarkable. Neurology recommended discontinuing donepezil and amitriptyline out of concern for medication adverse reactions and concerns of pseudodementia.

The patient was monitored over the following year for alleviation of symptoms but did not have significant change despite her medication changes. She continued to complain of difficulty with concentration, memory, and restlessness but did have some improved mood. Due to the persistence of forgetfulness, ADHD was considered in the differential diagnosis. Her evaluation for ADHD at this time was consistent with many DSM-5 criteria for inattention including difficulty sustaining attention, frequent careless mistakes, not following through on instructions, frequently losing necessary items, difficulty maintaining sequential tasks, being easily distracted, and did not listen when spoken to directly as if her mind was elsewhere.

The patient was prescribed methylphenidate 5 mg twice a day and reported near-immediate improved focus, increased energy, and improvement in her memory. 6 months into treatment the patient developed insomnia which resolved by decreasing her dose of methylphenidate to 5mg daily. However, 4 months after the decrease in dose, symptoms of inattention returned, and she was restored to methylphenidate 5mg twice daily and tolerated the medication without insomnia. The patient was followed for 3 years thereafter before moving out of the county, during this time she had no reported adverse reactions to methylphenidate and continued alleviation of symptoms.

This case report describes the rare onset of geriatric ADHD in the context of long-standing adult bipolar disorder that was effectively managed with psychostimulant medication and mood stabilizers. The findings of this case report emphasize the importance of appropriately recognizing and treating comorbid ADHD and bipolar disorder in any age group, including the geriatric population for which this occurrence appears very rare, as there are no known reported cases prior.

Importantly, major neurocognitive disorders were considered in the differential diagnosis for this patient, and donepezil was prescribed by psychiatry prior to the initiation of psychostimulants with no observed clinical benefit. Additionally, neurology consultation was not suggestive of cognitive decline, but rather of suspected undertreated psychiatric illness, and even recommendation to discontinue donepezil. The incidence of major and minor neurocognitive disorders is far more common in the geriatric population than geriatric onset ADHD. Still, both conditions also have overlapping symptoms in regard to difficulties with concentration and attention. When symptoms of inattention develop in the geriatric population, and when major and minor neurocognitive disorders are ruled out, ADHD may be considered a rare but possible diagnosis. Notably, there have been recent investigations of utilizing psychostimulants (including methylphenidate) in treating apathy associated with Alzheimer’s disease [7, 8].

Methylphenidate is also used off-label for major depression in the elderly with medical illness, palliative care, or terminal illness [9]. It is possible that the patient we describe in this case report benefitted from methylphenidate in this manner. However, because the primary symptoms were intention with subsequent frustration and depression thereafter, we consider it more likely that the therapeutic response was due to treating the geriatric onset ADHD.

Utilizing psychostimulants with other psychotropic medications in the geriatric population requires careful monitoring, as they may be more prone to adverse reactions even from lower doses [10]. Further, some clinicians may have hesitations about prescribing stimulant medications for ADHD to those with comorbid bipolar disorder or a history of substance use disorders [6]. These hesitations may be mitigated with proper risk management, including assessment for cardiac tolerability, monitoring for the development of mania/hypomania, and utilizing controlled substance review programs [4].

The findings of this case report emphasize the importance of appropriately recognizing and treating comorbid ADHD and bipolar disorder in any age group, including the geriatric population for which this occurrence is very rare. Additionally, this case report demonstrates the safe utilization of psychostimulant medications in a geriatric patient with bipolar disorder without inducing a manic episode or other significant adverse reactions.

ADHD

attention-deficit/hyperactivity disorder

TSH

thyroid stimulating hormone

RPR

rapid plasma reagin

EEG

Electroencephalogram

Computed tomography

MRI

magnetic resonance imaging

DSM-5

the diagnostic and statistical manual of mental disorders, fifth edition

Ethics approval and consent to participate
- Informed written consent was obtained for this case report and approved by Kern Medical Center’s Institutional Review Board Case #22139
Consent for publication
- Informed written consent was obtained for publication purposes by the patient and approved by Kern Medical Center’s Institutional Review Board Case #22139
Availability of data and material
- No datasets were used or generated for this manuscript. All data for the case report is included in the published article.
Competing interests
- The authors declare they have no competing interests
Funding
- No funding was provided for this study.
Authors' contributions
- JW, NK, RB TT: wrote the manuscript. All authors have read and approved the manuscript.
Acknowledgements
- Not applicable

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No competing interests reported.

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Journal Publication

published 05 Mar, 2024

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Editorial decision: Revision requested
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First submitted to journal
31 Mar, 2023

You are reading this latest preprint version

Geriatric Onset of Attention-Deficit/Hyperactivity Disorder in a Patient with Comorbid Bipolar Disorder

Status:

Journal Publication

Version 1

Abstract

Background

Case Presentation

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1