Is It Alzheimer’s Disease Or Misdiagnosed Adult ADHD?

Is Adult ADHD in older people being misdiagnosed as Alzheimer’s or dementia?  I worry about this. A lot. This misdiagnosis poses devastating consequences for those individuals and everyone who loves them.

The medical community should be taking this possibility seriously. But it mostly doesn’t seem on their radar. That’s why I found it important to keep searching for the type of story I share with you today.

One thing I know about Alzheimer’s: There is no consensus as to cause—only competing theories. That means we should be cautious before accepting a diagnosis with essentially no treatments. This calls for second, third, and maybe even fourth opinions.

Moreover, most of us are well aware that, even now in 2022, ADHD is far too commonly misdiagnosed as depression and anxiety.  I suspect the misdiagnosis rates are even higher among those 65 and older. Yet, I haven’t seen this formally studied.

We should exhaust all alternate possibilities. That includes screening for ADHD by taking a thorough life history. This is especially important because “seniors” mostly missed out on the awareness of ADHD in childhood and then adulthood. Some might even have been “self-medicating” with nicotine (ADHD & Nicotine: Historical Ads). ADHD misdiagnosed as Alzheimer’s is a distinct possibility.

In the introduction to Is It You, Me, or Adult A.D.D.?, I wrote about my own “force of nature” mother slipping away to stroke dementia. Recurring dreams had me discovering that it was a misdiagnosis—and soon she was back to her sweet, sassy self! These dreams were so real that when I awoke, I had to think very hard: Did I dream that or is it real? I never stopped wishing that some medical miracle would bring her back to us.

For Maria Pugliese, MD, she made my dream—at least in a sense—a reality for her own mother. We met when we both answered a question on Quora. I’ll save that question for a future post.

This post tells her story in the form of my questions and her answers.  I will follow up in coming weeks with two more posts on ADHD and aging. Be sure to subscribe so you don’t miss them.

—Gina Pera

Questions and Answers:

First, tell us about your professional background. Did you study ADHD as part of your medical training?

Dr. Pugliese: I attended the University of Pennsylvania School of Medicine, graduating in 1974. Always wanting to be a pediatrician, since age 8, I took as many courses in pediatrics I could. ADHD was never mentioned in any of them.

There was a one-month course on ADHD in Adult Psychiatry and a  two-month elective in Child Psychiatry. ADHD was not much talked about. This was 1973.

For my internship and first year of residency, I was accepted to the pediatric residency at Children’s Hospital of Philadelphia. For years, US News & World Report has named it the number 1 children’s hospital.

It was a grueling internship— and, again, ADHD was not mentioned at all. How grueling was it? I was on duty around Christmas for five days and four consecutive nights— in three different hospitals. I asked, “When do I sleep? “Catnap,” they said, “and you have 5 days off afterward.”

As much as I loved Pediatrics, I was physically ill most of the time with every infectious disease. Physically, I couldn’t do it. I switched to Psychiatry at the Institute of Pennsylvania Hospital, thinking I would do Child Psychiatry.

When I got to the elective, however, I found I loved the kids but hated the parents. The parents believed their children were deliberately being disobedient instead of accepting that their behavior was secondary to a medical disorder. Spanking was big in the 70s.

Serendipitously I was assigned to Addiction Psychiatry and found my place. The Institute was psychoanalytically oriented. Though I enjoyed every minute, I found that psychoanalysis didn’t work with addicts and alcoholics. They needed a more “here and now” approach.

When did you start focusing on ADHD?

Dr. Pugliese: I am retired now. But all together I had a private practice for 44 years and worked part to fulltime at a local suburban rehab for 31 years. After 8 years at the rehab, I took 4 years off from my job (but not my private practice) to adopt my daughter.

After those four years, a Medical Director at the rehab arrived whose primary interest was ADHD. His name was Douglas Dionne, MD. He heard about me and rehired me.

By this time, I had become imbued with a lot of knowledge about ADHD from my daughter, who was born with it. I took her to a pediatric neurologist at age 9 months for ADHD and breath-holding spells.

So, as with most professionals who truly understand ADHD, you learned first-hand with loved ones.

Dr. Pugliese: My husband’s ADHD was the biggest surprise. He has two PhDs in Organic Chemistry and in Pharmacology. Science was his passion. In many practical things, though, he was hopeless.

For example, we had separate checking accounts because he always went into overdraft and had great difficulty paying bills on time. So, I took over that. It took me a long while to figure him out as I thought brilliant people couldn’t have ADHD.

He eventually saw our pediatric neurologist. Later, my son’s psychiatrist gave him a trial of medication. Unfortunately, he had some unacceptable side effects. Knowing the diagnosis was real, I felt less angry toward him.

A funny thing happened when my son received the Tourette’s diagnosis. My husband always made strange noises and he realized that he also had a vocal tic disorder. They are, of course, not biologically related.

Did your medical training and status help or hurt your advocacy efforts on behalf of your children and your mother?

Dr. Pugliese: My medical training did little to help me understand ADHD.

What taught me the most? My experience with my children and their treatment with their pediatric neurologist, L. Douglas Wilkerson, MD.

After growing tired of advocating for my children in the educational arena, I homeschooled my daughter through high school and my son through third grade. I felt I knew better how they learned than any of their teachers.

It was also my kids who taught me how to understand my mother. I never had to advocate for my mother because she did not believe there was anything wrong with her until she hit age 80 and developed medical problems.

How did you interpret some of your mother’s puzzling behaviors before you learned about Adult ADHD?

Dr. Pugliese:  Well, what I had thought was her personality was the exact opposite. I could never understand how she could be “so stupid.”

Like many women with ADHD, she always threw herself into books. Her passion for the law meant that she obsessed in that area. She gave it all up when she married and had us three kids. That was when most of her ADHD characteristics began to show.

My father was very obsessive-compulsive and spent his time working and in charitable, ethnic and religious organizations. My mother did, however, do a good job of raising us girls—two doctors and a lawyer.

I remember being 11 years old and going shopping with her for a washing machine. The salesman tried three or four ways to explain how it worked before getting angry at her. I told her I would explain it to her when we got home.

She also had a problem with anger. She did not express it as anger. When she was angry, she would get physically ill and expect to be waited on by her children. Or she would jump into the car, without a word, and disappear for hours.

What else do you remember about her from when you were a child?

Dr. Pugliese: One behavior typical of my mother: making decisions based on an emotional whim devoid of logic and, unintentionally and by consequence, without regard to her children. For example, she made strange decisions regarding her pregnancies and childbirth.

When pregnant with me, she was so sick that she had to move back to Philadelphia to stay with her parents. My father stayed in New York, where he was working. Then, when I was three years old, she had fibroids removed in New York by her favorite doctor. I was sent to Philadelphia to stay with grandma. She came to idolize this doctor.

My mother got pregnant again when I was 4. By this time, we had moved to Wayne, Pennsylvania. Since she needed another C-section, her New York doctor wanted her to spend the last month of pregnancy near his hospital. So, she moved back to New York, leaving my father at home. I was shipped off again for a month to my grandmother’s.

For her third pregnancy, she did the same thing. She spent a month alone in New York in a Catholic women’s home. I was sent at age 8 to live with a neighbor; my younger sister was sent to grandma’s house. My father stayed at home and went to work and apparently didn’t feel the need to be involved.

None of this made sense to me as a child.

Did your mother have diagnosable ADHD, do you suppose, earlier in her life?

Dr. Pugliese: I know little about her early life. Growing up as the middle of five in a conservative Italian immigrant family, she was very bright,  skipped several grades, and spent a lot of time reading in order to avoid the world.

Always in a hurry to do things, she sailed through college in three years. She had an operatic singing voice and went to New York weekly for professional lessons. But when it was time to move to New York for better roles, she didn’t.

My mother was lively and had a lot of personality. My father was the sixth man to propose to her. She didn’t accept the other five—clearly great at leading people on but short on the follow-through.

With no clear idea about what she really wanted to do, she went to secretarial school, where she learned shorthand, and worked at many secretarial jobs.

How did your parents meet?

Finally realizing she wasn’t getting anywhere, she enrolled at the University of Pennsylvania for a master’s degree in Political Science. Her next job: librarian at the University of Pennsylvania Law School Library. There she briefly met my father, who was a lawyer, when he was in uniform and heading for the OSS in Washington.

He wrote her a letter four years later. The only thing she could remember about him was that he pronounced his beautiful Italian last name Anglicized. Awful!

After they married, a few years later, my father learned that his new wife had never even boiled an egg or watched her mother cook. When she tried cooking spaghetti in a pressure cooker, it blew up. Practical things were not her strong suit.

How did your mother go from librarian to law school student?

Dr. Pugliese: Tired of being the librarian looking at the outside of law books, she decided to look inside. She could be very focused on the things she was passionate about—but little else. She also had a photographic memory. On a full scholarship, she completed law school in two and a half years.

My father saw her name in the Law Review, remembered her from her librarian days, and wrote to her. They had a very amusing correspondence.

She worked as a lawyer at the firm of Drinker, Biddle, and Reith for three years. Mr. Drinker saw in her resume that she had been a college glee club soloist. He immediately invited her to his monthly singing parties where they sang the classics. As the only female lawyer there, however, she socialized mainly with the office staff.

When my parents married in 1947, she stopped working for fulltime motherhood. She moved out of her parents’ house into an apartment in New York City, where my father had a job at RKO.

At what age was she diagnosed with ADHD and by who?

Dr. Pugliese: I always knew she was dealing with something, but once I had to learn about ADHD through my adopted children, I saw the diagnosis clearly.

By then I had many adult patients that I was treating. One or two were in their 60s. I had suggested earlier that my mother would benefit from a trial. She read the material, saying she saw how the material applied to my children but not to her—at least as far as she would let on.

So, what tilted the balance toward her acceptance?

Dr. Pugliese: In her early 80s, her rushing here and there started to cause real problems. She paid little attention to where she was going and tripped over things. Then one day, while getting back into her car after running an errand, she knocked her head against the car’s roof, to the point that she passed out. A policeman drove her home. Nothing like that had happened before.

Also, my mother was working on the preliminaries for her income tax. It usually took her a month or so. The only thing she had to tabulate was medical expenses and charitable deductions. But it took her three months to get it to her accountant.

All her medical problems were orthopedic. So, I thought it would be good to see if stimulant medication made a difference with her physical coordination and awareness of her surroundings. She agreed.

I started her out on Concerta 18 mg and a month later 36 mg. It made a subtle but big difference. She stopped falling. This improvement allowed her to stay in her home with an aide for 5 years. She went into a nursing home only when a substitute aide let her go down steps. She fell and broke her leg in 18 places.

I made the diagnosis and treated her. Treating ADHD was my specialty at this point, and I knew her history and medical problems better than anyone else. It made sense.

I know “seniors” treated for ADHD for years who “time out” when they reach 65 or so, despite having no cardiovascular

issues. The physicians simply won’t prescribe.

Dr. Pugliese: Shop around for a psychiatrist or neurologist or gerontologist who treats elderly people and a lot of ADHD.

Because I used Concerta and her internist had used Ritalin to help some elderly people who had dementia, he had no objection. Her cardiologist had no objection. Her internist was also my doctor and I had worked with him for 13 years at one point, so he trusted me.

I worry that Adult ADHD is too often misdiagnosed as Alzheimer’s. Should we be screening more older people, given that ADHD was little known in their youth?

Dr. Pugliese: Absolutely. I think we can prevent more car accidents, falls, and other injuries and extend their lives as well as the time they go to long-term care.

Can you share a personal experience on this topic?  We’d love to hear it.

—Gina Pera
An earlier version of this post appeared December 3, 2019.