Adult Attention-Deficit/Hyperactivity Disorder and the Risk of Dementia
jamanetwork.com
jamanetwork.com
Known:
- Dementia has many lifestyle risk factors (poor education, hypertension, obesity, hearing loss, depression, diabetes, physical inactivity, smoking, drinking, social isolation)
- ADHD can make it easy to have certain lifestyles (addictions to drugs or food, trouble maintaining relationships, emotional dysregulation, poor education, poor work performance, high risk behavior)
New connection:
- There is significant overlap in the two
As others have mentioned, ADHD is also comorbid with other mental health disorders including eg depression and alcoholism. That’s also a reasonable mechanism. Personally as someone with the condition a 6% increased chance does not scare me though it’d be great to understand the mechanism in case it’s caused by preventable behaviors rather than the condition itself.
But the way they’re controlling for stimulants is very poor. To begin with, out of the 100k in the study, only 730 had ADHD and of that only 163 were in the psychostimulant cohort. So to establish statistical significance regarding dementia, which only affected 96 people out of the 730 with ADHD, would be almost impossible if the relationship were mild. And you see that in the huge P-value for the infra-ADHD comparison (0.74) which shows a slight decrease in dementia for stimulant-takers. Basically there is too little data to take that seriously at all.
The comparison across ADHD and no-ADHD populations regarding psychostimulants is deeply flawed too. They’re bucketing [0] dopaminergic stimulants with modafinil (much less dopaminergic) and even nootropics like racetams - literally prescribed to heal brain damage and treat or prevent dementia in former Soviet Union countries, with an entirely different safety profile and mechanism compared to dopaminergic stimulants. Having trouble finding data on racetam legality and use in Israel, so they may not be in scope given the medication would need to be formally prescribed IIUC. But that leaves the remainder as likely taking prescribed dopaminergic stimulants and modafinil, which for those without ADHD are mostly taken by those with narcolepsy. So the non-ADHD psychostimulant users are likely strongly biased towards narcoleptics with the remainder being those taking drugs for the purpose of treating or preventing cognitive decline, and the intra-cohort ratio is 1.1:22.3 so roughly only 5% of the ADHD-stimulant group is comparable to the nonADHD-stimulant group assuming similar, uncorrelated incidence of narcolepsy.
In other words, their two attempts to control for stimulant use either have a uselessly low amount of data giving a p-value of 0.74, or are confounded by comparing against narcoleptics taking stimulants’ dementia rates (not healthy people taking stimulants; they wouldn’t have been prescribed stimulants so long without having ADHD or narcolepsy) with the possible wildcard of some of these “psychostimulant” users taking non-dopaminergic stimulants or even non-stimulant nootropics.
It makes me wonder if ADHD patients would more often fall on the other side of this functional/coping divide and so get earlier diagnoses. And if so, how could you control for this? Across a population, I would think that delayed detection means lower diagnosis rates since some patients would die before the delayed diagnosis could happen.
The relationship between dementia and ADHD wasn't mild. So the claim a mild relationship would have been impossible to detect is irrelevant even if true. And they didn't say to to take the less elevated risk in the stimulant taking ADHD group as conclusive evidence of a real effect.
Dopaminergic stimulants and modafinil are nootropics prescribed to treat dementia also. And you would need to suppose those drugs were prescribed more to people without ADHD or dementia diagnoses to believe this explained the elevated risk of dementia in people with ADHD.
https://www.sciencedirect.com/science/article/abs/pii/S01452...
The specific symptom they were looking at in what I was reading, was how people with ADHD easily walk away from things (friends, family, etc.), never to return. Basically a lot of kids attempt to run away, but people with ADHD are far less likely to return if they succeed in "getting away".
The article was relating having lived the earliest part of their lives being pushed away, to the ability to more easily separate and push everyone away permanently later in life (which they referred to as "shutting down"), and the possibility that ADHD itself might be a coping and survival mechanism.
Maybe there’s something neurologically wrong from the beginning that manifests as ADHD and later turns into dementia?
It’s definitely weird how I am just completely unmotivated by anything for months at a time then suddenly will be intensely motivated and impossibly into something new.
One of my main symptoms was MCI. Interesting that after long term treatment not only the MCI improved or subsided but also my very long standing ADHD (present for as long as I can remember) got dramatically better, makes you wonder.
I have nasty seasonal allergies (at least one per season). Whenever it flares up, the is a marked increase in my needs and decrease in my productivity. I'm hoping to start immunotherapy for them soon. I get my ADHD and my allergies from my dad and immunotherapy has done him wonders.
I can’t speak to the dementia portion, but it would not surprise me. As for the adhd being the result of something ‘neurologically wrong’… I feel like we should replace ‘wrong’ with something less charged, maybe ‘sub-optimal’ or ‘problematic’, but you intuited your way into something I’ve spent years in therapy and reading books to finally grok.
Two specific books that come to mind: The Myth of Normal and What Happened to you
We can define wrong as counterproductive, while seeking to accommodate those configurations and seek to reduce their affects or mitigate them entirely
personally I feel that the symptoms of adhd are less relevant and doesn't impair my daily functions as much if I focus my entire waking time on outdoor activities like biking and swimming, and while I never hunted with primitive tools it might share some similarities
I think this is something that could be verified in practice too, since we still have hunter-gatherers societies
"Dementia occurred among 96 of 730 participants (13.2%) with adult ADHD and 7630 of 108 488 participants (7.0%) without adult ADHD."
This really matters for things with a very low probability.
And the difference between the two is?
"Per cent means one hundredth of something. Percentage point is used when comparing percentages to one another. For example, when inflation drops from three to two per cent, inflation decreases by one percentage point and 33.3 per cent."
When you say it is 6 percentage points higher it means you had a percentage Y% and it is now (Y+6)%, a value which cannot be determined unless you know Y, never mind the reference absolute value it relates to.
In this particular case you can say it went from 7% to 13.2%, so if you ignore "%" as the unit the actual change is from 7 to 13.2; a ((13.2-7)/7) ≈ 0.8857 = 88% change. Had the original percentage been say 67%, a 6.2 p.p. change would have increased the percentage to 73.2%; a much smaller ((73.2-67)/67) ≈ 0.0925 = 9% change.
Had the change been "six percent of seven percent", the new value would be 7+7*(6/100) = 7.42 (percent).
* Doubled rate of premature death (largely attributed to accidental injury)
* 47% anxiety disorder comorbidity
* 38% severe mood disorder comorbidity (including depression)
* 15% substance abuse disorder comorbidity
Between the heightened risk of concussions, anxiety, depression, and substance abuse, it's not at all surprising that dementia shows up twice as often in the statistics. With that being said, it doesn't tell us much at all about whether there's a shared pathology.
And also note that dementia is associated with a very high incidence of depression. So the question now is: How many of these ADHD->Dementia or Depression->Dementia cases were actually a sort of early onset cognitive problem that was lumped into the closest matching mental health condition?
ADHD cohorts are especially difficult to evaluate because the clinical diagnostic standards are all over the place. A proper diagnosis requires ruling out other common causes of attention problems (insomnia, depression, sleep apnea and other common conditions can have severe attention problems as a secondary effect) but rushed providers will often hand the patient a questionnaire and then hand them a diagnosis if the number is above the threshold. As my friends in clinical practice will lament, there are a lot of people with underlying conditions who are getting ADHD diagnoses because it doesn’t carry the stigma of a depression diagnosis (for reasons I still can’t understand) and it’s easier to “diagnose” than doing a proper work up and background history to check for other conditions like apnea. This makes correlational studies with ADHD even harder to interpret.
https://www.alzheimers.org.uk/about-dementia/risk-factors-an....
[1] leads me to believe they would look like someone with a high degree of hyperactivity and a low degree of inattentiveness.
This is super interesting. The authors point to some needed future research into this in their discussion:
"There are different interpretations of the finding that adult ADHD treated with psychostimulant medication was not clearly associated with an increased dementia risk. It is possible that ADHD treated with medication reflects more severe ADHD compared with ADHD not treated with prescribed psychostimulants, which may reflect milder symptoms or even a less-accurate diagnosis. Also, ADHD is a chronic condition and may have negative long-term sequelae when untreated. Hence, the lack of association among individuals exposed to psychostimulants contradicts the conclusion that ADHD is associated with dementia risk. Alternatively, one may accept our ADHD ascertainment procedures. Among patients with adult ADHD, psychostimulant exposure is uncommon (22.3% in our study and less elsewhere5). The ADHD medication and diagnosis combination is 0.5% (567 of 109 218), possibly an underestimate of adult ADHD. Also, psychostimulants are cognitive enhancers hypothesized to reduce dementia risk.19 In addition, our study results should be interpreted within the broader literature that generally supports the association between adult ADHD and dementia.14-17 Seen this way, including psychostimulants in the association between adult ADHD and dementia risk may account for confounding by medication. That said, future research is necessary, including the assessment of adult ADHD symptom severity, to examine the role of psychostimulant medication in old age."
I hadn’t seen this info before… thanks for mentioning this!
I’m of the opinion, as a sufferer and an offspring, their lack of motivation comes from undiagnosed adhd (different times).
There’s Alzheimer’s and then there’s OldTimers. The latter is a correctable condition that if prevented could, (again, my own opinion) stave off the former. The brain is a muscle, do not let it atrophy. You need to exercise all parts of it - especially social which is difficult for seniors.
(No, I don’t mean a fee applied by a government, I mean more associated physical and mental issues which are co-morbid with or indirectly caused by ADHD)
0 In my specific enviroment I try move to another province. 1 Employers 2 Potential partners
I think ADHD is great. People with ADHD are fun, and interesting and just generally cool people. It could be worse, you could be an actual boring neurotypical person - I genuinely think that would be so boring.
I don’t know if I have adhd… it seems like the definition of adhd is almost constantly expanding. Whatever the case, I hope dementia becomes treatable or curable in my lifetime. My grandfather suffered with it and it was awful.
From https://en.wikipedia.org/wiki/JAMA_Network_Open:
"According to Journal Citation Reports, the journal has a 2021 impact factor of 13.353, ranking it 15th out of 172 journals in the category "Medicine, General & Internal". Additionally, it ranks 5th among purely open access journals in that subject category."
Ignoring JAMA Network Open because it doesn't look pretty on a cell phone isn't a great move.
ADHD is more well understood now (which is why it is separated into Compulsive, Hyperactive or both) but the diagnostics, as determined by professionals in psychiatry, have not changed in decades. The biggest change in studies for ADHD is how it affects females differently than males.
Nah, it's pretty stable. What sometimes changes is the exact wording to describe it or the wording of diagnostics or new insights from comorbidities for better differential diagnosis. But the core adhd concept has been stable for a long time.
See the latest wording here: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int...
The amount of money and researches dumped into dopamine transporter studies, brain diffusion tensor image scanning, the outspoken desire to test the pre-frontal cortex of monkeys, because lab mice don't have them and they still don't have any quality evidence to identify adhd.
Enron has a better return on investment for shareholders than ADHD clients have for research dollars.