CLINICAL INVESTIGATIONS

Attention-Deficit/Hyperactivity Disorder, Physical Health,

and Lifestyle in Older Adults
Evert J. Semeijn, MSc,* J.J. Sandra Kooij, MD, PhD, Hannie C. Comijs, PhD,*
Marieke Michielsen, MSc,* Dorly J.H. Deeg, PhD,* and Aartjan T.F. Beekman, MD, PhD*

OBJECTIVES: To increase insight into the effect of attention-deficit/hyperactivity disorder (ADHD) on health in
general in older adults.
DESIGN: Two-phase sampling side-study.
SETTING: Longitudinal Aging Study Amsterdam (LASA).
PARTICIPANTS: Two hundred twenty-three randomly
selected LASA respondents.
MEASUREMENTS: Information was collected during
home visits on physical health, medication use, and lifestyle characteristics in Phase 1 and on ADHD diagnosis in
Phase 2. The associations between independant variables
and ADHD were examined with linear and logistic regression analyses.
RESULTS: The adjusted regression estimates of the linear
regression analysis showed that the number of ADHD
symptoms was positively associated with the presence of
chronic nonspecific lung diseases (CNSLD) (B = 2.58,
P = .02), cardiovascular diseases (B = 2.18, P = .02), and
number of chronic diseases (B = 0.69, P = .04) and negatively associated with self-perceived health (B = 2.83,
P = .002). Lifestyle is not a mediator of the association
between ADHD and physical health.
CONCLUSION: Attention-deficit/hyperactivity disorder in
older adults was associated with chronic physical illness
and poorer self-perceived health. Contrary to expectations,
there were no associations between symptoms of ADHD
and lifestyle variables. J Am Geriatr Soc 2013.

Key words: attention-deficit/hyperactivity disorder; physical health; lifestyle; older adults

From the *Department of Psychiatry, VU University Medical Center and

GGZ inGeest, Amsterdam; Expertise Centre Adult ADHD, PsyQ, The
Hague; and Department of Epidemiology and Biostatistics, VU University
Medical Center, Amsterdam, The Netherlands.
Address correspondence to Evert Semeijn, VU University Medical Centre
Amsterdam, LASA, Van der Boechorststraat 7, 1081BT Amsterdam, the
Netherlands. E-mail: e.semeijn@vumc.nl
DOI: 10.1111/jgs.12261

JAGS 2013
2013, Copyright the Authors
Journal compilation 2013, The American Geriatrics Society

lthough it is increasingly recognized that attentiondeficit/hyperactivity disorder (ADHD) is not restricted

to children and younger adults, little is known about ADHD
in later life. A recent study found that the prevalence of
ADHD is stable in older adults.1 Given substantial numbers
of older adults with ADHD, the question arises as to what
the effects of ADHD may be on their physical health.
It is important to study physical health in older adults
with ADHD because the disorder is associated with
unhealthy lifestyle behaviors. ADHD has been linked to
smoking, alcohol and drug use, unstable eating patterns,
sleeping disorders, migraine, and high healthcare use and
costs.28 The disorder is a risk factor for the development
of substance use disorder at an early age, with a moresevere and longer course of the substance abuse.5 Recent
observational studies have found significantly higher rates
of asthma in children and adults with ADHD and greater
risk of ADHD in children and adults with asthma.9,10 A
high prevalence rate of ADHD has also been found in individuals who are obese.1114 Obesity may be linked to oftenfound sleep problems in children and adults with ADHD.
Approximately 80% of children and adults with ADHD
may have a delayed sleep phase,3,4 which may lead to a
short sleep duration, which in turn may induce greater
food intake to compensate for energy loss, leading in the
long term to becoming overweight. Chronically eating and
sleeping at undesirable times can contribute to the
development of, among others, mood disorders, obesity,
cancer, cardiovascular disease (CVD), and immune
suppression.1518 Lack of sleep has been found to be associated with obesity in epidemiological studies.9,10,19,20 Seasonal affective disorder is seen in 2030% of individuals
with ADHD and is also associated with greater appetite in
the winter, leading to weight gain.1114,21,22 Because of the
chronic nature of ADHD, people with this disorder have a
prolonged exposure to these unhealthy factors.
With aging comes an increase in physical health problems. It therefore seems likely that ADHD in older adults
is associated with unhealthy lifestyle behaviors and with
physical diseases. It seems likely that unhealthy lifestyle

0002-8614/13/$15.00

SEMEIJN ET AL.

characteristics can at least partly explain the association

between physical health problems and ADHD.
It was therefore hypothesized that older adults with
ADHD would have more unhealthy lifestyle behaviors and
more physical problems and diseases than those without
and that unhealthy lifestyle behaviors associated with
ADHD would explain poor physical health in older adults
with ADHD. The findings of this study can increase
insight into the effect of ADHD on health in general in
older adults.

METHODS
Study Sample
The study was part of the Longitudinal Aging Study
Amsterdam (LASA), an ongoing population-based study of
the predictors and consequences of changes in physical,
cognitive, emotional, and social functioning of older
people in the Netherlands. Procedures, sampling, and data
collection have been described previously in detail.23 In
short, a random sample of older men and women, stratified
according to age and sex according to expected 5-year
mortality, was drawn from the population registries of 11
municipalities in three geographic areas of the Netherlands.
Data collection started in 1992 (N = 3,107; response rate
62%). Respondents born between 1908 and 1937 were
included. Further follow-ups have been conducted every
3 years since. In 2002/03, a new cohort was sampled (birth
years 19381947, N = 1,002) from the same sampling
frame as the earlier cohort. Both samples were combined,
and follow-up was conducted every 3 years. The most
recent follow-up was in 2008/09 (wave G; N = 1,601).
Attrition during the 16 years of follow-up in LASA was
because of death (40.5%), refusal (9.3%), frailty (4.1%),
and inability to contact (1.9%). Interviews were conducted
in the homes of respondents and consisted of a main and
medical interview in which tests were performed and structured questionnaires completed. Attrition between the
main and medical interview (6.9%) was because of refusal
(n = 86), frailty (n = 13), death (n = 4), and inability to
contact (n = 4). Informed consent was obtained from all
respondents according to prevailing Dutch legislation, and
the ethical review board of the VU University Medical
Center approved the study.
The ADHD study started in 2008. To reduce the number of interviews needed, ADHD data were collected using
a two-phase sampling design. The ADHD screening list
(see Methods section) was incorporated into the medical
interview (N = 1,494) at wave G (Phase 1 for the current
article).24,25 In previous research, the list showed good
validity when used in older individuals.25 To further diagnose ADHD, diagnostic interviews were conducted in
Phase 2. Based on their score on the screener, 271 (18%)
respondents were randomly but nonproportionally selected
for Phase 2. Scores were stratified into three levels: high
(most likely to have ADHD; score 39), moderate (score
12), and low (score 0). To create three groups of equal
size, all participants in the high-scoring group and a random sample of the participants in the moderate- and
low-scoring groups were approached for a diagnostic interview. Eighty-four respondents from the high-scoring group

2013

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(99%), 93 from the moderate-scoring group (43%), and

94 from the low scoring group (14%) were approached;
69 (82%), 80 (86%), and 85 (90%), respectively, consented to be interviewed. Three respondents were excluded
from statistical analyses because of too many missing values on the Diagnostic Interview for ADHD in Adults
(DIVA) 2.0 (  3), a cerebral vascular accident, or not
being able to recollect childhood conditions (Table 1).
Thus, the study sample consisted of 231 participants. Specially trained and closely supervised interviewers conducted
interviews in the homes of respondents. All interviews were
tape-recorded to check the quality of the data. All data
regarding physical health were collected in 2008 and
2009.

Measures
ADHD Diagnosis
The DIVA 2.0 is a semistructured diagnostic interview for
the assessment of ADHD in adults. It is based on the
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR), criteria for
ADHD, and mental health care professionals in the Netherlands and abroad use it widely (www.divacenter.eu).26,27
It assesses current and childhood symptoms and impairment. With every DSM-IV-TR criterion, several examples
are given to facilitate recognition. Respondents were classified as cases when they met the following criteria: at least
four symptoms of inattention, hyperactivity, or impulsivity
at least 6 months before the interview and at least six
symptoms of inattention, hyperactivity, or impulsivity in
childhood (aged 512).28 No information was collected
from any family member, relative, or partner. According
to DSM-IV-TR criteria C and D, respondents had to have
had clinically significant impairment in at least two areas
of daily life (work, education, family, social and relationships, and self-confidence) for at least 6 months before the
interview and in childhood.

ADHD Symptoms
The score of all current ADHD symptoms and of those in
childhood was summed. The score ranged from 0 to 36,
with higher scores indicating more ADHD symptoms.

Medication Use
A question about medication use was asked during the
main interview. A maximum of 16 medications were
included.

Physical Health
By asking respondents whether they currently or previously
had any of the following chronic diseases or disease
events, the presence of the most-prevalent chronic diseases
was assessed: cardiac disease (including myocardial infarction), peripheral atherosclerosis, stroke, diabetes mellitus,
chronic obstructive pulmonary disease (asthma, chronic
bronchitis, or pulmonary emphysema), arthritis (rheumatoid arthritis or osteoarthritis), and cancer.29 When a
chronic disease was reported to be present, branching

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2013

ADHD, PHYSICAL HEALTH, AND LIFESTYLE IN OLDER ADULTS

Table 1. Characteristics of Respondents with and without Attention-Deficit/Hyperactivity Disorder (ADHD) Diagnosis

Characteristic

Age, mean  SD
Male, n (%)
Chronic nonspecific lung disease, n (%)
Cardiovascular, n (%)
Diabetes mellitus, n (%)
Rheumatoid arthritis, n (%)
Cancer, n (%)
Hypertension, n (%)
Number of chronic diseases, mean  SD
Smoking consumption (units/week)b, mean  SD
Smoking, n (%)
Current smoker
Past smoker
Never smoked
Years smoked, mean  SD
Alcohol (glasses per week), mean  SD
Body mass index, mean  SD
Waist circumference, cm, mean  SD
Good self-perceived health, n (%)
Better self-perceived health than peers, n (%)
Hours of sleep, mean  SD
Number of ADHD symptoms, mean  SD

Total,
N = 231

No ADHD
Diagnosis,
n = 208

ADHD
Diagnosis,
n = 23

71.6  7.7
94 (40.7)
41 (17.7)
74 (32.0)
22 (9.5)
144 (62.3)
41 (17.7)
80 (34.6)
2.1  1.3
63.2  51.9

72.0  7.8
83 (39.9)
35 (16.8)
67 (32.1)
19 (9.1)
131 (63.0)
39 (18.8)
71 (34.1)
2.1  1.3
65.5  52.1

68.0  4.9
11 (47.8)
6 (26.1)
7 (30.4)
3 (13.0)
13 (56.5)
2 (8.7)
9 (39.1)
2.0  1.3
53.3  54.3

31 (13.4)
133 (57.6)
67 (29.0)
20.6  19.3
9.2  12.1
27.8  4.7
98.5  14.2
145 (62.8)
106 (45.9)
7.8  2.1
7.7  6.6

25 (12.0)
120 (57.7)
63 (30.3)
21.3  19.3
9.0  11.9
27.80  4.6
98.3  14.1
75 (36.1)
110 (52.9)
7.7  2.1
6.3  5.2

6 (26.1)
13 (56.5)
4 (17.4)
14.8  19.4
11.1  13.3
28.0  6.1
99.7  14.8
11 (47.8)
15 (65.2)
8.0  2.0
20.6  4.3

P-Value

<.001
.46
.26a
.86
.47a
.54
.39a
.63
.82
.61
.12

.15
.42
.86
.67
.27
.26
.49
<.001

At least one cell count <5 (Fischer exact test).

Unit is 1 cigarette, cigar, or pipe.
SD = standard deviation.

questions about the specific disease where asked. The questions were derived from the Health Interview Questionnaire from the Central Bureau of Statistics.30 In 2010,
information on chronic diseases was also obtained from
general practitioners. The accuracy of self-reports of these
diseases was shown to be adequate and independent of
cognitive impairment.31

Lifestyle Characteristics
Questions about current and former smoking habits were
used to classify respondents into three categories: smoker,
past smoker, and never smoker. For current smokers,
weekly consumption was calculated as the sum of cigarettes, cigars, and pipes smoked per week. For current and
former smokers, how many years they had smoked was
calculated.
Alcohol consumption was assessed by asking participants how many glasses of alcoholic beverage they consumed per week.
Duration of sleep was assessed by asking participants
what time they usually fell asleep and woke up.
A stadiometer was used to measure height to the nearest 0.001 m. Body weight was measured to the nearest
0.1 kg with respondents wearing light clothing, using a
calibrated scale. Body mass index (BMI) was calculated as
measured body weight (kg) divided by measured height
(m) squared. Waist circumference (cm) was measured in a
standing position midway between the lower rib and the
iliac crest after a normal expiration.32,33
Self-perceived health was assessed using two questions:
perception of ones health in general and perception of

ones health compared with age peers. Response categories

ranged from excellent (1) to poor (5) and from much better (1) to much worse (5). Responses were dichotomized
by combining the categories (1) and (2) as good and (3) to
(5) as poor.34

Statistical Analysis
Differences in respondent characteristics according to diagnostic status were examined using independent-sample t-tests
for continuous variables and chi-square tests for categorical variables. A series of logistic regression models were
used to investigate the association between ADHD diagnosis
and independent variables. Even when embedded within a
large community-based study such as LASA, the number of
respondents diagnosed with ADHD may be too small to
allow sufficient statistical power to detect associations, so
the data were also analyzed using a continuous measure of
ADHD symptoms. The association between the independent
variables and the number of ADHD symptoms was
examined using linear regression models. All linear and
logistic regression analyses were performed with age and
sex as confounding variables. For smoking status, two
dummy variables were computed (current and former
smoker) and respondents who had never smoked were the
reference group.

RESULTS
In total, 231 respondents participated in this study. The
participants in the ADHD group were significantly younger

SEMEIJN ET AL.

2013

(68.0  4.9) than those without (72.0  7.9; t(36.1) =

3.49, P = .001). One respondent without an ADHD
diagnosis was using stimulant medication often prescribed
for ADHD. Other descriptive statistics of the respondents
with and without an ADHD diagnosis are presented in
Table 1.
In Table 2, the results of the logistic regression analysis with ADHD diagnosis as an outcome measure are presented. Although there appear to be substantial differences
between those with and without ADHD in some of the
chronic physical illness domains, none of the associations
between ADHD diagnosis and physical health and lifestyle
variables were found to be statistically significant. Table 3
shows the adjusted regression estimates of the association
between total number of ADHD symptoms and the physical health and lifestyle variables. No associations were
found between number of ADHD symptoms and lifestyle
variables, although the number of ADHD symptoms was
associated with the presence of chronic nonspecific lung
diseases (CNSLD), CVD, and number of chronic diseases
and negatively associated with self-perceived health
(Table 3).

DISCUSSION
To the best of the knowledge of the authors, this is the
first study to explore the association between ADHD and
physical health and lifestyle in older adults. The results
suggest that there is a modest association between symptoms
of ADHD and chronic diseases. This was most evident with
CNSLD and CVD. An association with self-perceived
health also indicated a negative association with general
health. It was hypothesized that an association between
ADHD and unhealthy lifestyle behavior might account for

Table 2. Associations Between Attention-Deficit/Hyperactivity Disorder and Physical Health and Lifestyle Measures; Results Logistic Regression Analyses Adjusted for
Age and Sex

Measure

Chronic nonspecific lung disease

Cardiovascular disease
Diabetes mellitus
Rheumatoid arthritis
Cancer
Hypertension
Number of chronic diseases
Smoking consumption
Smoking status
Current smoker
Past smoker
Years smoked
Alcohol (average glasses per week)
Body mass index
Waist circumference
Good self-perceived health
Better self-perceived health than peers
Hours of sleep
Degrees of freedom for all analyses was 1.

Odds Ratio
(95% Confidence
Interval) P-Value

2.43
1.15
1.55
1.04
0.43
1.51
1.12
1.00

(0.837.09)
(0.443.03)
(0.415.83)
(0.402.71)
(0.091.95)
(0.613.76)
(0.791.60)
(0.991.02)

.11
.78
.52
.94
.27
.38
.52
.52

2.08
0.93
0.98
1.00
1.02
1.01
0.39
0.70
1.02

(0.745.87) .17
(0.382.27) .87
(0.961.01) .13
(0.971.04) .81
(0.93;1.12) .72
(0.981.04) .64
(0.151.00) .05
(0.281.77) .45
(0.851.22) .85

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Table 3. Associations Between Physical Health Measures and Total Number of Attention-Deficit/Hyperactivity Disorder Symptoms Adjusted for Age and Sex

Measure

Chronic nonspecific
lung disease
Cardiovascular disease
Diabetes mellitus
Rheumatoid arthritis
Cancer
Hypertension
Number of chronic
diseases
Smoking consumption
Smoking status
Current smoker
Past smoker
Years smoked
Alcohol (average glasses
per week)
Body mass index
Waist circumference
Good self-perceived
health
Better self-perceived
health than peers
Hours of sleep

Degrees
of
Freedom

P-Value

6.14

.02

(0.94)
(1.46)
(0.96)
(1.13)
(0.91)
(0.35)

6.00
4.42
4.37
4.15
4.29
5.73

3
3
3
3
3
3

.02
.38
.43
.96
.53
.04

0.03 (0.02)

4.16

.84

(1.27)
(0.89)
(0.02)
(0.04)

4.51
4.26
1.24
4.16

3
3
3
3

.31
.57
.12
.84

0.05 (0.09)
0.03 (0.03)
3.03 (0.92)

4.12
4.14
7.97

3
3
3

.55
.39
.002

1.01 (0.87)

4.62

.25

0.26 (0.21)

4.44

.23

B (Standard
Error)

2.67 (1.12)
2.16
1.28
0.76
0.64
0.57
0.73

1.29
0.51
0.04
<0.01

B = unstandardized regression coefficient.

this association, although no significant associations were

found between ADHD and any of the lifestyle characteristics.
The finding that ADHD is associated with CNSLD is
in line with previous research in children and younger
adults. It has been found that children with asthma have
ADHD 2 to 3 times as often as those without.9 A higher
rate of ADHD has also been found in individuals with
allergic rhinitis.10 A study of younger adults found that
the prevalence of asthma was higher in individuals with
ADHD, and controls with asthma had higher past and
present ADHD symptom scores than controls without
asthma.8 It has been suggested that smoking behavior
causes the association between ADHD and CNSLD in
adults,3537 but the present study did not find any association between ADHD and current or past smoking. Furthermore, the association between ADHD and asthma has
been found in children as well, who usually have not
started smoking yet. It therefore seems unlikely that smoking alone caused these lung diseases in older adults with
ADHD.
The data showed a significant association between
ADHD symptoms and CVD. Such an association has not
been reported before in younger adults with ADHD.
Therefore, this association may be specific for older adults.
A closer inspection of CVD showed that older people with
ADHD more often had heart disease, cerebrovascular accident, or medications for one of these conditions than those
without. In a recent study of younger adults, an association was found between number of hyperactivity and
impulsivity symptoms and hypertension, but this association

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2013

disappeared when controlled for BMI. The current study

found no associations between ADHD and hypertension,
BMI, or waist circumference, suggesting that this cannot
be the underlying factor in the association between
CVD and ADHD in older adults. Thus, it remains unclear
what causes the association between ADHD and CVD.
Further research is necessary to find the underlying
mechanisms.
No associations were found between severity of ADHD
and smoking or alcohol consumption. Previous studies in
adolescents and adults found ADHD to be a risk factor
for smoking and alcohol use.3742 Because adults with
ADHD smoke at rates significantly higher than those
without, a possible explanation for not finding differences
in smoking behavior and consumption in older adults
could be that these smokers have already died at a younger
age.35,4345 A second explanation could be that smoking
and alcohol consumption reduce with aging and thus lose
their association with ADHD when studied in older
adults.46

Strengths and Limitations

This is the first study to report data on ADHD and physical health and lifestyle in older adults. An important
strength of the study is that a representative cohort of
older adults with access to diagnostic data on ADHD and
information a wide range of physical health and lifestyle
variables was used. Another strength of the study is the
use of a population-based sample, in which, in contrast to
a clinical sample, only one respondent was using stimulant
medication. Nevertheless, some limitations need to be
addressed. First, the diagnostic instrument used in this
study, the DIVA 2.0, has not been validated in older
adults. It is a diagnostic interview that was developed to
operationalize the DSM-IV-TR criteria for ADHD. It is
unclear whether the DSM criteria for ADHD, which were
developed for children and younger adults, are appropriate
for older adults. It may be that the expression of symptoms of ADHD changes with age, which would lead to the
DIVA 2.0 missing symptoms and underestimating the prevalence of ADHD in older adults. Similarly, other health
problems that are more prevalent in older than younger
adults (e.g., cognitive decline) may mimic the symptoms of
ADHD, leading to concerns that the DIVA 2.0 overestimates the prevalence of ADHD in older adults. It was
possible to accommodate the latter concern not only by
basing the ADHD diagnosis on the presence of current
symptoms, but also by requiring symptoms to be present
currently and during childhood. A second limitation is
that, even though there was access to a relatively large
cohort of older people, the numbers of older adults with
ADHD were modest. The power of the statistical analyses
to uncover clinically relevant associations was therefore
modest. The fact that analyses using continuous ADHD
symptom scores reached statistically significant results bore
this out. Although several lifestyle variables were included
in the study, no data were available about, for instance,
exercise, diet, or routine health maintenance. Third, the
frailest older adults may have not been included in this
study because of nonresponse, loss to follow-up, or death,
whereas those persons may have been the most vulnerable

ADHD, PHYSICAL HEALTH, AND LIFESTYLE IN OLDER ADULTS

to the effects of ADHD. A result of this may be an underestimation of the effects of ADHD and lifestyle on physical
health.

CONCLUSION
This study is the first epidemiological study examining the
physical health and lifestyle of older adults with ADHD. It
showed that ADHD in older adults was associated with
chronic physical illness and poorer self-perceived health.
Contrary to expectations, there were no associations
between symptoms of ADHD and current lifestyle factors.
This study was the first to explore the putative health consequences of ADHD in older adults. Given its methodological limitations, it may be that it shows that it is
worthwhile for future research to further focus on ADHD
and related health consequences in older adults.

ACKNOWLEDGMENTS
Conflict of Interest: J.J. Sandra Kooij has been a speaker
for Eli Lilly, Janssen, and Shire and received unrestricted
research grants from Janssen and Shire for this study.
Aartjan T.F. Beekman received an unrestricted research
grant for this research from Eli Lilly and for another study
from AstraZeneca and has been a speaker for Lundbeck
and Eli Lilly. The other authors have reported no competing interests.
Author Contributions: Evert J. Semeijn: analysis and
interpretation of data, preparation of manuscript. J.J. Sandra
Kooij, Hannie C. Comijs: study concept and design,
interpretation of data, critical review of manuscript.
Ma-rieke Michielsen, Dorly J.H. Deeg, Aartjan T.F.
Beekman: critical review of manuscript.
Sponsors Role: None.

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