International Psychogeriatrics (2017), 29:4, 695–697 © International Psychogeriatric Association 2016

Letter to the Editor

doi:10.1017/S1041610216001599 medicine, geriatric psychiatry, consultation-liaison

psychiatry) may not have a full understanding of
Aging with autism spectrum disorder: an the childhood aspects of ASD (which is often
thought of as primarily a childhood disorder),
emerging public health problem whereas clinicians working with ASD patients
From 1943, when Leo Kanner originally described (e.g. pediatrics, developmental pediatrics, child
autism, and to the first objective criteria for neurology, child and adolescent psychiatry) do
“infantile autism” in DSM-III and the inclusion not necessarily have clinical currency in problems
of Asperger’s disorder in DSM-IV, the subsequent of aging (unless they are following ASD patients
classification scheme for autistic disorders has throughout the life span) since they do not typically
led to a substantial change with the 2013 treat geriatric patients. Bringing awareness of this
issuance of the DSM-5 by including subcategories imminent wave of ”graying ASD” is required for
into one umbrella diagnosis of autism spectrum medical care delivery systems to provide expert
disorder (ASD) (Baker, 2013). ASD is a lifelong care for those aging with ASD. To support this
neurodevelopmental disorder, characterized by endeavor, more research on the natural history
social and communication impairments and re- of ASD with aging and an appreciation of its
stricted, stereotypical patterns of behavior (Baker, relative stability versus deterioration with aging is
2013). It is currently expected that most, or all of critical.
the actual cases of ASD, are identified in a timely Although overt symptoms of ASD become
way (i.e. in early childhood). However, there are established in the early developmental period,
many undiagnosed older adults who may have met core difficulties tend to persist through life,
the current diagnostic criteria for ASD as children, often in a less severe form with increasing age.
but never received such a diagnosis due to the Geriatric patients with ASD will not typically reach
fact it had yet to be established. In addition, some normal levels of social functioning (Geurts and
patients with relatively less impairing phenotypes Vissers, 2012; Baker, 2013). Nevertheless, little is
may escape formal diagnosis in childhood, only known about its geriatric clinical presentation and
to later be diagnosed in adulthood. Nevertheless, comorbidity. Recognizing previously undiagnosed
the first generation of diagnosed patients with ASD in geriatric patients, with or without comorbid
ASD is now in old age. Many such ASD patients neuropsychiatric syndromes, is imperative. James
have needed family and institutional support for et al. (2006) presented a case series of geriatric
their lives subsequent to childhood diagnosis. Due patients (aged 67–84 years) believed to have
to aging and death of their parents and other met the criteria for Asperger’s disorder. They
supportive figures leading to a loss of social argued that recognizing and diagnosing ASD in
structures, there is no better time than now for the those patients facilitated their treatment, especially
medical community to act. because these patients originally were misdiagnosed
There are two “telescoping” issues: (1) aging with mood and anxiety disorders, deemed as
ASD patients who are clinically stable may “treatment resistant”, and may have received
now be bereft of familiar supportive figures and unnecessary, lengthy clinical psychiatric care that
structures and will need alternative placements was not directed toward their core illness of
and supports, and (2) the “natural history” of ASD. James et al. (2006) suggested that for older
aging with ASD and these patients’ specific patients with a history of social skills problems
risk of acquired neurocognitive disorders (NCDs; evident from early childhood, clinicians should
formerly dementia) (e.g. degenerative or vascular routinely take a lifelong history in understanding
dementia), which has yet to be fully elucidated. patients’ interpersonal deficits, particularly in those
Clinical interventions specific to this complex aging geriatric patients with a longstanding, “detached”
population need to be developed and validated. premorbid personality style, chronic social anxiety,
More research about aging with ASD with a difficulties in coping with change, and unusual
focus on transition from middle adulthood to older behaviors of rigid routines, which may contribute
age, management of social cognition impairments, to the profile in support of a new diagnosis of ASD
management of systemic medical comorbidity, and in an older patient.
quality of life and support system issues, is greatly Research on the cognitive profile of ASD
needed. Clinicians who regularly work with patients has been mainly restricted to childhood and
experiencing physiological aging (e.g. geriatric early adulthood subjects even though physiological

https://doi.org/10.1017/S1041610216001599 Published online by Cambridge University Press

 696 Letter to the Editor

aging is known to have a strong impact on “virtual” outreach consultations using telemedi-
cognitive functioning (Geurts and Vissers, 2012). cine and similar technological applications rather
Since executive dysfunction is also commonly than standard in-person face-to-face outpatient
reported in ASD (Geurts and Vissers, 2012), appointments.
neuropsychological findings in the geriatric ASD In conclusion, little is known about ASD and its
patients have to be interpreted with caution clinical presentation and comorbidity with NCDs
as dysexecutive phenomena are also present in in the geriatric population. Although dysexecutive
NCD syndromes. Moreover, the effect of aging syndromes are commonly reported in ASD, the
was found to differ between patients with and exact risk of developing dementing illness per se
without high functioning ASD (Geurts and Vissers, complicating ASD in geriatric patients remains
2012). How the interaction of the aging process to be elucidated. Nevertheless, we argue that
and ASD affects resultant cerebral structure and there is a great need, even for older adults, to
functioning, and thereby cognition and behavior, receive an accurate diagnosis of ASD. This could
is yet undetermined. A study focusing on cerebral benefit their treatment especially as they could
structure in patients with ASD (aged 10–60 otherwise inaccurately be diagnosed and treated
years) showed that age-related reduction in cortical as “treatment-resistant” depressive and/or anxiety
volume seen in specific areas of healthy persons disorders, largely because of misinterpreting some
is less profound in those with ASD (Raznahan ASD symptoms (e.g. psychomotor agitation,
et al., 2010), which might potentially suggest a anxious affect). Some warning signs that an older
smaller age-related decrease in cognitive function in adult may have undiagnosed ASD include a chronic
older ASD patients. Whether ASD patients develop history of social anxiety, pervasive social skills
compensatory cognitive mechanisms throughout problems, and esoteric ritualistic behaviors and
life and/or experience progressive cognitive deteri- routines (e.g. repetitive, focused, rigid and limited
oration remains to be elucidated. range of social interests and activities). These
Advanced age is one of the risk factors for symptoms are not individually specific for ASD
NCDs, but little is known about the prevalence of in isolation, but can suggest a diagnosis of ASD
these acquired disorders in geriatric ASD patients. when present as a characteristic constellation of
It is largely unknown whether aging patients with symptoms, thus supporting a diagnosis of ASD.
ASD are more (e.g. as in Down syndrome), Aging patients with ASD are in need of a high level
less, or similarly predisposed to developing NCDs of support, at least due to problems with social
when compared to the general population of communication and interaction, may have a double
geriatric patients. Other risk factors typically “cognitive vulnerability” (due to baseline ASD plus
associated with NCDs appear to also constitute secondary dementing illness), and may face a high
systemic medical comorbidity of ASD (e.g. risk of social isolation. Studies on the efficacy and
seizure disorders, depression, metabolic disorders, safety of psychopharmacological interventions in
sensory dysfunction) (Bauman, 2010), which could geriatric patients with ASD are needed, particularly
predispose ASD patients to developing comor- in regard to cholinesterase inhibitors (which have
bid NCDs. Whether the established prevention an increased risk of seizures), or antipsychotics
strategies for NCDs may play a role in potential (which have an increased risk of metabolic
cognitive preservation in ASD remains to be syndrome and cognitive impairment). In light of
ascertained. the rapidly growing geriatric population, coupled
Multidisciplinary assessment and coordination with the considerable lack of societal awareness of
of clinical and social interventions for the patient the realities of aging in ASD, now is the time for
with ASD are needed throughout the life span. researchers to turn their attention to investigating
Clinicians, families, caretakers, and friends should the needs of geriatric ASD.
be involved in these processes, as appropriate.
This may subserve mitigating the risk of isolation
and social exclusion. Moreover, the Internet has
helped ASD persons bypass their issues with Conflict of interest
social communication and, more broadly, the social
cognition difficulties of this population, and has None.
proven to be an effective platform to work remotely
or form online communities (Biever, 2007). Since
digital communication may be a more effective
method to reach out to this “invisible” aging Acknowledgments
population, medical systems (particularly primary
care clinicians) may wish to explore the use of None.

https://doi.org/10.1017/S1041610216001599 Published online by Cambridge University Press

 Letter to the Editor 697

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https://doi.org/10.1017/S1041610216001599 Published online by Cambridge University Press