Does Bipolar Disorder Get Worse with Age?

How Does Bipolar Disorder Change as You Age?

Unlike many diagnosable mental health conditions, bipolar disorder symptoms are caused by genetic predisposition. Although talk therapy does help individuals acquire effective coping strategies, a combination of medication and talk therapy is necessary to curb undesired symptoms. Contemporary research has found a link between bipolar disorder and aging in which biological aging differs from chronological aging.² In other words, as individuals with bipolar disorder age, their years of life have a more significant impact than those without bipolar disorder.

A 65-year-old with bipolar disorder, especially when untreated, presents biologically older than someone without the condition of the same age. This faster aging has been attributed to the deterioration of telomeres, which “act as protective caps on the ends of DNA strands. Each time a cell divides, the telomere becomes shorter, until it is so short that the cell can no longer replicate.”²

Shortened telomeres are primarily found in neuropsychiatric conditions such as dementia, major depressive disorder, and schizophrenia.² Ultimately, they impact mood regulation and memory, which are common issues seen in bipolar disorder, particularly bipolar memory loss.² Given this disposition, one’s ability to manage bipolar disorder cycles, especially without treatment, becomes increasingly difficult with age.

Within the different types of Bipolar Disorder, these are the main mood episodes that may change with someone’s age:

• Mania is a state in which one’s mood and energy are elevated to a point in which one struggles to make coherent decisions. Individuals feel atop of the world, perhaps to the extent of having superhuman abilities, and disregard the consequences of their actions.
• Hypomania is less severe than mania but marked by symptoms of being unusually upbeat, agitated, euphoric, decreased need for sleep, racing thoughts, distractibility, heightened talkativeness, and poor decision-making.³
• Depression is a condition that appears in episodes in bipolar disorder in which one feels lowered affect (mood). Here, an individual may feel low in self-worth and love, become detached from previously endeared persons, places, and things, lack of motivation and energy, experience suicidal ideation, et cetera.
• Rapid cycling is a condition in which one quickly cycles between manic and depressive episodes. Especially when gone untreated, individuals of advanced age experience these to an increasing extent.⁴

When considering the rates of bipolar diagnosis, it is essential to note that many cases go undiagnosed or misdiagnosed. This misdiagnosis is especially true of individuals of advanced age.

Recent bipolar statistics indicate the following:

• Globally, 46 million people have bipolar disorder.⁵
• One survey of 11 countries found the lifetime prevalence of bipolar disorder was 2.4%. The U.S. had a 1% prevalence of bipolar type I, which was notably higher than many other countries in this survey.⁶
• On average, bipolar disorder results in a 9.2-year reduction in expected life span.⁷
• The risk of suicide is high in people with bipolar disorder, with 15% to 17% dying by suicide.⁸
• Of those with bipolar disorder, co-occurring health conditions, such as migraine, asthma, and high cholesterol, were commonly reported. They also had a higher likelihood of high blood pressure, thyroid disease, and osteoarthritis.⁹

Although rates of late-onset bipolar disorder are markedly lower than those of younger populations, this does not minimize the severity of the condition.

In Children & Adolescents

Bipolar disorder is a condition that is often misdiagnosed. Especially for mental health therapists working with clients presenting in a depressive phase, it is easy to overlook a history of mania. Though the average age of onset is around 25 years old, it is often diagnosed during adolescence (ages 16-18) but may be considered earlier or even later in life (ages 60+).¹⁰ Given that early diagnosis leads toward earlier interventions to increase stability throughout life, diagnosing bipolar disorder in children affords the best opportunity to minimize symptoms’ severity as one ages.

Common symptoms for children experiencing bipolar disorder include but are not limited to:¹¹

• Cycling episodes of sadness, rage, and ecstasy
• History of impulsivity, aggression, self-harm, or suicidal thoughts and actions
• Substance abuse/Self-medication
• Manic response to antidepressant or psychostimulant (ADHD) meds
• Higher emotional reactivity compared to most same-age peers
• History of extreme and abrupt changes in:
  • Appearance
  • Interests
  • Goals
  • Affiliation
  • Overall self-image

Although said symptoms do not guarantee that one has a bipolar diagnosis, early diagnosis and treatment may minimize the severity of the condition as one ages.

In Adulthood

Though the onset of bipolar disorder often begins in late adolescence into early adulthood, it is not uncommon for the condition to start in one’s 50s or later, referred to as “late-onset bipolar disorder.”¹² “Age of onset can have a significant impact on the nature and course of bipolar illness.”¹² With those who experience a late onset, it is essential to consider other natural complications simultaneously occurring with advanced age. Considerations associated with additional neurologic illnesses, white matter hyperintensities (WMH), and cortical atrophy are specific to this condition.¹²

Though incidents of co-occurring disorders, such as substance use and incidents of mixed episodes, are not necessarily higher for late-onset, hospitalization stays are notably longer.¹² Also, the impact on mood regulation and memory is more substantial in late-onset.² Accordingly, late onset bipolar disorder may be misdiagnosed for other conditions associated with aging, such as dementia, Alzheimer’s and depression, and otherwise.

Comorbidities that may develop in adults with bipolar disorder include:

• Obsessive-compulsive disorder (OCD)
• Panic attacks
• Generalized anxiety disorder (GAD)
• Specific phobias or anxiety disorders
• ADHD

Furthermore, in a study of physiological complications occurring alongside a diagnosis of late-onset or untreated bipolar disorder, the National Institute of Health identified increases in many different medical conditions across all body systems compared to those without bipolar disorder:¹³

In Older Adults

Though 90% of bipolar diagnoses occur before age 50, 10% occur after.¹² Unfortunately, the changes in frequency and severity of symptoms in older age groups with bipolar disorder trend towards more severe than in younger groups.

Earlier onset groups trended toward more psychotic features, mixed episodes, more significant comorbidity with panic disorders, and poorer prophylactic lithium response.¹⁴ But with later onset groups, we see more issues with mood stability, memory, and other physiological considerations.^{12, 13}

A significant disadvantage of those with late-onset diagnoses is that they did not receive treatment earlier in life. They may lack adequate coping skills and medication management to stabilize the condition. Further, in combination with other health issues associated with advanced aging, treatment becomes more complicated.

Some common changes in bipolar symptoms for older adults include

• More frequent episodes
• More depressive episodes and less time spent in manic or hypomanic states
• Less severe manic symptoms and fewer psychotic features with mania
• Feelings of hopelessness or despair alternating with feelings of extreme happiness and excitement
• Changes in energy level; sleeping much more or much less than usual
• Changes in appetite
• Making major plans or commitments but not following through with them
• Engaging in risky or impulsive behavior, such as reckless driving or overspending
• Frequent changes in self-image or self-esteem
• Neglecting self-care and activities of daily living
• Resistance to treatment options, such as certain medications
• Suicidal thoughts or suicidal ideation, though the risk of completed suicide may be lower than in younger populations due to survivorship bias ¹⁵

Though individual experiences will vary, any one or a combination of the above complications may indicate a potential late-onset bipolar diagnosis.

Aging with Bipolar Disorder

Bipolar disorder, whether undiagnosed or late onset, is associated with cognitive decline and co-occurring physical and mental health disorders that affect our ability to age well and manage daily living. Fortunately, there are ways to experience positive aging despite the condition. This positive aging begins with acceptance of the diagnosis, awareness of the symptoms, and concerted efforts to work through it. Successful outcomes are often associated with strict adherence to a combination of psychopharmacological and talk therapies (in addition to treating any other co-occurring disorder).

Cognitive Decline

Research has indicated that bipolar disorder is positively associated with cognitive decline.¹⁶ “Among the different cognitive domains, bipolar patients exhibit psychomotor retardation and impaired declarative memory, executive function, and, to a lesser extent, visual memory and attention when compared with healthy controls.” ¹⁶

Accordingly, complications arising here may contribute toward overall cognitive decline, dementia, or Alzheimer’s. Further, a late-onset bipolar diagnosis may be misdiagnosed as one of these conditions, leading toward a treatment regimen that is not specifically catered to the condition, allowing it to become further complicated.

Late Stages of Bipolar Disorder

The peak onset of symptoms generally occurs between 20 and 40 years of age.¹³ This average peak does not mean someone with a late onset will not peak later in life. Accordingly, predicting precisely when the disorder will most significantly impact one is tricky.

At older ages, individuals may be more reluctant to acknowledge the condition or follow through with treatment. Individuals may also already be engaged in other invasive treatments that they believe are more pressing than their bipolar diagnosis. Accordingly, a combination of physiological and cognitive factors complicates the condition further.

Does Bipolar Disorder Impact Life Expectancy?

Unfortunately, the life expectancy for individuals with bipolar is, on average, 8-12 years shorter than the general population, with an average lifespan of 67 years.¹⁷ Again, this results from a combination of other factors that are not solely exclusive to the condition itself. Beyond the presence of telomeres, which advance biological age, lifestyle choices also make a difference.

Factors that can affect life expectancy in those with bipolar disorder include:

• Genetics
• Vigor
• Mindfulness
• Determination
• Lifestyle choices
• Health habits
• Adherence to safe medication protocols
• Other medical diagnoses
• Participation in therapy

Treatment for Older Adults with Bipolar Disorder

The earlier the diagnosis and implementation of bipolar treatment, the better. The progression is slower when a bipolar diagnosis occurs early, and one abides by treatment. These shifts also ripple through the household, and children of a mother with bipolar disorder often feel the effects of untreated mood cycles. One may be able to stabilize the disorder with medication while living a lifestyle consisting of healthier choices. Treatments typically include medication, therapy, and self-care strategies.

Therapy

It is crucial to consider one’s physiology, cognitive ability, and other factors when deciding what therapy practice to use.

Some new therapies to consider adding to your late-onset bipolar treatment include:

• Depression and Bipolar Support Alliance
• Bipolar disorder | NAMI: National Alliance on Mental Illness