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. 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:

• TMS: Transcranial magnetic stimulation changes the magnetic field of electric currents in specific brain areas, ultimately impacting cognition and affect.
• ECT: Electroconvulsive therapy, though less used today than TMS, introduces electric impulses in the brain to rewire neural pathways.
• DBT: Dialectical behavioral therapy focuses on helping individuals ground themselves in the present—being mindful of the current moment. Doing this alleviates rumination on unpleasant thoughts and emotions stemming from the past or otherwise having not yet occurred. This approach is grounded in CBT.
• CBT: cognitive behavioral therapy works to adjust maladaptive beliefs (such as negative self-talk) and values that impact one’s thoughts, emotions, and behavior according to a given stimulus. Here, the goal is to arrive at more rational responses.

Medication

Because bipolar disorder is a genetic condition leading to neurological complications, medication is warranted. Various bipolar medications are used to treat the condition but may vary depending on the patient’s age.

Popular classifications of medications used for bipolar treatment include the following:

• Mood stabilizers
• Antipsychotics
• Antidepressants
• Antianxiety / Anxiolytics

For the medication to be effective, taking it as prescribed while reporting complications from side effects to one’s prescribing physician is paramount. These medications will likely change over time depending on one’s age, other developing medical conditions, the severity of the disorder, and other factors.

Self-Care

Self-care varies by person. What works for one individual may not work for another. Further, it changes over time. It is important to note and adjust when you feel you have aged out of previous coping mechanisms. Many strategies are simple ones that someone may readily implement, while others are more invasive—requiring additional attention, money, and time. Finding what works for you may make a substantial difference in daily functioning and longevity.

Some self-care practices for bipolar disorder that may work best for older adults include:

• Consistent interpersonal engagement: Continually engaging with supportive others will help one attain a sense of belonging as well as solicit the involvement of others in maximizing well-being. When something seems off, they may comment on this, which may be followed up by speaking with a mental health provider. Group therapy and support groups are great ways to maintain this engagement.
• Remain engaged with what you like: Remaining engaged in enjoyable activities, especially those that require critical thinking, may help. When the brain remains active, it keeps neural pathways fluid. Further, an achievement attained from engagement leads toward a sense of accomplishment, which boosts mood.
• Spirituality/religiosity: Being connected to a higher power or purpose gives one hope. Here, one establishes and maintains meaning. There is a reason for living and continuing to fight the good fight, which in this case is healthy living. Faith-based counseling can be an additional therapy practice to help grow one’s faith.
• Engaging in therapy: With a condition as severe as bipolar disorder, regardless of the age of onset or severity, it helps to work with a professional. A mental health professional and patient work together toward a holistic wellness treatment plan that addresses all areas warranting attention. For further assistance with finding a therapist, finding an online therapist directory and reading more on how to find a therapist can help find a therapist that is right for you.

Questions to Ask Your Care Team about Aging with Bipolar

Aging with bipolar disorder, especially when the condition has a late onset, can feel unfamiliar and scary. Know that you are not alone. With 10% of the population experiencing late-onset bipolar disorder, the condition is familiar to many professionals.¹² Help is readily available, and one may resume a healthy life. The first step is to be aware of and acknowledge the disorder’s issues. Next, one will need to be motivated to undergo a treatment regimen. Though this may prove seemingly inconvenient, especially at first, it can prove the difference for you and significant others in your immediate social circle.

Some questions to consider asking your Primary Care Provider include:

• “What comorbidities should I be aware of?”
• “What type of interdisciplinary team is recommended for treatment?”
• “Are the medications I am currently taking problematic with this diagnosis?”
• “How will this diagnosis impact my aging?”
• “What do you recommend for the healthiest lifestyle?”
• “Will I be able to manage the condition on my own or require additional support?”

Some questions to consider asking your psychiatrist include:

• “What medications work better with a lower metabolism?”
• “What talk therapy should I engage in while taking medication?”
• “What are the best recommended coping strategies for me?”
• “How will this impact my physical health?”
• “Who in my immediate environment should I inform and have on my side while I deal with this?”
• “Although there is no known cure for bipolar disorder, to what extent can treatment help?”
• “Should I be aware of other mental health disorders or co-occurring conditions?”

Some questions to consider asking your lawyer, family members, support networks, case managers, caregivers, etc include:

• “What type of additional support do you recommend?”
• “Will I need to have someone else serve as my power of attorney?”
• “Is it appropriate that I continue living alone, or do I need to live in supportive housing?”
• “Can you help support me through the daily tasks of living?”
• “Will you please let me know if you notice any changes in my behavior?”
• Et cetera

Final Thoughts

Bipolar disorder can worsen with age considering additional changes in physical health and brain functioning. But worsening symptoms don’t happen for everyone, and proper treatment can manage degrading conditions. It is essential to speak up and seek support when you notice changes to your well-being, regardless of how subtle they are. Help is readily available but requires ongoing effort and attention to the problem.