Bipolar disorder in later life

Bipolar disorder does not go away with age. Most older adults who live with it have had it since their younger years. A smaller group has their first high (manic) episode after age 50. About 1 in 4 people with bipolar disorder are 60 or older.¹

Later life brings new questions. Lithium and other medicines need more care as the kidneys age. A first-ever mania in an older person can be a sign of a stroke, a brain illness or a medicine side effect. And many families worry about memory. This page walks through each of these.

How bipolar disorder can look different in later life

Bipolar disorder causes episodes of mania or hypomania (a "high" or irritable mood with too much energy and little need for sleep) and episodes of depression. See signs of mania, hypomania and bipolar depression for the full list.

In older adults, these episodes can look a bit different:

• Mania can be mistaken for delirium or dementia. Delirium is a sudden state of confusion, often caused by an infection or a medicine. Confusion and restlessness that get worse at night point more toward delirium or dementia than toward mania.²
• Depression episodes can overlap with other late-life health problems. See depression in later life.
• Health problems pile up. People who develop bipolar disorder late often have more risk factors for blood vessel disease, such as high blood pressure. Many also take several medicines for other conditions, which raises the chance of drug interactions.¹

Older adults with bipolar disorder tend to use more health services and have a higher risk of early death than their peers.³ That makes regular care with a doctor who knows your full health picture especially important.

New mania after age 50: rule out other causes first

When a person has their first manic episode after about age 50, doctors call it late-onset bipolar disorder. It makes up only about 5 to 10 in every 100 people with bipolar disorder.¹

A first mania this late in life is a warning sign that something else may be going on in the brain or body. In studies, between about 1 in 6 and 2 in 5 older people with mania showed signs of a brain disorder.¹ Doctors call this secondary mania, meaning mania caused by another illness or by a substance.

Possible causes include:^1,2,8

• Stroke, especially strokes on the right side of the brain. Mania after stroke is uncommon, but it does happen.
• Dementia. People living with dementia have a higher risk of manic episodes.
• Head injury, brain tumors or seizures.
• Hormone problems, such as an overactive thyroid or Cushing's syndrome (too much of the stress hormone cortisol).
• Medicines, especially steroid pills such as prednisone. Steroid-related mania often starts within days of starting the medicine. Some antibiotics have also been linked to mania.
• Infections that affect the brain.

Frontotemporal dementia (FTD) deserves special mention. Its most common form changes personality and behavior. A person may act on impulse, spend money unwisely, lose empathy or eat compulsively. FTD is sometimes mistaken for a mood disorder at first.⁹ Learn more on the frontotemporal dementia page.

What the medical check may include

Experts advise looking for treatable causes in anyone with a first mania, at any age.⁸ To tell bipolar disorder apart from other causes, doctors look at the person's life history, current medicines, physical health, symptoms and family history.² A family history of bipolar disorder makes it more likely. But having no known family history does not rule it out.²

Ask the doctor which tests make sense, such as blood tests, a neurological exam or a brain scan. Bring a list of every medicine and supplement, and note any that were started or changed recently. See getting diagnosed, types of bipolar disorder and treatable conditions that look like dementia.

Lithium in older age

Lithium is one of the oldest and best-studied medicines for bipolar disorder. It is still a first choice for older adults, both to calm mania and to prevent new episodes, as long as it is watched closely.^1,2

Why older adults need extra care

Lithium leaves the body through the kidneys. Kidneys slow down with age, so lithium can build up more easily.^2,5 The FDA label notes that older adults may have side effects at blood levels that younger people handle well.⁵ Doctors usually start low and go slow, and they often aim for lower blood levels in older adults than in younger ones.^2,4

The gap between a helpful level and a harmful level is small. That is why regular blood tests are part of taking lithium.⁵

Regular checks

The FDA label for lithium calls for:⁵

• Lithium blood levels, more often at the start, after any dose change, when a new medicine is added and during illness.
• Kidney tests before starting and during treatment. Long-term use can harm the kidneys. Lithium is not recommended for people with severe kidney disease.
• Thyroid tests before starting, at about 3 months, and then every 6 to 12 months. Lithium can cause an underactive thyroid.
• Calcium checks. Long-term use can cause the parathyroid glands (tiny glands in the neck that control calcium) to become overactive.

Lithium can also make the kidneys less able to hold on to water. This causes heavy thirst and frequent urination.⁵

Medicines that can raise lithium levels

Many common medicines can push lithium to a harmful level. These include:⁵

Some antidepressants and other drugs that act on serotonin (a brain chemical) can rarely cause a serious reaction called serotonin syndrome when taken with lithium.⁵

Dehydration and illness

Heavy sweating, vomiting, diarrhea or fever can raise lithium levels quickly. The label advises a normal diet with enough salt and fluids.⁵ Hot summer days, a stomach bug or a new low-salt diet are times to call the doctor. Ask the doctor how much you should drink each day.

Signs that lithium may be too high

Early signs include a shaky hand tremor that is new or worse, nausea, vomiting, diarrhea, feeling lightheaded, weakness and poor balance. More serious signs include sleepiness, slurred speech, blurred vision, ringing in the ears, muscle twitching and stumbling. Severe toxicity can cause confusion, seizures and coma.⁵

Other treatments in later life

Lithium is not the only choice. The best plan depends on the person's other health problems and medicines.

Strong research in older adults is still limited. Much of what doctors know comes from studies in younger adults.² For more on each medicine, see medicines for bipolar disorder. A geriatric psychiatrist can help with complex medicine lists.

Memory, thinking and dementia

Memory worries are common and understandable. Here is what research shows:

• About 1 in 3 older adults with bipolar disorder have some trouble with thinking, such as memory, attention or planning.²
• Thinking problems do not always get worse. In one 5-year study, older adults with bipolar disorder started with more thinking problems than their peers. But their rate of decline was about the same.²
• Dementia risk is higher. A review of 10 studies found that people with bipolar disorder had about 3 times the odds of developing dementia compared with other people.⁶ One review estimated that about 19 in 100 older adults with bipolar disorder develop dementia, compared with about 7 in 100 of their peers.¹
• More mood episodes may mean more risk. Dementia risk seems to rise with the number of episodes a person has had.¹ This is one more reason steady treatment matters.

Does lithium protect the brain?

Some studies have found that people who take lithium have lower rates of dementia. A review of 5 studies found that people with bipolar disorder who took lithium had about half the odds of dementia of those who did not.⁶ A large UK study of adults 50 and older found a similar link.⁷ Promising

These were observational studies. They show a link, not proof that lithium causes the benefit. Other differences between the groups may explain part of it.⁷ Larger trials are still needed. This is not a reason to start or stop lithium on your own.

Helping the brain stay healthy

Steps that help both mood and memory include keeping treatment steady, protecting sleep, managing blood pressure and blood sugar, limiting alcohol and staying active. Ask for a review of medicines that can cloud thinking. See living well with bipolar disorder, medicines that can affect mood and memory and keeping your brain healthy.

If memory gets worse, ask for a checkup. See the first doctor visit about memory.

Planning ahead

Later life is a good time to make plans while you are well. Consider:

• An advance directive that names a health care agent. See advance directives and health care agent.
• A financial power of attorney, which can help protect money during a manic episode. See durable power of attorney.
• A written crisis plan with early warning signs and who to call. See the safety plan tool.

Family members can find practical tips in supporting someone with bipolar disorder. For coverage questions, see what Medicare covers for mental health.

When to get help

Bipolar disorder usually needs treatment for life.¹⁰ Contact the doctor soon if:

• An older person has a first episode of mania, very high energy or odd behavior with no past history.
• Mood symptoms return, or sleep drops sharply for several nights.
• You notice signs that lithium may be too high, or a new medicine was just started.
• Memory or thinking seems to be getting worse.

Call 911 if a person is very confused, has a seizure, cannot be woken easily, or shows signs of a stroke, such as a drooping face, weakness on one side or trouble speaking. Call or text 988 if someone talks about suicide or seems in danger of harming themselves.¹⁰

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.