Although manic depressive illness ("bipolar disorder") usually begins before old age, we believe that approximately 10% of patients with bipolar disorder become ill for the first time after age 50. Some older people with bipolar disorder may be in state hospitals or nursing homes, not in the community. Some of them may become substance abusers or cognitively impaired, and, therefore, their mood disorder may be overlooked. Sometimes, patients may be willing to report their bouts of depression, but not their manic ones because they do not feel that they are sick when they are manic. Older patients with bipolar disorder are frequently seen in clinical settings, where they typically represent 3-10% of all elderly patients with mood disorders.

Manic episodes are characterized by heightened mood or even euphoria, and sometimes extreme irritability, as well as grandiosity, suspiciousness, increased activity and pressure of speech, and diminished sleep. When mania becomes severe, the patient loses touch with reality and may believe that he or she possesses special powers. These false beliefs often lead to loss of financial judgment, over spending, and risk taking that may endanger the well being of the patient, family members, and others. Mania can "switch" abruptly into depression, posing a significant threat for suicide.

Patients with late-onset bipolar disorder usually have been found to have a lower rate of mood disorders among their family members. Sometimes mania first appearing in late life is caused by another underlying physical disorder, particularly head trauma, stroke, delirium, or other neurological illnesses, or to prescribed or non-prescribed drugs (particularly alcohol, corticosteroids, L-dopa, and thyroid medications). Also, it is often the case that patients with late onset bipolar disorder have been reported to have a history of major depression and a first manic episode associated with antidepressant medication treatment.

Unfortunately, there are no controlled studies on the treatment of bipolar disorder in old age. The limited data available do support the usefulness of lithium in the acute and preventive treatment of mania in older patients. Older patients are typically treated with lower doses and levels of lithium. When we examined the case registry of the University of Pittsburgh’s Stanley Center for the Innovative Treatment of Bipolar Disorder, we found that close to two thirds of the patients older than 65 were still receiving lithium and that just below one third were receiving anticonvulsants.

Anticonvulsants (such as Depakote) are increasingly being used as a safe and effective alternative to lithium. One of their main advantages, especially in the elderly, is that the side effects are tolerable. Furthermore, there may be a subgroup of bipolar patients with frequent mood swings (rapid cycling between low and high moods) who may respond better to anticonvulsants than to lithium.

To the best of our knowledge, no studies have focused on the treatment of depression in older patients with bipolar disorder. For younger patients, the best practice is first to prescribe a mood stabilizer like lithium or Depakote and to reserve use of an antidepressant for those who do not respond. There is some information that older tricyclic antidepressants are more likely than Wellbutrin or serotonin antidepressants (Paxil, Celexa, or Zoloft) to induce a switch from depression to mania.

Because of the great need for scientific evidence to guide the treatment planning in late life bipolar mood disorders, our Intervention Research Center has opened a treatment program for patients aged 60 and above with a diagnosis of bipolar disorder. We are working with other doctors at the University of Pennsylvania and at Cornell to plan a multisite study of treatments for bipolar disorder in old age. Despite improvements in their diagnosis and treatment, older patients with bipolar disorder remain at high risk for excessive illness and early death. We need to know more about safe and effective treatments for bipolar illnesses in this age group.

We ask that family members of older bipolar patients work with us to improve the treatment of their loved ones. We are also developing educational and support services for family members who may feel exhausted or overwhelmed by this devastating illness in a family member.

For more information, please call us at 412-246-6006.