Why Does Bipolar Disorder Get Worse With Age?

Medically reviewed by Elle Markman, PsyD, MPH

Bipolar disorder can have a lifelong impact, and symptoms may worsen with age when left untreated. People with bipolar disorder and other co-occurring conditions (comorbidities) may experience a significant reduction in their quality of life and life expectancy.

One literature review that examined studies on bipolar disorder and age found that nearly 1 in 4 people with bipolar disorder are 60 or older.

This article discusses how aging impacts this bipolar disorder, what can make it worse, and treatment and management of bipolar disorder.

How Does Aging Affect Bipolar Disorder?

Bipolar disorder causes mood episodes—periods of altered mood, behavior, and energy—which last from hours to weeks. People with bipolar disorder cycle through the following states:

• Mania: Feeling abnormally high, buoyant, or agitated, as experienced in bipolar 1

• Depression: Feeling hopeless, sad, lacking in energy, and loss of interest in activities you enjoy

• Hypomania: A less intense manic episode that typically doesn’t last as long as experienced in bipolar 2

• Euthymia: The symptom-free state in between the high of manic episodes and the low of depressive ones

Bipolar disorder symptoms change and even worsen as you age. Researchers have found that people over age 60 who have bipolar disorder experience mood episodes more often and are more likely to be depressed rather than manic.

However, people of advanced age with bipolar disorder are less likely to become suicidal compared to those under 60 living with this condition.

Bipolar Disorder As You Age

In most cases, bipolar disorder sets on in the late teens or early 20s. Compared to symptoms in early life and midlife, people of advanced age tend to have symptoms more frequently (shorter euthymic periods) and are more likely to experience manic episodes. Additionally, medications for people over 60 may be less effective.

Bipolar disorder in older age is also associated with cognitive decline—a reduction in your working memory, executive function (flexible thinking and self-control), and ability to focus and pay attention. Having this condition may speed up the effects of other neurological conditions that impact cognition, like Alzheimer’s disease.

Evidence suggests that living with bipolar disorder can impact the brain’s structure. Imaging studies have found reduced gray matter—the areas associated with emotional regulation—in the brains of people with bipolar disorder. However, researchers must explore this topic more deeply to understand this relationship.

What Makes Bipolar Disorder Worse?

A combination of biological, environmental, and genetic factors contribute to bipolar disorder. Several health and lifestyle factors influence this condition, trigger mood episodes, interfere with treatment, and worsen symptoms.

Trauma

Traumatic life events, such as a divorce or breakup, child abuse, financial problems, or the loss of a loved one, can trigger mood episodes. Some research suggests that each adverse life event increases the odds of developing bipolar-associated depression by 10%. Other studies have found that disruptions to daily living due to challenging times can also raise the risk of manic episodes.

Stress

Stress can trigger depressed or manic mood states and increase the severity of bipolar disorder symptoms. Researchers have found that people with bipolar disorder have higher baseline levels of cortisol—a stress hormone—making them more prone to stress. Stress can also contribute to developing bipolar disorder, alongside genetic and environmental factors.

Poor Sleep

Disrupted sleep is a hallmark of bipolar disorder and contributes to its severity. During manic episodes, people feel less of a need for sleep and experience insomnia, an inability to fall or stay asleep. Conversely, depressive episodes are marked by hypersomnia—excessive sleep and constant drowsiness.

Sleep loss and interruptions can also trigger bipolar disorder, especially manic episodes. Researchers found that sleep deprivation is associated with bipolar disorder attacks, especially in those assigned female at birth.

Substance Abuse

Between 21.7% and 59% of those with bipolar disorder develop a substance use disorder (SUD), and the two conditions are closely linked. Studies show that SUD can worsen bipolar symptoms and vice versa. Researchers believe the two may be overlapping disorders or that having one makes you vulnerable to the other.

Reproductive Hormone Shifts

Researchers have found many links between bipolar disorder and changes in female reproductive hormones. In one study, 77% of participants had episodes triggered or become more severe during menstruation (your period), postpartum (after childbirth) periods, and menopause (12 months after your final period).

Thyroid Hormone Shifts

Changes in levels of thyroid hormone, which is produced by the thyroid gland in front of the throat, can contribute to bipolar symptoms. Researchers found low levels of this hormone, caused by hypothyroidism (an underactive gland), are associated with bipolar-associated depression. In addition, there’s evidence that this can also lead to manic episodes.

Changes in Weather

Seasonal shifts and changes in the weather can also lead to and influence bipolar disorder episodes. Seasonal affective disorder (SAD), a type of depression that occurs during winter or colder months due to insufficient sun exposure, often overlaps with bipolar disorder episodes. In addition, other changes in weather, such as temperature drops or rises, rain, atmospheric pressure, and overcast skies, can also contribute to the condition.

Other Medical Conditions

Bipolar disorder has many comorbidities, which can trigger or worsen episodes. Common bipolar disorder comorbidities include:

• Anxiety disorders (e.g., generalized anxiety, social anxiety, panic disorder, and phobias)

• Personality disorders (e.g., obsessive-compulsive, narcissistic, or borderline personality disorder)

• Substance use disorders

• Migraine

• Obesity

• Metabolic syndrome

• Cardiovascular disease (e.g., coronary artery disease and heart failure)

Living With Bipolar in Older Age

Overall, studies have found that older people with bipolar disorder have more severe symptoms and worse outcomes. Due to the cognitive decline caused by this condition, this population scored lower on measures of independence, autonomy, job or financial performance, and interpersonal relationships.

As with those with bipolar overall, comorbid mental health conditions can add to the burden of this disease. Between 30% and 44% of those with bipolar also have anxiety disorders, such as generalized and social anxiety (agoraphobia). Healthcare providers consider possible or confirmed comorbidities when diagnosing and treating this condition.

Bipolar Disorder and Life Expectancy

Those with bipolar are more likely to have cardiovascular and metabolic diseases. As a result, bipolar disorder negatively impacts life span. Those with the condition live, on average, 10 years less than those without this condition. That said, treatments and therapies can dramatically improve outcomes for people with bipolar disorder. If you've been diagnosed, seek treatment.

Does Bipolar Treatment Offset Cognitive Decline?

Between 40% and 60% of people with bipolar disorder experience cognitive decline. Ranging from medications to therapy and other procedures, treatments for bipolar have a variable record in managing cognitive decline associated with bipolar disorder.

Medications and Cognitive Decline

Healthcare providers prescribe several classes of medications to treat bipolar manic and depressive episodes. These include antidepressants, mood stabilizers, and second-generation antipsychotics. However, these aren't effective for cognitive symptoms, and no standard pharmacological approaches to treat these symptoms exist.

Therapies

Often recommended alongside medications, sessions with a therapist or psychiatrist are beneficial for people with bipolar disorder and cognitive decline. Among these approaches, a therapy called "functional remediation" focuses on improving memory, attention, and executive function in people with bipolar disorder.

Over a three-week period, people engaging in this treatment attend individual and group sessions to develop practical skills in life-like situations.

Other Treatments

Though the evidence is limited, researchers have found promising results in treating cognitive decline due to bipolar disorder with transcranial magnetic stimulation (TMS), or electrical stimulation.

Typically used for Alzheimer’s disease, traumatic brain injury (TBI), severe depression, or other neurological conditions, this treatment involves wearing a headset that uses magnets or electrical waves to stimulate specific parts of the brain.

Special Bipolar Treatment Considerations in Older People

Treatments for bipolar disorder depend on the individual case. Healthcare providers generally take the same approach for everyone with the condition, regardless of age. Medications and therapy are the mainstays of therapy. However, healthcare providers take extra care when treating older adults.

Healthcare providers prescribe three classes of medications for bipolar disorder:

• Antidepressants, such as the selective serotonin reuptake inhibitors Prozac (fluoxetine) or Celexa (citalopram).

• Mood stabilizers, such as lithium and Depakote (valproate)

• Second-generation antipsychotics, with the combination of Zyprexa (olanzapine) and Seroquel (quetiapine), which are approved for bipolar disorder.

How your body metabolizes medications changes as you age, raising the risk of side effects. For this reason, certain medications may not be suitable for older adults.

For instance, this population is more susceptible to lithium toxicity, especially if taken alongside other medications, including angiotensin converting enzyme (ACE) inhibitors, calcium antagonists, and diuretics (water pills). Depacon side effects can also occur when taken alongside Jantoven (warfarin), Digitek (digitoxin), Phenytek (phenytoin), and lamotrigine.

Summary

Older adults tend to have more frequent episodes of bipolar, and the nature of the symptoms changes. This population is also prone to cognitive decline: deficits in attention, memory, and other thinking skills. Treatments for bipolar disorder include medications and therapy, often in combination. Though researchers found only mixed evidence that these therapies help with cognitive deficits, they improve overall outcomes for older people.

Read the original article on Verywell Health.