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Late Onset Bipolar Disorder and Dementia: What’s the Difference?

Angel Ridout
By Angel RidoutJune 3, 2020

Renee was a doting 60-year-old grandma, active in her community and seeming to age well. But when she started showing signs of aggressiveness, agitation, and erratic behavior, her daughter made an appointment with a neurologist. Renee was diagnosed with dementia, and she continued to spiral downward. After further testing and an appointment with a neuropsychiatrist, Renee was diagnosed with late onset bipolar disorder.

What is late onset bipolar disorder?

Bipolar disorder, formerly called manic depression, is defined by mood changes that alternate between depression and mania. Mania is typically characterized by euphoria, hyperactivity, disorganized or impulsive behavior, and less need for sleep. Late onset bipolar disorder is a new diagnosis of a manic or hypomanic (less extreme) episode after age 50 that isn’t explained by other potential causes like drugs, brain lesions, or brain injuries.

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Can bipolar disorder show up later in life?

Yes, but infrequently. “The majority of bipolar disorders have their onset in the late teens and early adult years,” says Dr. Bruce Shapiro, adjunct professor of psychiatry at New York Medical College. “It’s estimated that only about 10% of individuals who have a bipolar disorder will have an onset after age 50, and that 5% will have an onset of the disorder after age 60.”

How is bipolar disorder different in elderly adults than in a younger person?

Seniors have similar symptoms as younger adults with bipolar disorder, although seniors are likely to have longer hospital stays. Younger adults are more likely to have substance abuse issues in addition to bipolar symptoms.

Elderly adults are also more likely to show a mix of depression and manic symptoms. “These are very serious issues in seniors, and it is often overlooked that the rate of suicide is higher in senior years than in any other age group,” Shapiro says.

What are the similarities and differences between late onset bipolar disorder and dementia?

Late onset bipolar disorder and dementia have many of the same symptoms including:

  • Agitation
  • Depressed mood
  • Restlessness
  • Anxiety
  • Auditory hallucinations

However, there are some significant differences. People with bipolar disorder are more likely to have a slower buildup to mania and a slower change from mania to a depressed mood. While some people with bipolar disorder experience multiple rapid mood changes throughout the day, this symptom is more commonly seen in people with dementia — especially in the evenings, a phenomenon known as sundown syndrome.

Is mania a symptom of dementia?

Mania can be a symptom in all types of dementia, but it’s more commonly seen in frontal lobe dementia and Lewy body dementia. Both diseases can cause agitation, hyperactivity, inappropriate social behavior, and other symptoms often associated with mania.

Do both dementia and bipolar disorder cause psychosis and hallucinations?

Yes, they can. Brain changes caused by dementia can result in dementia psychosis, hallucinations, and delusions. These are common in frontal lobe dementia and Lewy body dementia, especially in the later stages of the disease. Hallucinations and delusions may also occur in the later stages of Alzheimer’s disease. Psychosis is uncommon in bipolar disorder, but some people may experience delusions and auditory hallucinations.

Generally, if an individual with bipolar disorder experiences auditory hallucinations or psychosis, they are given a diagnosis of bipolar disorder with psychotic features. Psychosis and hallucinations are more likely to happen during a manic phase. While hallucinations can involve any of the five senses, auditory hallucinations are the most common form in both dementia and bipolar disorder.

Is there a link between mental illness and dementia?

There is limited and sometimes conflicting research on the relationship between an early adult diagnosis of bipolar disorder and later development of dementia. There’s a slight association between adult psychiatric disorders — especially depression and schizophrenia — and risk for dementia later in life, according to one research review from Johns Hopkins University. Another study from the American Journal of Geriatric Psychiatry showed a high correlation between having an early adult bipolar disorder diagnosis and a higher risk of dementia in old age.

How can I tell if my aging loved one has bipolar disorder or dementia?

Mental illness can be very difficult to diagnose in seniors as confusion, erratic behavior, and memory loss are symptoms of both dementia and mental illness. This makes it difficult to differentiate between the two conditions and why it’s recommended to consult with a mental health professional who specializes in older adults.

Common signs of bipolar disorder

Depressed behaviors:

  • Loss of interest in previously enjoyed activities
  • Eating too much or too little
  • Sleeping too much or too little
  • Fatigue and inability to concentrate
  • Feelings of hopelessness and worthlessness
  • Suicidal thoughts and behaviors

Manic behaviors:

  • Agitation and increased energy
  • Decreased need for sleep
  • Grandiose ideas and plans
  • Impulsivity and reckless behaviors
  • Racing thoughts which are often manifested in rapid speech
  • Euphoria

Common signs of dementia

Cognitive changes:

  • Memory loss
  • Getting lost in familiar surroundings
  • Difficulty planning or reasoning
  • Communication difficulties

Psychological changes:

  • Depression
  • Agitation, especially in the evening
  • Anxiety
  • Hallucinations and delusions
  • Behaving inappropriately

How to diagnose late onset bipolar disorder and dementia

A mental health professional — such as a geriatric psychologist (or geropsychologist), psychiatrist, or neuropsychiatrist — will attempt to clarify whether symptoms suggest anxiety, bipolar disorder, dementia, depression, or psychosis. Potential types of testing for dementia and late onset bipolar include:

  • Cognitive tests
  • Complete medication and supplement review
  • Laboratory assessments
  • Mental status examinations
  • Neuroimaging, such as CT scan or MRI
  • Thorough developmental, physical, and social history
  • Discussions with family members or caregivers

How is bipolar disorder in elderly loved ones treated and managed?

Bipolar disorder in seniors is typically treated much like it is in younger adults, with medications and talk therapy. However, there are some key differences. 

Medications

Mood stabilizers such as lithium and Depakote can be very effective in helping people manage behavioral symptoms, Shapiro says. However, “the metabolism in seniors differs from that of a younger individual,” he says. “There are often changes in kidney and liver function in this age group. These changes will make the senior more sensitive to medications, and many medications must be given with 1/3 to 1/2 reduction of the usual adult dosage in the elderly.” Lithium in particular must be used cautiously, as seniors’ kidneys can’t clear the drug efficiently.

Renee’s bipolar medication worked well at first. Then she became severely depressed, leading her doctor to prescribe a different drug. After several weeks, her condition stabilized again.

“Seniors who take mood-stabilizing medications may have behavioral or personality changes, particularly if they experience changes in the blood levels of their mood-stabilizing medication. This is generally addressed with blood level testing and medication dosage adjustments,” Shapiro says.

Talk therapy

The therapy needs of seniors differ from those of younger adults. Cognitive decline, loss of loved ones, memory changes, physical changes, and retirement can all bring on significant emotional issues. Geropsychologists are well-suited to help seniors explore and deal with these issues.

“Treatment of seniors often involves working with the family as well,” Shapiro says. “The role of psychotherapy, with both individuals and families, has unfortunately all too often been minimized during the geriatric years. Short-term, problem-focused therapies can be very beneficial in the treatment of seniors.”

For Renee, the correct diagnosis and mediation, along with therapy, enabled her to once again enjoy life with her grandchildren.

Personalized help finding assisted living or memory care

Do you have a senior loved one who has been diagnosed with bipolar disorder or dementia? A Place for Mom’s local Senior Living Advisors can help if you’re looking for assisted living or memory care facilities.


Sources:

McDonald, W. & Nemeroff, C. (1998) Practical Guidelines for Diagnosing and Treating Mania and Bipolar Disorder in the Elderly. Medscape Psychiatry & Mental Health eJournal https://www.medscape.com/viewarticle/430757_4

Onyike, C. (2016) Psychiatric Aspects of Dementia. Continuum – American Academy of Neurologyhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5390928/

Prabhakar, D. & Balon, R. (2010) Late-Onset Bipolar Disorder. Psychiatry MMC https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848458/

Morgan, S. (2017) Psychotic and Bipolar Disorders: Behavioral Disorders in Dementia. American Family of Physicianshttps://pubmed.ncbi.nlm.nih.gov/28437057/

Diniz, B., Teixeira, A., Cao, F., Gildengers, A., Soares, J. Butters, M. & Reynolds, C. (2017) History of Bipolar disorder and the risk of dementia: a systematic review and meta-analysis – American Journal of Geriatric Psychiatry https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5365367/

Angel Ridout
Author
Angel Ridout

Angel Ridout has been a content writer and SEO editor at A Place for Mom since 2012. She’s put her psychology degree to use working in residential care homes in Washington and writing about mental illness in the elderly. She loves interacting with families and professionals dedicated to seniors’ well-being and sharing their experiences.

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