It’s known in psychiatric circles as “Geri-BD,” says Robert C. Young, MD, professor in the Department of Psychiatry, Weill Medical College of Cornell University, and attending physician in psychiatry at New York Presbyterian Hospital.
“Most of what little is known in geriatric patients is about type I bipolar disorder, which is ‘severe,’ says Young. “There are other forms, such as type II, which are ‘milder’ in some ways, but research has mainly focused on type I in older people.”
Young’s longstanding research interest is in optimizing the use of medicine for treatment of older people with severe mood disorders. While less is known about milder forms, severe bipolar disorder in elder adults seems to fall into three categories. He defines these as:
- Those who have had bipolar disorder their whole lives, and now they’re having more of it. “That’s a well established pattern,” says Young.
- Those who have had one or more episodes of “unipolar” major depression early in life, for example, before 60, and then have one or more manic episodes later in life. “It’s a change in polarity,” he says.
- Those who develop manic and depression symptoms late in life. People with late onset of bipolarity tend to have less family history of mood disorder and more frequent medical/neurological disorders or treatments that can cause mood problems, Young explains.
So, who’s got the edge? A mature adult diagnosed early in life, or one diagnosed later? Is it better to have bipolar disorder when one is young versus reaching old age? Colin Depp, PhD, assistant clinical professor of psychology and research fellow at the University of California, San Diego, is known for his work in the field of aging and bipolar. As with most things in life, Depp says the answers to these questions are not black and white.
No sour grapes for David—the acronym GRAPES means something quite the opposite for this vibrant 63-year-old living in seaside California.
David participated several times in a cognitive program that taught him to incorporate these words into his daily life: ‘Gentle, Relaxation, Accomplishment, Pleasure, Exercise, and Social.’ GRAPES, he says, are great motivation. “Just do a little of each. For example, walking to the local convenience store accomplishes both the exercise and social components.”
The determined and reflective David, diagnosed with bipolar I at age 24, is a dedicated facilitator at the peer-to-peer Depression and Bipolar Support Alliance (DBSA), San Diego chapter. He relies upon his “three-legged stool”—medical management, a skilled therapist whom he trusts, and his family and friends. These friends include his DBSA group, which meets each Monday “because illness does not know vacation and it’s not a walk-in-the-park illness, but one that is chronic and cyclical,” he says. “You never know when it’s going to sneak up on you again, so be aware of ‘gradations,’ those subtle changes.”
You give in to this illness, and you’re done. Go to work on behalf of other people to escape your own misery.
Not far away in Solana Beach, California, David’s friend, Don Bottomley, DO, MPH, manages bipolar II. Now 81, he was finally diagnosed in 1992 at 66 (though he was diagnosed with major depression in 1962 and reflects poignantly on a frustrating, sometimes exasperating childhood). “At that point, I don’t think bipolar disorder really had that much of a ‘history.’” After initially denying his bipolar II diagnosis, Bottomley recognized “those ‘steeplechase’ symptoms—up and down. I was angry that I’d not been receiving the right combination of medications.”
Indeed, Bottomley often felt isolated in his journey down the long and winding road toward the truth, consulting several psychiatrists along the way. This caring, retired physician has been hospitalized 16 times, quit work as a skilled occupational therapist and pharmacist in 1982, and reluctantly accepted disability.
Along with being older, Bottomley is definitely wiser, sharing his sage advice “to get organized, keep life simple, and don’t drink alcohol or use any other drugs. Also, don’t wear ‘bipolar’ like a badge,” he insists. “It’s your disorder, not an excuse for doing something wrong. Sometimes people say, ‘It’s not me, it’s my ‘bipolarism.’ No, it’s still you.”
Sometimes, as in Bottomley’s case, it’s a frustrating work in progress. “On average, the time from first onset of symptoms and real diagnosis is ten years, and it takes another ten to manage bipolar disorder and devise the correct ‘recipe’ of medications,” Depp explains.
Moreover, an individual diagnosed in his or her 20s, who sustains the disorder for 40 years, will typically manifest certain medical comorbidities (the effects of all other diseases an individual patient might have other than the primary disease of interest). “Those patients could have cardiovascular disease, diabetes, or other chronic illnesses, frequently because of lifestyle choices—a patient may smoke, for instance,” Depp states. “Additionally, managing medications for bipolar—plus other illnesses—creates a more ‘complicated’ patient.”
Do not be afraid to let people know you have bipolar disorder– it makes life a little easier. It’s nothing to be ashamed of.
While age and experience might appear to be advantages in living with bipolar disorder, Young says various factors unfortunately can get in the way. “Physical disorders tend to accumulate, perhaps more frequently in bipolar patients than in depressed patients without bipolar disorder,” he explains. “Life expectancy may be reduced in elders with bipolar disorder compared to those who are depressed.”
Of course, consumers in general know that cognitive impairment, dementia, and Alzheimer’s disease are increasingly more common as we live longer—those with bipolar are not exempt. “There is some indication that memory problems and other neuropsychological functions become more prevalent in older adults with bipolar disorder,” Depp confirms.
On the “upside,” Depp cites limited data that suggest that as older adults, “patients may spend less time experiencing active symptoms and the mania is most likely less severe.” Broader surveys of epidemiological data, he says, show that older people are less depressed and less stressed. “Middle age is the time of most frequent depression due to acute stressors of taking care of kids or parents and working,” he says. According to Depp, older adults are also less likely to undertake dangerous activities, abuse substances, and experience interpersonal conflicts.
Older people who have bipolar are often better at managing illness, says Depp. This is because they’ve most likely tried self-management strategies such as exercise and sufficient sleep, are adherent to medications, and like David, have found a health care professional in whom they have faith and trust.
Young offers this take-to-heart advice. “Learn about your disorder—remember that it is a ‘disease’—and its treatment, and talk to your family and primary care doctor and psychiatrist. Psychiatrists with specialized experience in older adults may be members of
the American Association for Geriatric Psychiatry (AAGP) or the International Psychogeriatric Association (IPA). Collaborate with your psychiatrist in keeping track of what has been tried and what was the result, and what hasn’t been tried. Treatments can reduce symptoms and keep them away—if something has helped and is tolerable, stick with it until your doctors say to change it. Keep your medical health the best it can be.”
Also, be open to talking, a very important part of working with your doctors, Young advises. “It encompasses encouragement and education, and recommendations to keep your daily schedule regular.” However, talk therapy alone is considered insufficient for most bipolar patients, he says. “Researchers are hoping to learn about whether certain styles of talking can best help certain patients.”
Then, of course, there are the benefits of getting together. Elders can benefit from support networks and also from those close to them who are able to recognize the early onset of symptoms and can step in to help, Depp says. Moreover, though not all mature adults embrace the Internet, it remains a remarkable resource. Depp encourages these individuals “to learn to be smart consumers.” In fact, he says, “many become ‘experts’ in their disorder because they know more, since the landscape of bipolar treatment has changed in the last few years.”