The recognition, diagnosis, and management of late-onset bipolar disorder.
INTRODUCTION Late-onset bipolar disorder (LOBD) represents a clinically relevant but understudied subtype of bipolar. Compared with early-onset bipolar disorder, LOBD may present with distinct clinical features, increased somatic comorbidity, and potential associations with neurodegenerative and vascular processes. Specific diagnostic and therapeutic recommendations for LOBD are currently limited. AREAS COVERED This narrative review examines the current evidence regarding epidemiology, pathophysiology, diagnostic workup, and management of LOBD. Literature was identified using PubMed to conduct a structured literature search of the MEDLINE database for articles between 2015 and 2025, and review of relevant articles. Particular attention is given to differential diagnosis with secondary mania and neurodegenerative disorders, the role of medical and neurological evaluation, and treatment considerations including pharmacological strategies, neuromodulation, psychosocial interventions, and longitudinal follow-up. EXPERT OPINION Current evidence suggests that LOBD likely represents a heterogeneous condition with multiple underlying mechanisms, including vascular burden, neurodegenerative processes, and age-related biological vulnerability. Comprehensive somatic and cognitive assessment is essential. While treatment generally follows established bipolar disorder guidelines, careful adaptation is required due to comorbidity, polypharmacy, and age-related pharmacodynamic changes. Lithium, with its potential neuroprotective properties, may be the first-choice medication. Future research should focus on clarifying pathophysiological mechanisms and developing tailored management strategies.