<p>In older adults, bipolar disorder (BD) frequently presents atypically, with manic symptoms manifesting as irritability or confusion rather than euphoria. Cognitive impairments, including mild cognitive impairment and dementia, can obscure or mimic bipolar symptoms, complicating accurate diagnosis. Depressive episodes tend to be more frequent and prolonged, increasing misdiagnosis risk as unipolar depression. Pharmacological management requires careful consideration of age-related pharmacokinetic and pharmacodynamic alterations. Mood stabilizers including lithium, valproate, and lamotrigine are commonly employed but necessitate vigilant monitoring for adverse effects and drug interactions. Atypical antipsychotics such as quetiapine and aripiprazole are generally preferred for their tolerability profiles, though comorbidity burden and polypharmacy substantially elevate risks of adverse drug reactions and interactions. Late-onset and early onset bipolar disorder in older adults (LOBD and EOBD) represent clinically relevant subgroups with differing diagnostic considerations. However, current evidence does not clearly support major differences in pharmacologic management. The purpose of this narrative review is to address this gap by comprehensively exploring the clinical presentations and diagnostic challenges in older-age BD (OABD) as well as the pharmacological treatment patterns worldwide. We also outlined clinically focused synthesis of special considerations and tailored approaches, and finally critically appraise the literature to determine future directions and research needs. Addressing the multifaceted diagnostic and pharmacotherapeutic challenges of OABD through dedicated age-specific clinical trials, comparative effectiveness studies, systematic evaluation of deprescribing strategies, and enhanced clinician awareness will be fundamental to improve outcomes for this understudied and expanding population.</p>