BACKGROUND: Bipolar disorder is a difficult disease to treat because of its cycling nature, frequent residual symptoms, and poor compliance to treatment. Several guidelines have been proposed for treatment, but there is limited data on best treatment practices in elderly, bipolar patients. This study assessed patterns of psychopharmacological treatment and treatment response in acutely ill, bipolar patients over the age of 60. METHODS: Naturalistic pharmacologic data was obtained on 138 acutely ill, elderly bipolar patients from the Duke University Medical Center electronic psychiatric record. Clinical Global Impression (CGI) severity and improvement scale ratings were performed at each visit, and time to response was measured. Pharmacological treatment selected was reviewed. RESULTS: Standard mood stabilizers (lithium, valproate, carbamazepine, and lamotrigine) were the most prescribed medications (68%), followed by antipsychotics (54%) and antidepressants (34%). Combination therapy was more common than monotherapy (57% vs. 38%). Remission was achieved in 35% of subjects, while 32% showed no significant improvement. There was no difference in antipsychotic prescription between old old and young old patients. CONCLUSIONS: In this naturalistic, real-setting study of pharmacologic treatment, acutely ill, elderly bipolar patients were treated primarily with mood-stabilizing agents, followed by antipsychotics and antidepressants. Combination therapy is much more common than monotherapy. Results can be useful in understanding the current clinical standard of care in elderly bipolar patients, and are consistent with current clinical guidelines for mixed-age bipolar patients.