Delirium is more common in older adults, especially those with major neurocognitive disorders. Always do a thorough review of medications when considering any mental status changes in older adults. Medications and infections are the most common causes of delirium in older adults. Delirium is a medical emergency and warrants immediate medical evaluation and treatment.

Some factors shown to increase anxiety include very high levels of social contact, dysfunctional patient-caregiver relationships, and high physical dependency. Other factors that can negatively impact anxiety in older adults include boredom, social isolation, and unmet physical needs for proper nutrition, warmth, and cleanliness, for example. Pharmacologic treatment options for those with panic disorder can include a short course of benzodiazepines and long-term SSRIs or SNRIs. Cognitive behavioral therapy has proven to be a particularly effective nonpharmacologic approach to treatment of anxiety and panic. As-needed medications for anxiety can be helpful in the initial weeks of treatment as the therapeutic effect of SSRIs and SNRIs is approached. Useful medications for as-needed treatment of anxiety include low-dose trazodone (25 or 50mg every 4-6 hours as needed). Other options might include gabapentin, mirtazapine, or low-dose propranolol.

Primary health care providers and mental health professionals are likely to be engaged with family or care staff with questions regarding end-of-life care issues in those in the terminal stages of major neurocognitive disorders. Those who provide care in the long-term care setting should be familiar with issues regarding end-of-life care in MNCD. Palliative care is an approach to medical care that focuses on providing relief from pain, other symptoms, and the physical, emotional, and psychosocial stress that individuals with serious illnesses may experience. The primary goal of palliative care is to improve the quality of life for patients and their families, particularly when dealing with complex, chronic, or terminal medical conditions. Hospice care is appropriate for patients that are entering the terminal stage of illness and is provided through a licensed hospice agency. The hospice care model focuses on improving comfort and quality of life. It is a holistic approach that encompasses physical, emotional, social, and spiritual support and can be provided in almost any care setting.

The implications of unrecognized pain in those with MNCD are far-reaching.  Untreated pain can lead to the destabilization of psychiatric conditions such as anxiety, depression, and agitation.  Those with cognitive impairments are more likely to have longer waits for the evaluation of pain and receive weaker analgesia.As needed pain medications given to those with MNCD in the LTC setting may depend too heavily on the judgment of those inadequately trained to assess pain.  Regularly scheduled pain medications may be a more appropriate option. Always keep the possibility of medication error in the differential diagnosis for apparent changes in mental status. Inadequate pain control negatively impacts mental health in older adults.  Those with MNCD with inadequately controlled pain may present with atypical symptoms when compared to those without MNCD. Consider both pharmacologic and nonpharmacologic interventions when formulating a treatment plan for chronic pain in older adults. Opiates may have the best benefit/risk ratio for the treatment of chronic pain in some older adults.