The potential of substance use disorders in older adults is often overlooked in a general health assessment. Substance use disorders have a high comorbidity with other psychiatric disorders. Physiologic changes in older adults make them more susceptible to the negative effects of alcohol use. With the proper support and resources older adults with alcohol use disorder can live a healthier, happier life free from alcohol. Cannabis use is increasing in all age groups including older adults. Be aware that older adults may be using cannabis to self medicate psychiatric conditions such as anxiety and depression or to treat chronic pain despite limited evidence for long term improvement. Older adults may be at risk of opiate use disorder due to chronic pain issues, multiple medical comorbidities, and psychiatric comorbidities. Treatment options for opioid use disorder such as medications, outpatient treatment programs, and psychosocial supports are often as effective in older adults as in younger patients.

Schizoaffective disorder is a psychiatric disorder in which patients demonstrate a combination of symptoms associated with schizophrenia and a mood disorder such as bipolar disorder or depression. The symptoms of schizophrenia and mood disorder occur concomitantly for a substantial portion of the illness duration. If a resident has been stable on a psychiatric drug regimen, it is advisable to avoid any major change because obtaining a similar good therapeutic response from a different drug regimen is not predictable or assured. All antipsychotics have the potential to cause weight gain and increase the risk of obesity and related hyperlipidemia and diabetes. Atypical antipsychotics can be thought of as being high, medium, and low risk for these complications. Antipsychotics thought to be low risk for metabolic syndrome include cariprazine, lurasidone, lumateperone, ziprasidone, pimavanserin, aripiprazole, and brexpiprazole.

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.

Delirium as a complex neuropsychiatric syndrome characterized by disturbances in attention, awareness, and cognition that are not explained by a pre-existing neurocognitive disorder. The causes of delirium are varied. The most common causes of delirium in the long-term care setting are likely urinary tract infections, untreated pain, and medication side effects. The initial steps recommended in managing delirium involve identifying and addressing underlying medical conditions, reducing environmental triggers, and minimizing exposure to drugs. Besides treatment of the cause, management of delirium primarily involves psychosocial interventions. These can include environmental modifications such as addressing poor lighting, excessive noise, or lack of orientation cues.

Alzheimer’s disease is the most common form of major neurocognitive disorder, causing gradual declines in many areas of cognition. Alzheimer’s disease accounts for 60-70% of cases of dementia worldwide. Donepezil is the prototypical cholinesterase inhibitor and was approved for use in 1996. It is FDA approved for the treatment of mild, moderate, or severe Alzheimer’s disease and is considered a symptomatic treatment for Alzheimer’s disease and some other dementias as it does little to alter the course of the disease. The advantages to maintaining patients on cholinesterase inhibitors include continued slowing of the decline in cognition, delaying need for a higher level of care, and potentially delaying the need for medications to address neuropsychiatric symptoms.

Health providers of those with major neurocognitive disorders are in a unique position to provide support to primary caregivers who may be struggling with the many responsibilities of being a primary caregiver. Be sensitive to the presence of potential caregiver stress. Offer suggestions to caregivers that may assist in better interactions with their loved one with MNCD. Become familiar with the various support resources and supported living environments available to those with MNCD. Having a connection with a social worker/geriatric case manager can be helpful as a referral source for those families that may need more extensive assistance and planning for care needs. Be familiar with and ready to refer family members of those with MNCD to local support groups such as the Alzheimer’s Association for ongoing caregiver support.

A significant percentage of older adults remain sexually active. Studies have shown that sexual activity in older adults is associated with better cognitive and mental health and better sleep. Major neurocognitive disorders are a common cause of sexually inappropriate behavior. Despite the few studies discussing sexual aspects in MNCD, existing reports indicate that up to 25% of patients suffering from Alzheimer’s disease have inappropriate sexual behavior, including increased sexual urge and hypersexuality. The ability of patients to consent to sexual relations may be underestimated by healthcare staff. Therefore, the issue of consent is an important point of discussion among staff members and each case should be assessed separately. Long-term care facilities should have policies in place that address the evaluation of a patient’s capacity to consent to sexual activity.

Mania is most commonly thought of as a phase of bipolar disorder and, for this reason, it can be easily misdiagnosed as such when a secondary cause of mania may truly be the culprit. Primary mania results from bipolar disorder. Secondary mania is a distinct form of mania that arises due to an underlying cause or condition. Mania secondary to an underlying medical condition can result from various causes. Conditions to keep in mind include primary neurological disorders, endocrine abnormalities, medications, illicit substances, infectious disease, metabolic abnormalities, autoimmune disorders, and primary brain lesions.

The workup of suspected secondary mania should first include a good history and physical. The history should focus on current medical symptoms, recent infections, use of medication or drugs of abuse, and any personal or family history of psychiatric conditions.

Pseudobulbar affect is described as episodes of involuntary, unprovoked, and sudden episodes of crying or laughing that happen as a result of central nervous system pathology. Pseudobulbar affect can be easily overlooked or misdiagnosed as a primary mood disorder. Several classes of medications have been used to treat it with varying success. These include SSRIs, SNRIs, and tricyclic antidepressants. Dextromethorphan/quinidine (Nuedexta) was approved in 2010 for the treatment of pseudobulbar affect.

Antidepressants, when used appropriately and in combination with an individualized psychosocial approach, can dramatically improve depressive symptoms and the quality of life of residents who have major depressive disorder. The selection of antidepressants needs to take into account the patient’s medical problems, as well as what side effects one wants or wants to avoid for a particular patient. There is no compelling evidence that one antidepressant works better than any other for the treatment of majpr depressive disorder in long-term care populations. Selective serotonin reuptake inhibitors (SSRIs) are probably the most commonly selected first-line medications for the treatment of major depressive disorders in long-term care residents. Serotonin-norepinephrine reuptake inhibitors) have also been associated with a potentially increased risk of bleeding, although the risk appears to be lower compared to SSRIs.

Eating disorders are complex chronic medical conditions that have both psychological and medical consequences. They are characterized by abnormal eating behaviors that can lead to significant morbidity and even mortality. The pathophysiology of binge eating disorder involves both biological and psychological factors. Just as in substance use disorders, dysregulation in neurocircuitry related to reward and emotional processing might contribute to the development and maintenance of binge eating behavior. Pharmacologic treatment options for binge eating disorder have provided disappointing results. Comorbid mood and anxiety disorders are more common in this population and treatment of these conditions may produce related improvements in comorbid eating disorders. Ethical challenges can present themselves when dealing with those with eating disorders in long-term care settings. Patients in long-term care settings have as much right to engage in legal, albeit self-destructive, behaviors as those outside of long-term care.

Frontotemporal dementia (FTD) is the name of a group of dementias that primarily involve the frontal and temporal lobes of the brain. They are progressive neurodegenerative disorders that are typically diagnosed in individuals under the age of 65. Symptoms of FTD are variable and depend on the subtype of disease but most show some changes in behavior, personality, language, and movement. A history of insidious onset of apathy and lack of concern for self should raise the possibility of FTD. There is no cure for the disease.

Apathy syndrome is a frequently observed condition among older adults, particularly in long-term care environments. Estimates suggest that up to 70% of individuals with Alzheimer’s disease, 40% of those with Parkinson’s disease, and 38% of those with late-life depression may experience symptoms of apathy. Apathy syndrome is a clinical condition characterized by a lack of motivation, interest, or emotional responsiveness. It involves a reduced or diminished ability to initiate and sustain goal-directed behavior, leading to a general indifference or disinterest in one’s surroundings, activities, or social interactions. Some studies have shown improvement in apathy syndrome with methylphenidate.

Extrapyramidal symptoms are movement disorders associated with antipsychotics and include acute dystonias, akathisia, Parkinsonism, tardive dyskinesia, and neuroleptic malignant syndrome. Antipsychotic-related Parkinsonism and akathisia are the most commonly encountered antipsychotic related movement disorders. Tardive dyskinesia occurs with long-term antipsychotic use and can be very impactful on quality of life. Treatment options exist for those with tardive dyskinesia dependent on antipsychotics.

The population of the world is ageing. This has led to an increase in interventions and surgical procedures that would have been unheard of about fifty years ago. In this chapter we discuss the perioperative management of older patients, and the emphasis is on hip fracture patients. Factors such as limited physiological reserve, comorbidities, and the trauma of surgery itself are discussed, together with their perioperative management. The impact of pre-existing dementia and of post-operative delirium and depression is also covered here. The pre-operative management of fluid and electrolyte imbalance, the reversal of anticoagulation before surgery, and the treatment of infections are included. The evidence base around cut-offs for haemoglobin levels acceptable for surgery is also discussed. Finally, the post-operative management of acute kidney injury, infections, myocardial infarction, congestive cardiac failure, post-operative delirium, post-operative cognitive dysfunction, and depression is explored in conjunction with their evidence base.

This chapter seeks to promote both awareness and understanding of evidence-based psychosocial factors that enhance well-being, adjustment, and recovery in older people admitted to hospital.

The chapter begins by exploring ageing from biological, psychosocial, and existential perspectives. It then focusses upon the psychological sequel of illness and disability in this population and goes on to identify components of psychological well-being drawn from both qualitative and quantitative research studies that promote recovery in older people who have been admitted to hospital.

The chapter also explores the role of culture, faith, and ethnicity in the well-being of hospitalised older people and concludes by highlighting essential components in the development of a positive, recovery-focused culture of care.