Sleep-related complaints are quite common in the long-term care setting. It is estimated that 40-70% of older adults have some type of chronic sleep-related complaint. Up to 50% of these go undiagnosed. Older adults are known to have increased wakefulness at night, increased number of sleep arousals, and increased sleep latency. Older adults are known to have decreased total sleep time, slow wave sleep, REM sleep, and sleep efficiency. Some common sleep-wake cycle disturbances seen in older adults include primary insomnia, delayed sleep phase syndrome, advanced sleep phase syndrome, irregular sleep-wake rhythm, non-24-hour sleep-wake disorder, sleep state misperception, hypersomnia, and narcolepsy. Good nonpharmacologic principles beneficial to sleep quality are often safer and more effective than pharmacologic therapies. These include good sleep hygeine practices, sleep restriction, increased physical activity, limiting daytime naps, and daytime bright light exposure.

Hoarding disorder is now considered one of the obsessive-compulsive and related disorders. It is thought to affect about 6% of those over the age of 70. Symptoms of hoarding disorder are thought to begin in young adulthood and increase in severity with age. Sufferers are likely to be diagnosed late in the course of their disease due to prominent lack of insight, shame, and social stigma. Complications of hoarding disorder include food contamination, malnutrition, medication mismanagement, falls, and eviction from the home. The best treatment outcomes have been shown with cognitive rehabilitation and exposure/sorting therapy. This treatment can be limited by availability of appropriately trained professionals and lack of insight by patients.

Those with depression with psychosis meet the criteria for diagnosis of depression but also experience psychotic symptoms. When individuals with major depressive disorder (MDD) experience delusions, hallucinations, or catatonic symptoms, it is referred to as MDD with psychotic psychosis, also known as psychotic depression. The nature of the psychosis in those with depression is usually mood-congruent somatic, pessimistic, or guilt-related delusions. It is crucial for healthcare providers to diagnose psychotic depression early due to its high risk of suicide and poor response to antidepressant treatment alone. Additional antipsychotic medication is typically necessary, in addition to the antidepressant, for an effective response. Electroconvulsive therapy is more commonly used in those with severe depression with suicidality, catatonia, and those with psychotic depression. Studies have shown a response rate of 70-90% with electroconvulsive therapy in those with severe depression.

Clozapine is now an important medication in the treatment of schizophrenia. It is used primarily in cases of treatment-resistant schizophrenia but is also useful in patients with schizophrenia that have had adverse effects to multiple other antipsychotics. The use of clozapine in schizophrenia has several benefits in addition to improving the control of the symptoms of schizophrenia for those with treatment-resistant schizophrenia. The risks of using clozapine are well known and the most feared side effect of clozapine is agranulocytosis. Agranulocytosis risk is highest in the first three months of use of the drug but is possible even after years of use. There are some off-label uses of clozapine that healthcare providers in long-term care should be aware of. Some studies have suggested that clozapine may be effective in treating treatment-resistant depression. Clozapine has been used off-label in the treatment of bipolar disorder, particularly in people who have not responded to other more commonly prescribed medications.

Dementia with Lewy bodies (DLB) is a neurodegenerative disorder characterized by the presence of Lewy bodies, which are abnormal protein deposits, in certain areas of the brain. The symptoms of DLB can be variable and fluctuate from day to day, making it challenging to diagnose. The most common symptom is cognitive impairment. There are central features, core features, suggestive features, and supportive features that can be used to aid in the diagnosis of DLB. REM sleep behavior disorder is common in DLB and Parkinson-related dementia.

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.

Agitation is a neuropsychiatric syndrome that is commonly seen in those with major neurocognitive disorders. Those demonstrating agitation can show increase in motor activity, restlessness, emotional distress, and physical or verbal aggression. Agitation is the third most common neuropsychiatric symptom in dementia after apathy and depression. Up to 80% of people with dementia experience some degree of agitation at some point during the course of the illness. The pharmacologic management of agitation in those with major neurocognitive disorders is complex and many studies have shed light on the topic.

The pharmacologic treatment of post-traumatic stress disorder attempts to alleviate the symptoms associated with the condition including anxiety, depression, and sleep disturbances. SSRIs are first-line medications and SNRIs such as venlafaxine are also effective, especially in instances where there has been a suboptimal response to SSRIs. There are quite a few options for nonpharmacologic therapy in older adults. Outcomes are best in those who participate in both pharmacologic and nonpharmacologic treatments. Some of the best outcomes are seen with cognitive behavioral therapy combined with pharmacotherapy. Follow-up for those with post-traumatic stress disorder should involve regular visits with a provider to assess response to treatment. Rating scales such as the PTSD Checklist 5 can be quite helpful in objectively assessing the severity and nature of symptoms over time. The prognosis varies widely among individuals and some patients may experience significant improvement or even full remission of symptoms over time.

A major influence on positive or negative therapeutic responses to a medication is the drug’s metabolism in a given individual. The metabolism of pharmaceuticals is influenced by age-related factors. Lithium, valproic acid, and carbemazepine levels are still important to obtain periodically when these drugs are used in the management of bipolar disorder and some other psychiatric and neurologic conditions. The metabolism and serum concentrations of medications do not always correlate well with clinical response. At this time pharmacogenetic information used to guide antidepressant therapy does not consistently show improved outcomes. Some studies show improved outcomes and some show no difference in outcomes.

Borderline personality disorder is a complex mental health condition. Those with the condition have unstable moods, a history of difficulty functioning in relationships, and a dysfunctional self-image. Patients have emotional dysregulation that can lead to impulsive behaviors, self-harm, and fear of abandonment and have significant challenges in life that can lead to poor psychosocial outcomes. Interpersonal relationships can often be intense and dysfunctional and demonstrate frequent conflicts. Emotional dysregulation can lead to rapid and intense mood swings. Impulsivity can lead to issues such as reckless spending, risky sexual behaviors, and substance abuse. The treatment of borderline personality disorder is largely through long-term psychological therapy and the gold standard therapy approach is dialectical behavior therapy. This therapy focuses on optimizing emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness skills.

Symptoms of adult ADHD can mimic early major neurocognitive disorders in older adults. Deficits uncovered in standard cognitive tests can be due to impaired attention in those older adults with ADHD. Treatment of adult ADHD in older adults is similar to that in younger patients and includes stimulant and non-stimulant medications. Extra caution should be used when prescribing stimulant medications to those with medical or psychiatric comorbidities. About 60% of children or adolescents with ADHD go on to experience adult ADHD. Symptoms of adult ADHD may lessen or be less problematic in older adults. Some older adults may still benefit from treatment.

Sexually inappropriate behavior can be a manifistation of disinhibited behavior seen in older adults with major neurocognitive disorders. Sexual expression in older adults with major neurocognitive disorders is normal and should not be universally discouraged when in an appropriate setting and when the rights of others are not violated. The evaluation of sexually inappropriate behavior should include a detailed history that includes what the behavior is, who is involved, what is the context of the behavior, who is being impacted, and if the behavior is out of proportion with other disinhibited behaviors. Look for and potentially remove medications that could be contributing to sexually inappropriate behavior including dopamine agonists, anticholinergic agents, and benzodiazepines.

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.