Delusional disorder is a mental illness characterized by the presence of one or more delusions for a period of at least one month. Delusional beliefs are based on the misinterpretation of external reality and are not made better with education or persuasion. The prevalence of delusional disorder in older adults is thought to be double that seen in younger adults. The occurence of delusional disorder is more common in later life when compared to other psychotic disorders such as schizophrenia. Seven subtypes of delusional disorder are recognized in the DSM-5. These include persecutory type, somatic type, jealous type, grandiose type, erotomanic type, mixed type, and unspecified type. Response to treatment of delusional disorder with antipsychotics is fair.

Chronic alcohol use disorder is an important cause of major neurocognitive disorder. There are several suggested mechanisms for how alcohol use disorder leads to major neurocognitive disorder. Medical treatment of alcohol use disorder can help limit the late effects of alcohol use. Alcohol-induced major neurocognitive disorder can be partially reversible with abstinence but this depends on the severity of the pathology.

Sundowner syndrome is a common neuropsychiatry syndrome seen in residents of long-term care. Several theories are proposed to explain the pathophysiology and contributing factors. Treatment options are also discussed.

Traumatic brain injury (TBI) is more common in older adults than any other age group. It is the most common fall-related injury in adults over the age of 65. The pathogenesis of TBI involves multiple mechanisms. Medications generally do not alter the course of the disease process but can treat the neuropsychiatric symptoms. Mood and anxiety disorders are commonly comorbid with TBI.

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.

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.

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.

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.

The ability to clinically diagnose and treat medical conditions within the home is rapidly becoming a reality for millions of Americans. In parallel, the vast majority of older adults currently report a preference to age in place, in part because of the independence and autonomy this affords, as well as the enhanced ability to socially distance oneself during a pandemic. The interest in receiving long-term services and support in the home is exemplified by the 820,000 Medicaid-eligible Americans on waiting lists nationwide for home- and community-based services (HCBS), with an average wait time of over three years. As a result, many Americans today face the difficult decision of whether to move to a nursing home or stay in their home, facing the risk of falls, medication adherence errors, and other safety challenges. Diagnosing and monitoring health in the home has the potential to abate this distressingly difficult decision as a cost-efficient, patient-centered alternative to reduce HCBS waiting lists and expand the long-term care options for millions of non-Medicaid-eligible Americans. This chapter delineates the ethical, social, legal, and regulatory issues around implementing diagnostic and digital health in the homes of older adults, in the context of this population’s unique vulnerability to abuse, social isolation, declining cognitive health, frailty, and diagnostic error. Broad-based conceptual and practical reforms to modernize HCBS follow, addressing the adoption of self-administered diagnostic tests for highly prevalent chronic conditions, validated decision-support tools to foster consent, and real-time health data acquisition and management strategies that support government oversight and equitable access to home telehealth.