The oldest person in the United States is 115 years old, and in the 2010 Census, there were 53,364 centenarians (individuals 100 years of age or older) [1]. Older adults, considered to be individuals 65 years of age and older, make up 16% of the U.S. population. Moreover, the number of individuals 85 years of age and older is projected to double by the year 2040, and by 2050, it is projected that one in five people in the United States will be older than 65 years of age [2,3]. By the year 2060, it is projected that 589,000 people will be 100 years of age or older [4]. These figures alone demonstrate the need for increased familiarity and comfort with the mental health care of the older adult. Aside from age, the older adult presents with other potential complications, such as living in extended care facilities.

The oldest person in the United States is 115 years old, and in the 2010 Census, there were 53,364 centenarians (individuals 100 years of age or older) [1]. Older adults, considered to be individuals 65 years of age and older, make up 16% of the U.S. population. Moreover, the number of individuals 85 years of age and older is projected to double by the year 2040, and by 2050, it is projected that one in five people in the United States will be older than 65 years of age [2,3]. By the year 2060, it is projected that 589,000 people will be 100 years of age or older [4]. These figures alone demonstrate the need for increased familiarity and comfort with the mental health care of the older adult. Aside from age, the older adult presents with other potential complications, such as living in extended care facilities.

The probability of an older adult living in an extended-care facility increases with age, with 1% of individuals 65 to 74 years of age, 2% of those 75 to 84 years of age, and 8% of those 85 years of age and older living in an extended-care facility [2]. As the general population grows older, it is expected that the number of those in extended-care facilities will increase as well.

Dementia is a general term for difficulties with cognitive functioning, including impairment in executive functioning (e.g., balancing a checkbook), memory loss, poor judgment, impulsivity, getting lost in familiar places, and taking longer than usual to complete daily tasks. Although the likelihood of developing dementia increases as one ages, it is not considered a normal part of aging. Dementia is further categorized by type and severity. Alzheimer disease is one of the most common forms of dementia, with an estimated 6.5 million individuals 65 years of age and older in the United States affected [6]. Other types of dementia include frontotemporal dementia, vascular dementia, and dementia with Lewy bodies. It has been suggested that the total number of Americans with some form of dementia could rise to 14 million by 2040 [7].

Suicide is a public health concern in the United States and worldwide; in 2020, older adults experienced a suicide mortality rate of 16.86 deaths per 100,000 population [13]. Loneliness, dementia, and depression are commonly seen characteristics of the oldest individuals who complete suicide; also, older men had the highest rates of death by suicide in nearly all countries [14]. The older adult is more likely to choose a more violent means of attempting suicide and are more likely to die following an attempt than younger patients [5]. Working with older adults through complex grief, finding meaning in life, relieving psychiatric symptoms, and, above all, establishing a strong therapeutic alliance are crucial to improving quality of life and decreasing suicide risk [12]. Problem solving and problem adaptation therapy are two psychotherapeutic modalities that have shown some promise in decreasing suicide risk in the older adult [12]. Contributing factors should be continually assessed by the nurse caring for the older adult.

Anxiety disorders are thought to be more common in older adults than depression, with a prevalence rate of 7% to 14.2% for this population [12]. Anxiety can manifest differently in older individuals compared to younger populations due to various factors, including age-related changes, comorbidities, and life circumstances. Furthermore, the older patient may also experience lower self-confidence, reduced activity and movement, loss of friends/social supports, reduced financial and physical independence, and medical comorbidities, all of which can further fuel anxiety symptoms [16]. These factors culminate to the development of anxiety surrounding death among older adults; additionally, generalized anxiety disorder, anxiety related to a general medical condition, and agoraphobia are more likely to occur in late adulthood [12,17]. As individuals get older, they may experience death anxiety, or a heightened awareness and fear of death, whether conscious or unconscious. The mental health and quality of life of the older adult improves if death anxiety is addressed psychotherapeutically. Lower death anxiety is associated with higher levels of meaning in life [18]. Nurse psychotherapists can be very important in helping the older adult patient find meaning in life to mitigate the risk of depression and anxiety in late life [12].

Characteristics of schizophrenia in older adults can vary widely from younger individuals diagnosed with the disorder [24]. This may be due to a combination of a different symptom profile among those with late-onset schizophrenia and significant symptom reduction among those with early-onset disease who have reached older adulthood. Older adults with schizophrenia are also more likely to have acquired medical comorbidities that complicate the clinical picture. It has been noted that individuals with late-onset schizophrenia have better premorbid functioning than those who develop the disorder earlier in life [23]. Those who develop schizophrenia later in life tend to have fewer negative symptoms and less severe neurocognitive impairments [23].

When formulating a treatment plan for older adults, nonpharmacologic options should be considered first as a safer alternative. If medication is necessary, adhering to the principle of "start low, go slow, don't stop, be patient" is crucial [30]. "Start low" acknowledges that older adults often require lower initial doses compared to younger patients. In some cases, as little as half or even one-quarter of the recommended starting dose may be appropriate for older adults [21,30]. "Go slow" advises avoidance of aggressive dose titration commonly used with younger patients. "Don't stop" emphasizes the need to avoid abrupt discontinuation of antipsychotics or any medications in the elderly. "Be patient" suggests allowing older patients sufficient time to adjust to new medications. Demonstrating patience is important when evaluating the effectiveness of psychiatric medication in older adults. Even with a low dose, they may still be sensitive to side effects, so close monitoring is essential to prioritize the safety of the older adult.

It is common knowledge that as individuals age, total body water content decreases, muscle mass decreases, body fat increases, and function of several organ systems (e.g., hepatic, renal) decrease. These age-related changes can contribute to differences in drug absorption, distribution, metabolism, and excretion. However, nurses should consider (on an individual basis as much as possible) to what extent these body systems have and will change. For example, glomerular filtration rate (GFR) can decrease with age, and this is considered a normal part of aging [87]. Further, some degree of decreased liver function is expected as hepatic size and blood flow decrease with age. Despite some degree of decreased function, enzyme induction of the CYP450 system can remain relatively unchanged in the older adult; others may experience a decrease of up to 30% of enzyme action [88]. Genetics may play a greater role in aging and in pharmacokinetics and drug metabolism in older adults than is generally appreciated [89]. Although decreases in hepatic and renal function are highly variable from patient to patient, an overall decrease in both hepatic and renal function is expected and should be part of prescribing decisions and drug monitoring in this group.

As a patient ages, they are increasingly likely to accrue medical comorbidities. The NCOA has reported that 80% of adults 65 years of age and older have at least one chronic condition, while 68% have two or more [5]. Medical concerns to be particularly watchful of in older adults include dehydration, hyponatremia, and impaired renal function. Some of the most common medical comorbidities in older patients include hypertension, type 2 diabetes, osteoarthritis, coronary artery disease, and hyperlipidemia—all of which often require at least one medication for control [5].

Despite this extensive side effect profile, first- and second-generation antipsychotics still cautiously have a place in a treatment regimen for older adult patients. A commentary on the Expert Consensus Guidelines for Using Antipsychotic Agents in Older Patients suggests that it is inappropriate to use antipsychotic medications in the older adults with generalized anxiety disorder, panic disorder, insomnia, nonpsychotic major depressive disorder, and severe nausea and vomiting [44]. The 2016 APA guidelines recommend that use of non-emergency antipsychotic agents for treatment of dementia-related psychosis should be limited to those patients with severe or dangerous symptoms or symptoms that cause significant distress to the patient (or care partner) after objective discussions about the risks and benefits. Second-generation antipsychotics (e.g., brexpiprazole, pimavanserin) are often considered for short-duration off-label use under close monitoring when absolutely necessary [45]. Antipsychotic medications can be used with caution in the older adult with schizophrenia and bipolar disorder.

The Beers criteria identify antidepressants with strong anticholinergic activity, alone or in combination, as drugs to avoid in older adults, as these medications are sedating and may cause orthostatic hypotension. Specifically, antidepressants to avoid include amitriptyline, amoxapine, clomipramine, desipramine, doxepin (>6 mg/day), imipramine, nortriptyline, and paroxetine. The effects of these agents predispose older adults to falls and related injury [31]. Paroxetine affects both anticholinergic and antihistamine receptors, leading to more sedation compared to other SSRIs [47]. It is worth noting that doxepin in doses of 6 mg or less has a safety profile similar to placebo.

Patients with behavioral and psychological symptoms of dementia are at heightened risk for psychiatric medication-related risks and side effects associated with the antipsychotic medications. The American Psychiatric Association (APA) guidelines suggest deprescribing antipsychotic medications to older patients with dementia after three months [50]. There is a lack of consensus of the dosing recommendations for older adults with dementia, and higher antipsychotic dosages have been associated with worse discontinuation syndromes among these patients [51]. The APA recommend limiting doses to maximums of 50 mg of quetiapine, 1.75 mg of olanzapine, and 0.5 mg of risperidone in those with dementia [51].

Reminiscence therapy is a treatment that places focus on reflections on life and the aging process and makes use of the patient's remote memory [12,64]. Simple, or unstructured, reminiscence therapy focuses on the telling of life events with focus on the positive to enhance well-being. Unstructured reminiscence therapy can be done in a group format and does not have to be provided by a psychotherapist. Conversely, structured reminiscence therapy involves moving through the life events in an organized way and reframing thoughts about the events in a positive light [12].

Phototherapy, also known as bright-light therapy, is a nonpharmacologic intervention most notably used in the treatment of seasonal affective disorder. With this approach, the patient follows the daily habit of sitting in front of a 1,500–10,000 lux lightbox each morning before sunrise [21]. One study explored the use of phototherapy in the treatment of mild-to-severe dementia. The researchers found that the phototherapy was more effective in managing the behaviors associated with severe dementia than mild-to-moderate dementia, but overall, the phototherapy was no more effective than placebo [66]. Another study focused on the treatment of sleep-related problems and the potential role of phototherapy, finding the approach effective for improving the sleep of healthy older people [67]. Another study noted the documented efficacy of phototherapy for seasonal affective disorder and bipolar depression, but studies including and/or focusing on older adults are limited.

One study sought to compare measures related to fall risk (e.g., strength, fear of falls, balance, functional mobility) in a group receiving a tai chi course and a group who did not (i.e., control group) [68]. This study found that the tai chi group improved in all measures, while the control group did not. The improvements in strength and ability to perform functional tasks can serve as a potential fall prevention intervention [68]. This supports the use of community-based tai chi programs in improving fall-risk measures in older adults. There is evidence that tai chi is effective in decreasing symptoms of depression and anxiety, managing stress, and ensuring exercise self-efficacy [10,70].

Elder abuse is a significant issue in the United States, but it is often under-reported; nurses play a crucial role in the identification and reporting of this abuse. An estimated 10% of older adults living at home have experienced elder abuse, including exploitation and neglect [77]. Having knowledge about the different types of elder abuse can assist nurses and other healthcare providers in recognizing signs and symptoms. Their vigilance and action are essential in addressing this problem and ensuring the safety and well-being of older adults.

Another study revealed a high prevalence of elder abuse within institutions [80]. The most reported types of institutional elder abuse were psychological/emotional (33%), followed by physical (14.1%), financial (13.8%), neglect (11.6%), and sexual (1.9%) abuse [80].

International migration, childbearing patterns, and mortality trends have a significant impact on the cultural diversity of the United States [83]. It is the responsibility of all healthcare providers to deliver culturally competent care that takes the patient's own self and culture into consideration; this has been shown to reduce healthcare disparities and improve health outcomes [83]. The U.S. population is becoming increasingly diverse, with notable increases projected in African American, Asian, Pacific Islander, and Native American populations by 2050 [83]. These demographic shifts necessitate an increased ability for nurses and all healthcare providers to provide culturally competent care. It is crucial, however, for nurses to engage in personal reflection and confront their own potential implicit and explicit biases. Implicit bias is defined as attitudes toward a specific social group of which one is not consciously aware and that could negatively influence care. Acknowledging and addressing areas of possible implicit bias are important steps to truly providing culturally competent care.

One key element of culturally competent care includes using professional interpreters instead of relying on family or friends ("ad-hoc" interpreters) for interpretation when caring for a patient with limited English proficiency [84]. When working with an interpreter, it is important for the provider and the interpreter to face the patient directly, with nurse addressing the patient directly rather than focusing on the interpreter.