**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 1 of 5 residents reviewed for unnecessary medications. (Resident #5) The facility failed to ensure Resident #5 had behavior monitoring for with the use of anti-psychotic medications. These failures could place residents at risk for receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: Record review of a face sheet dated 2/21/2024 indicated Resident #5 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's disease (memory loss disease), high blood pressure, and diabetes. Record review of a progress note dated 7/04/2023 reviewed from the electronic record from the facility indicated this was provided from the local behavior health hospital indicated Resident #5 was struggling with her lability (rapid, often exaggerated changes in mood) with frequent episodes of yelling and tearfulness. The progress note indicated the physician adjusted her medications to control her symptomology but continues to struggle with hallucinations requiring frequent redirection. Record review of discharge orders from the local behavioral health hospital indicated Resident #5 was planned for readmission to the facility on 7/06/2023 with the discharge medications of acetaminophen-codeine (pain medication) 300 milligrams 1 tablet twice daily started on 6/15/2023, clozapine (anti-psychotic) 125 milligrams nightly started on 7/03/2023, divalproex EC (anti-seizure) 500 milligrams three times daily started on 7/03/2023, Aricept (dementia treatment) 5 milligrams nightly started on 6/21/2023, melatonin (herbal sleep aide) 6 milligrams nightly started on 6/23/2023. Record review of a physician's order dated 7/10/2023 at 4:40 p.m., Resident #5 was ordered Lorazepam 1 milligram twice daily for Preventative by her physician. Record review of an admission MDS dated [DATE] indicated Resident #5 was rarely understood, and rarely understands. The MDS indicated Resident #5 had a long-term and short-term memory problem. The MDS indicated Resident #5 was moderately impaired in decision making tasks, had changes in mental status indicating delirium. The MDS indicated Resident #5 had inattention, and disorganized thinking that was continuously present. The MDS did not have any results entered for Resident #5's BIMS score. The MDS indicated Resident #5 required extensive assistance with two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS indicated Resident #5 required extensive assistance on one staff with walking in her room, locomotion on the unit and off the unit, and eating. The MDS indicated Resident #5 required total assistance of two staff for bathing. The MDS indicated Resident #5 was always incontinent of bowel and bladder. The MDS Section I had no psychiatric/mood disorders coded for Resident #5. The MDS Section J indicated Resident #5 had a fall in the last month and had a fall since admission. The MDS in Section J1900 indicated Resident #5 had two falls with no injury, and 1 fall with injury except a major injury, and no falls with major injury. The MDS in section N Medications indicated Resident #5 had received antipsychotic medications during the last 7 days of the assessment period, had 6 days of anti-anxiety medications used over the last 7 days, and she received an anti-depressant 1 day out of the 7 days. The MDS indicated Resident #5 received anti-psychotic medications routinely since admission. The MDS indicated in Section O the physician had made no examinations but there were 5 physician order changes over the last 14 days. Record review of the consolidated physician orders dated 6/01/2023 - 8/31/2023 indicated Resident #5 was ordered Aricept (dementia medication) 10 milligrams one tablet one time a day on 7/17/2023 and started on 7/18/2023, Aricept 5 milligrams one tablet daily on 7/17/2023 and started on 7/18/2023, Ativan (Anti-anxiety) 1 milligram three times a day ordered on 7/13/2023 and started on 7/13/2023, Ativan 1 milligram one tablet two times a day ordered on 7/10/2023 and started on 7/11/2024, benztropine (Cogentin) mesylate 1 milligram one tablet at bedtime ordered on 7/28/2023 and started on 7/28/2023, Celexa (anti-depressant) 10 milligrams one tablet daily for anxiety and depression ordered on and started on 7/06/2023; Clozaril (Anti-psychotic) 100 milligrams one tablet by mouth at bedtime ordered on and started on 7/06/2023; Cogentin (anti-Parkinson's medication)1 milligram one time a day ordered on 7/13/2023 and started on 7/14/2023, Depakote (anti-convulsant medication) delayed release 500 milligrams three times a day ordered and started on 7/06/2023, Gabapentin (anti-seizure medication)100 milligrams give 2 capsules three times daily ordered on 7/06/2023, started on 7/11/2023 and ended on 7/13/2023; Gabapentin 100 milligrams one capsule three times a day ordered on 7/06/2023, started on 7/07/2023 and stopped on 7/10/2023, Gabapentin 300 milligrams daily ordered on 7/06/2023 and started on 7/07/2023, Gabapentin 300 milligrams one capsule three times a day ordered and started on 7/08/2023; Haldol injection (anti-psychotic) 5mg/ml inject 1 ml intramuscularly one time for restless, aggressive ordered on, started on, and ended on 7/14/2023, Lorazepam (Anti-anxiety) concentrate 2 milligrams/milliliter give 1 milliliter every 4 hours as needed for agitation ordered and started on 7/08/2023, Lorazepam tablets 0.5 milligrams one tablet every 4 hours as needed for restlessness or agitation ordered on and started on 7/08/2023; Lorazepam 1 milligram tablet every 4 hours as needed for anxiety and agitation ordered on and started on 7/17/2024, Lorazepam 1 milligram every 6 hours as needed for anxiety and agitation ordered on and started on 7/27/2023, Lorazepam 1 milligram every 6 hours as needed for anxiety for 14 days ordered on and started on 8/15/2023 and ended on 8/29/2023, Seroquel (anti-psychotic) 100 milligrams twice daily for dementia/delirium ordered on and started on 7/08/2023, Seroquel 100 milligrams, twice daily for insomnia ordered on and started on 7/13/2023, Seroquel 50 milligrams one time only ordered on, started on and ended on 8/09/2023, Seroquel 50 milligrams twice daily for insomnia ordered on and started on 7/13/2023; Zyprexa (anti-psychotic) 2.5 milligrams as needed for agitation for 14 days ordered on, started on 8/28/2023 and stopped on 9/11/2023, and Zyprexa 5 milligrams by mouth at bedtime ordered on and started on 8/28/2023. Record review of the comprehensive care plan dated 7/20/2023 indicated Resident #5 used anti-depressant medications related to the diagnosis of depression. The goal of Resident #5's care plan was she should be free from discomfort or adverse reactions related to the use of anti-depressant therapy. The interventions for Resident #5 included administer the anti-depressant as ordered, educate the family on the risks, monitor, and report adverse reactions. The comprehensive care plan indicated Resident #5 used as needed anti-anxiety medications related to agitation from end stage dementia. The goal of Resident #5's care plan indicated she would be free from discomfort or adverse reactions related to anti-anxiety therapy. The interventions for Resident #5 included the administration of the anti-anxiety medications as ordered, monitor the resident for safety due to Resident #5 was at an increased risk of confusion, amnesia, loss of balance, increased falls, broken hips, and legs. Record review of the fall care plan indicated Resident #5 was at risk for falls related to poor balance, decreased safety awareness. The goal of Resident #5's fall care plan indicated she would be free from preventable injury from preventable falls. Resident #5's interventions failed to reflect any new interventions or a review during the time period of 7/09/2023, 7/10/2023 when she had multiple falls when she sustained substantial facial bruising, and on 9/13/2023 when she sustained a skin tear. Record review of an Unwitnessed Fall Report indicated on 7/09/2023 at 5:22 p.m., Resident #5 had a fall and was sitting on her buttocks in front of the glass doorway entrance. The incident report indicated Resident #5 was alert and crying. The report indicated there were no environmental factors, predisposing factors included confused, incontinence, gait imbalance, and impaired memory. The fall report indicated Resident #5's nurse practitioner was notified. Record review of a Witnessed Fall Report indicated on 7/10/2023 at 5:23 p.m., Resident #5 was sitting in the blue chair, staff was standing nearby, Resident #5 leaned over forward in chair and rolled out of chair on to the floor. The report indicated Resident #5 had not hit her head and had no injuries. The report indicated there were no environmental factors, predisposing physiological factors included confused, impaired memory, recent change in cognition, and weakness. Record review of a Witness Fall Report indicated on 7/10/2023 at 11:21 p.m., Resident #5 had fallen forward out of the chair in the lobby, after she had been sleeping in the chair and wrapped in a blanket because she would not stay in bed in the room. No injuries were noted other than Resident #5 had small swelling to right forehead. The report indicated no environmental factors noted, predisposing physiological factors included confused, drowsy, incontinent, recent changes in medications, and gait imbalance. The fall report indicated Resident #5 had recently readmitted from the behavioral hospital, admitted to hospice care, declined, and was a high risk for falls. Record review of a physician's visit note dated 7/12/2023 and signed by the nurse practitioner and physician as of 7/30/2023 indicated Resident #5 was seen for a routine monthly visit. The note indicated Resident #5 had bruise over her right eye being status post a fall. The note indicated Resident #5 was in a wheelchair but just sitting here with her head down and she did not communicate with us. The physician's note indicated Resident #5's medications were reconciled and included Lorazepam 0.5 milligrams one tablet by mouth three times daily as needed, and Seroquel 150 milligrams nightly. The physician's visit note indicated Resident #5 received the Lorazepam and Seroquel for anxiety disorder. Record review of a weekly skin assessment dated [DATE] indicated Resident #5 had bruising on her face. Record review of Resident #5's MAR dated July 2023 indicated on July 22, 2023, at 1:18 p.m., Resident #5 was administered Lorazepam 1 milligram tablet. The MAR failed to indicate behaviors demonstrated for the use of this medication for Resident #5. Record review of Resident #5's MAR dated July 2023 indicated she received: Aricept 5 milligrams 1 tablet by mouth daily started on 7/18/2023 noted administered remainder of the month. Cogentin (Benztropine mesylate) 1 milligram by mouth daily started on 7/14/2023 and discontinued on 7/28/2023. Benztropine Mesylate 1 milligram by mouth at bedtime was started on 7/28/2023 and administered the remainder of the month and discontinued on 8/10/2023. Celexa 10 milligrams one tablet daily was administered starting on 7/18/2023 through the remainder of the month. Gabapentin 300 milligrams one capsule by mouth daily was ordered on 7/07/2023 and discontinued on 7/08/2023. Seroquel 100 milligrams once every evening for dementia with behaviors was ordered on 4/11/2023 and discontinued on 7/06/2023. The MAR had no behavior monitoring for the use of this medication. Seroquel 50 milligrams 1 tablet daily started on 7/06/2023 and stopped on 7/08/2023. The MAR had not behavior monitoring for the use of this medication. Ativan (Lorazepam) 1 milligram twice daily for preventative was ordered on 7/11/2023 and administer each day then discontinued on 7/13/2023. The MAR had no behavior monitoring for the use of this medication. Gabapentin 300 milligrams 1 capsule twice daily for dementia was ordered on 7/06/2023, administered once and then discontinued. The MAR had no behavior monitoring for the use of this medication. Seroquel 100 milligrams ordered twice daily starting and administered 7/08/2023 and ended on 7/13/2023. The MAR had no behavioral monitoring for this medication use. Seroquel 100 milligrams ordered twice daily started on 7/13/2023 and administered as ordered until 8/28/2023. The MAR had no behavior monitoring for this medication use. Seroquel 50 milligrams ordered twice daily starting 7/13/2023 and administer until 7/17/2023. The MAR had no behavior monitoring for this medication use. Ativan 1 milligram tablet by mouth three times daily started on 7/13/2023 and stopped on 7/17/2023. The MAR had no behavior monitoring for this medication use. Depakote 500 milligrams one tablet three times daily for preventative ordered on 7/06/2023 one dose administered then discontinued on 7/06/2023. The MAR had no behavior monitoring for this medication use. Gabapentin 100 milligrams three times daily ordered on 7/07/2023 and to stop of 7/10/2023. Resident #5 received 3 doses of this medication before discontinued on 7/08/2023. Gabapentin 300 milligrams 1 capsule three times daily started on 7/08/2023 for preventative and continued administration until discontinued on 8/09/2023. The MAR had no behavior monitoring for this medication. Haldol Injection 5 milligrams/milliliter inject 1 milliliter one time only for restlessness, aggression dated 7/14/2023. The MAR had no behavior monitoring entry for this medication. Lorazepam 2 milligrams give 1 milligram every 4 hours as needed was ordered on 7/08/2023 administer on 7/14/2023, 7/17/2023, 7/18/2023, 7/23/2023, and 7/27/2023 and discontinued on 7/27/2023. The MAR had no behavior monitoring entry for this medication. Record review of a Witnessed Fall Report dated 8/07/2023 at 10:15 a.m., Resident #5 was being showered by the hospice aide when Resident #5 began to slide down. The report indicated Resident #5 did not fall but was assisted down to her knees. The report indicated the hospice staff failed to notify the nurse on the same day of the occurrence. The report indicated there were no injuries. Record review of a physician's visit note dated 8/08/2023 and signed on 8/23/2023 at 9:46 p.m., the Nurse Practitioner and the physician indicated Resident #5 was seen on this day and was asleep in a chair. The note indicated the staff voiced her spouse was very unrealistic about her outcome and has threatened to take her home. The note indicated the physician had spoken to the spouse and indicated home would have not been the best situation for Resident #5. The note indicated Resident #5's medication regimen included gabapentin 300 milligrams by mouth two times daily, Lorazepam 0.5 milligrams three times daily as needed, Seroquel 150 milligrams by mouth daily at bedtime. The plan of the note indicted the physician and nurse practitioner was treating Resident #5's anxiety with lorazepam and Seroquel. Record review of an Un-witnessed fall report dated 8/13/2023 at 6:06 p.m., the report indicated Resident #5 was sitting on the floor. The report indicated Resident #5 had gotten out of her bed, safety mat beside the bed, and scooted on buttocks to the door entry. The report indicated Resident #5 was alert and confused. The note indicated Resident #5 was transferred in her specialty chair with her legs elevated and taken to the lobby to be observed. The report indicated Resident #5 was confused, incontinent, had impaired balance, and impaired memory. The report indicated Resident #5 was clean, dry, room was well lit, and the floor was clean and dry. Record review of an un-witnessed fall report dated 8/21/2023 at 7:10 p.m. indicated Resident #5 was found sitting on her buttocks in another resident's room, alert, no complaints of pain or discomfort. The mental status on the report indicted Resident #5 was confused, aggressive at times, continued to walk fast and unsteady gait, and tries to get out of the Broda chair (reclining chair) at times. The report indicated there was predisposing factors of noise. The predisposing physiological factors included confusion, incontinence, gait imbalance, and impaired memory. The report indicated the situation factors were Resident #5 was an exit seeker, had improper footwear, and ambulated without assistance. The other information on the report indicted Resident #5 had no safety awareness and was not wearing her safety socks. Record review of an Un-witnessed fall report dated 9/02/2023 at 5:03 p.m. indicated Resident #5 was found on the floor in the hallway near the exit door. Resident #5 was noted to be lying predominantly on her right side. The report indicated the predisposing physiological factors included confused, incontinent, gait imbalance, and impaired memory. Record review of an un-witnessed fall dated 9/03/2023 at 5:54 p.m., indicated Resident #5 was in another resident's room and was found sitting on her buttocks in an upright position. The report indicated the predisposing physiological factors included Resident #5 was confused, incontinent, gait imbalance, and impaired memory. Record review of a physician's visit note dated 9/05/2023 and signed on 9/17/2023 by the Nurse Practitioner and the physician indicating he agreed with the assessment and plan of care indicated Resident #5 was seen for her advanced dementia disease. The note indicated Resident #5's medications regimen was reconsolidated and included Gabapentin 300 milligrams twice daily, Ativan 0.5 milligrams three times daily as needed, Seroquel 150 milligrams at bedtime. The physician's note indicted Resident #5 was taking the Lorazepam and Seroquel for anxiety disorder. Record review of an Un-witnessed Fall report indicated Resident #5 had a fall on 9/07/2023 at 10:14 a.m. The note indicated Resident #5 was found sitting on her buttocks between two chairs with dining table behind her. The report indicated Resident #5 had the physiological factors of confused, incontinent, gait imbalance, and impaired memory. The report indicated Resident #5 possibly missed the dining room chair and sat on the floor on her buttocks. Record review of a Witnessed Fall Report indicated on 9/08/2023 at 11:15 a.m., Resident #5 had a fall. The report indicated Resident #5 was walking in another resident room with her eyes closed, she bumped her forehead on the door facing of the bathroom, and then she turned and slid down the wall to the floor. The report indicated there was no injuries noted. The predisposing physiological factors included incontinent, impaired memory, and weakness. Record review of an Un-witnessed fall report indicated on 9/08/2023 at 11:38 p.m., Resident #5 had slid off the chair in the lobby. The report indicted Resident #5 was lying on the left side with her head up, on the floor next to low chair in lobby. The report indicated Resident #5 was alert, and confused speech, denied pain at the time. The report indicated the physiological factors were confused, drowsy, incontinent, gait imbalance, and impaired memory. The section other information indicated Resident #5 had been aggressive, cussing at the staff, refused to stay in her broad chair to relax. Record review of an Unwitnessed Fall report dated 9/13/2023 at 5:31 p.m., Resident #5 was heard falling. Resident #5 was found on her buttocks in front of a chair. The report indicated Resident #5 had a skin tear to left arm. The report indicated Resident #5 had predisposing physiological factors of confused, and impaired memory. Record review of a progress note dated 9/13/2023 at 5:37 p.m., LVN E indicated Resident #5 had a fall and was found sitting on her bottom in front of the chair. Record review of a progress note dated 9/13/2023 at 5:23 p.m., LVN E documented Resident #5 had a bruise to her right hand and forehead. Record review of a progress note dated 9/14/2023 at 5:16 p.m., Resident #5 was ordered Depakote sodium 250 milligrams one tablet twice daily for behaviors. Record review of a progress note dated 9/14/2023 at 5:43 p.m., LVN F documented Resident #5 was ordered by the hospice nurse Depakote 250 milligrams twice daily for behaviors, Mobic 15 milligrams daily for pain, and one dose of Morphine sulfate 0.25 milliliters. The note indicated Resident #5 was sitting in the day areas in a wheelchair at this time. Record review of a progress note dated 9/16/2023 at 12:12 a.m., LVN G documented Resident #5 was gotten out of bed and put into the lobby area in a chair due to multiple attempts of trying to get out of bed by herself, resident is a high fall risk and recently recovered from one. LVN G documented Resident #5 was swaying back and forth moaning, unlabored breathing with signs and symptoms of distress mentally. LVN G documented the as needed orders for anxiety and pain followed. Record review of a progress note dated 9/19/2023 at 4:30 a.m., LVN H documented Resident #5 had been resting quietly all night, during rounds this morning Resident #5 had noted audible gurgling, repositioned in high fowlers with her head up and suctioned Resident #5 three times with approximately 30 milliliters of clear mucous, oral care was given, lungs had bilateral wheezing. LVN H indicated she would notify Resident #5's hospice provider. Record review of a progress note dated 9/19/2023 at 5:59 a.m., LVN H documented she notified Resident #5's hospice provider reporting the gurgling and bilateral wheezing. LVN H documented she reported suctioning Resident #5 with some improvement. LVN H documented hospice would make a visit and check Resident #5. Record review of a progress note dated 9/20/2023 at 6:15 a.m., LVN K documented she notified the family Resident #5 was not breathing, she documented Resident #5 had no pulse, and hospice was notified to come and assess Resident #5. During an interview and record review on 2/13/2024 at 8:15 a.m., Resident #5's family members had voiced concern over the bruising Resident #5 sustained during falls on 7/10/2023. The family members reported they were not notified of the falls and was alarmed when they arrived at the facility for a visit on 7/12/2023. The family member provided picture dated from 7/12/2023 documentation of Resident #5 sitting in the dining area with dark purple bruising to both of her eye lids and the brow on both sides. The pictures include the right eye was a very deep purple color and the entire right forehead had varying colors of purple throughout the bruised area. A review of the pictures provided dated July 14, 2023, indicated Resident #5 had deep purple bruising on the right side of her face extending down below the eye, the left eye lid remained a deep purple color. Resident #5's forehead had various colors of purple and yellow colors. During an interview on 2/14/2024 at 10:02 a.m., LVN L said she had administered Resident #5 the newly ordered Ativan 1 milligram prior to her falls on 7/10/2023 at 5:23 p.m. and 11:21 p.m. LVN L said the Ativan should have indications for use where this medication said preventative. LVN L said the anti-anxiety medications should be used after non-pharmacological interventions were tried. LVN L said before the nurses administers an as needed medication the resident should be offered food, sweets, and incontinent care. LVN L said she should have documented those interventions prior to the administration. During an interview on 2/14/2024 at 10:37 a.m., the DON said she was not the DON when Resident #5 was residing in the facility but indicated Resident #5 was on all kinds of medications that required monitoring and documentation of behaviors. The DON said, this was horrible. The DON said she searched the electronic medical record and could not provide the any evidence Resident #5 was being monitored for behaviors indicating use of these medications. The DON said these medications required monitoring of behaviors and side effects. During an interview on 2/14/2024 at 11:00 a.m., the previous Administrator said she was not aware Resident #5's behaviors were not being monitored. The previous Administrator said behaviors should be monitored for the use of anti-psychotic medications. The Administrator said this was the responsibility of the DON. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048860 accessed on 2/22/2024 indicated: Along with cognitive decline, 90% of patients with dementia experience behavioral and psychological symptoms of dementia, such as psychosis, aggression, agitation, and depression. Atypical antipsychotics are commonly prescribed off-label to manage certain symptoms, despite warnings from the regulatory agencies regarding the increased risk of mortality associated with their use in elderly patients. Moreover, these compounds display a limited clinical efficacy, mostly owing to the fact that they were developed to treat schizophrenia, a disease characterized by neurobiological deficits. Thus, to improve clinical efficacy, it has been suggested that patients with dementia should be treated with exclusively designed and developed drugs that interact with pharmacologically relevant targets. Within this context, numerous studies have suggested druggable targets that might achieve therapeutically acceptable pharmacological profiles. Based on this, several different drug candidates have been proposed that are being investigated in clinical trials for behavioral and psychological symptoms of dementia. We highlight the recent advances toward the development of therapeutic agents for dementia-related psychosis and agitation/aggression and discuss the relationship between the relevant biological targets and their etiology. In addition, we review the compounds that are in the early stage of development (discovery or preclinical phase) and those that are currently being investigated in clinical trials for dementia-related psychosis and agitation/aggression. We also discuss the mechanism of action of these compounds and their pharmacological utility in patients with dementia Currently, a specifically approved pharmacotherapy for BPSD remains elusive. The most troublesome psychiatric events such as aggression and the remaining symptoms psychosis and agitation are addressed with atypical antipsychotics administered off-label [6]. However, the clinical efficacy of these drugs is unsatisfactory because a large percentage of patients do not respond or respond partially to the drugs [7]. Moreover, atypical antipsychotics are not actually recommended for elderly patients because they pose a risk of many side effects [8]. Elderly patients seem to be particularly sensitive to severe adverse reactions induced by atypical antipsychotics such as excessive sedation, orthostatic hypotension and related complications such as falls, extrapyramidal symptoms, cognitive slowing, cardiovascular complications, and anticholinergic side effects [9]. Notably, the use of currently available antipsychotics in patients with dementia has been associated with an increased risk of death. Consequently, in April 2004, the US Food and Drug Administration (FDA) issued a black-box warning against the use of atypical antipsychotics in elderly patients [10, 11]. The American and British clinical guidelines [12-14] state that antipsychotics can be used only if the patient constitutes a threat to self or others and should be administered after evaluating the benefit/risk ratio of the treatment [15]. If the physician decides to prescribe antipsychotics, clinical guidelines recommend the exclusive usage of the following drugs: risperidone, olanzapine, quetiapine, and aripiprazole [12]. Nevertheless, several reviews in this subject emphasized that prior to treatment with antipsychotics, one should always consider that these drugs exert detrimental effects and provide limited efficacy [6, 7, 16]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5840911 accessed on 2/22/2024 indicated: Treatment of geriatric anxiety actually involves more of non-pharmacological approaches which are first recommended rather than pharmacological approaches. The usual non-pharmacological measures advised are: 1. Lifestyle modification: Sleep, diet, exercise, socialization -all in moderation. Eliminate medical and non-medical triggers. Structured daily activities are one of the mainstays of elder care. The premise behind the same being, that activities provide some stimulation and interaction with the environment, give a sense of control and reduce overall anxiety. Apart from managing one's own daily routine, the following are commonly advocated. Physical Exercise: Regular physical exercise, even for just a few minutes daily, improves cerebral blood flow and metabolism. Sedentary individuals who are bound to their beds have a distinct reduction in cerebral blood flow. Exercise need not be strenuous in the form of aerobic exercises or gym-based exercises. A simple walk in the garden or outdoors should suffice, that too at the pace of the individual concerned. If wheelchair bound, then upper body can be exercised with simple stretches, use of a ball and hand exercises. Other forms of physical exercise could include: - Walking in the house if too frail - Swimming or aqua exercises or playing around in a large tub to mobilize the limbs - Physical games like playing ball, carrom, table tennis, etc. Sleep: We are aware that the sleep architecture gets altered with advancing age, hence a shorter night time sleep, phase advancement and more fragmented sleep are all seen in the elder. Hence while teaching about sleep hygiene, it is also important to counsel the elder individual about lowering their expectations about sleep duration. Nutrition: By virtue of decreasing appetite and increasing social isolation, elderly often have compromised nutrition and imbalanced electrolytes. Minor changes in blood levels of sodium, potassium, chloride, vitamin D etc. could give rise to anxiety symptoms. Monitoring through a simple nutrition chart, helps maintain basic parameters, and at times is the only intervention required to manage the anxiety. Behavior Therapy: Relaxation Therapy: Classical Jacobson's technique of progressive muscle relaxation can be taught to the individual with anxiety. This can also be coupled with guided imagery or practiced alone.b) Systemic desensitization: This works particularly for phobias and unspecified fears for eg. fear of falling. Creating a hierarchy and controlling the response helps. Exposure and Response Prevention: For OCD Eye Movement Desensitization and Reprocessing (EMDR): For PTSD. Cognitive Therapy: Cognitive Behavior Therapy: The aim of CBT in older adults is to target cognitive symptoms, physical symptoms as well as behavioral symptoms. First and foremost, psychoeducation is a must -about the anxiety in general and management of the same. Acceptance that the symptoms may not be suggestive of a medical emergency, at the same time being vigilant of associated co-morbidities, becomes a tricky issue to deal with and require a lot of awareness and self-monitoring. The principles of relaxation and hierarchal construction may also be used. The core of CBT, however, remains cognitive restructuring using the ABC model(antecedents-behavior-consequences), wherein cognitive errors and maladaptive behavior are identified and worked upon. The pace may have to be a little slow, as with age new learning takes time, and the template of old learned behaviors is hard to change. Mindfulness: Mindfulness as a therapeutic intervention is finding applicability in a wide range of disorders. Mindfulness is inculca[TRUNCATED]