The main objective of this chapter is to obtain an understanding of the interaction between pain, sedation, and delirium. Specifically, the reader should be able to identify the unique challenges for their management taking into account that the very old are a particularly vulnerable group with often conflicting treatment priorities. This chapter will discuss implications for short- and long-term ICU outcomes including mortality, time on mechanical ventilation, and increased ICU and hospital lengths of stay, as well long-term cognitive impairment. Finally, the reader should be able to formulate a plan for sedation, pain, and delirium management for the very old ICU patient using ABCDEF principles.