You can't say "they need help", and also say "all oldwalkers are necessarily insane." If the second statement is true, then they can't "be" helped, and all that you can do is put them in a padded cell or a pine box before they can harm anyone else.
I mean, that's the entire point of the Ice Age story? (and Planeswalker) It holds pretty true considering all the oldwalkers we've seen. I can only think of... maybe 3-4 that were pretty normal, but it's exceptionally hard to judge a being with so much power that is literally older than most civilizations. Even if you call them evil, there's not a lot you can do that matters in the face of what they are. They certainly don't recognize that you have any moral authority of them.
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And I think the latter is **** storytelling. First of all, you're prohibiting character development by saying that some aspect of their personalities can never change. Second, if their actions are caused by just being insane rather than being illustrative of some sort of deeper character, then why should we care about their actions?
Because of how they affect those around them, not because of how they affect the walkers themselves. I mean, there's a reason all the best characters were just working in the shadows of those titans. Jhoira, Barrin, Jodah, Xantcha, etc. They all had to deal with the fact that the beings around them were more force of nature than human. (okay, so basically all of those boil down to Urza, but Freyalise, Leshrac, and any number of others ran roughshod over mortals too)
It's made painfully clear Nahiri isn't insane. She kept her mind stable by thinking of Zendikar, and didn't go on outright irrational behaviour. As an oldwalker she wasn't at all deranged or grandiose.
She murdered thousands both because Sorin was a dick, but also because she legitimately thought Innistrad was a wicked place.
She was aware of her actions. She willingly attempted genocide because Innistrad was a place fitting for a monster such as Sorin.
Nahiri went out of her way to cause it.
And that doesn't sound crazy to you?
In the end, she has a very specific vendetta. I can't see her turning up as a villain outside of that purview.