The patient is a 71-year-old widowed man who is seen regularly in the clinic for health maintenance and follow-up of his chronic insomnia and anxiety. He has regular prescriptions for triazolam (Halcion) and clonazepam (Klonopin) for these problems. Recently he has been reporting frequent episodes of losing his balance and falling, and eight weeks ago was hospitalized for a hip fracture sustained during one of these falls resulting in hip surgery. On this visit, he also complains of becoming increasingly confused.
What information would be most critical for you to collect in the first visit?
What is the primary goal for the treatment of this patient?
Identify potential obstacles for change. Which educational approach would the PMHNP provide to overcome these obstacles?
How would you teach the patient about the Beers list and Halcion?
Discuss a medication in detail that could be safely substituted to treat insomnia in geriatric patients.
Full Answer Section
- Neurological history: This includes a history of any neurological conditions, such as stroke, dementia, and Parkinson's disease.
- Fall history: This includes a history of any previous falls, including the circumstances of the fall, the severity of any injuries, and any medical care that was received.
It is also important to assess the patient's cognitive function, mood, and anxiety levels.
Primary Goal of Treatment
The primary goal of treatment for this patient is to reduce his risk of future falls and improve his overall quality of life. This may involve a combination of medication management, non-pharmacological interventions, and lifestyle changes.
Potential Obstacles for Change
Potential obstacles for change in this patient include:
- Age: Older adults are more likely to experience falls and cognitive impairment.
- Multiple medical conditions: The patient has multiple medical conditions, including insomnia and anxiety, which may increase his risk of falls.
- Polypharmacy: The patient is taking multiple medications, which may increase his risk of side effects, including falls and cognitive impairment.
- Cognitive impairment: The patient is complaining of increasing confusion, which may increase his risk of falls.
- Social isolation: The patient is widowed and may not have adequate social support.
Educational Approach
The PMHNP can provide the patient with education on the following topics:
- Fall prevention: This includes education on the risks of falls, how to reduce fall hazards in the home, and how to exercise safely.
- Medication management: The PMHNP can review the patient's medications with him and make recommendations for changes, if necessary.
- Cognitive impairment: The PMHNP can provide the patient with education on the signs and symptoms of cognitive impairment and how to manage it.
- Social support: The PMHNP can help the patient identify social support resources in his community.
Teaching the Patient about the Beers List and Halcion
The PMHNP can teach the patient about the Beers List and Halcion by explaining the following:
- The Beers List is a list of medications that are considered to be potentially inappropriate for older adults due to the increased risk of side effects and adverse events.
- Halcion is a benzodiazepine medication that is used to treat insomnia. However, it is listed on the Beers List because it is associated with an increased risk of falls and cognitive impairment in older adults.
The PMHNP can also discuss the following with the patient:
- The benefits and risks of continuing to take Halcion.
- Alternative medications that are safer for older adults.
- Non-pharmacological treatments for insomnia, such as relaxation techniques and cognitive-behavioral therapy.
Medication Substitution for Insomnia
A safer medication that could be substituted for Halcion to treat insomnia in geriatric patients is eszopiclone (Lunesta). Eszopiclone is a newer generation benzodiazepine that has a shorter half-life than Halcion, which means that it is less likely to cause daytime sedation and hangover effects. Eszopiclone is also less likely to accumulate in the body over time, which reduces the risk of side effects.
Another option is to use a non-benzodiazepine medication, such as melatonin or ramelteon. Melatonin is a naturally occurring hormone that helps to regulate sleep-wake cycles. Ramelteon is a synthetic melatonin receptor agonist. Both melatonin and ramelteon are considered to be safe and effective treatments for insomnia in older adults.
The PMHNP should work with the patient to develop a treatment plan that is tailored to his individual needs and preferences.