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Geriatric Insomnia Management
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.
- Your initial post should be at least 500 words, formatted and cited in current APA style.
- Provide support for your work from at least 2 academic sources less than 5 years old
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Geriatric Insomnia Management
Management of Insomnia and Anxiety in an Elderly Patient: A Case Study Approach
The initial evaluation of a 71-year-old widowed male presenting with chronic insomnia, anxiety, increased confusion, and recurrent falls must begin with a thorough assessment. Critical information to collect includes a comprehensive medication review, including over-the-counter (OTC) and herbal supplements, dosage frequency, and adherence patterns. It is also vital to assess the patient’s cognitive status using tools like the Mini-Mental State Examination (MMSE), evaluate for signs of delirium or dementia, and screen for depressive symptoms. A fall risk assessment, gait analysis, orthostatic vital signs, and review of any recent imaging (e.g., post-hip surgery) are also essential. Given the patient’s age and complaints, reviewing liver and renal function is necessary, as impaired metabolism may increase drug toxicity (Boyle et al., 2021).
The primary goal of treatment is to minimize fall risk, improve cognitive function, and manage insomnia and anxiety using safer alternatives. This includes tapering and discontinuing high-risk medications such as triazolam and clonazepam, which are associated with significant central nervous system (CNS) depression, sedation, confusion, and increased fall risk in older adults (American Geriatrics Society [AGS], 2019). Another objective is to introduce behavioral and pharmacologic strategies that prioritize patient safety and cognitive preservation.
Obstacles to change in this case may include the patient’s psychological dependency on benzodiazepines, fear of insomnia recurrence, and possible withdrawal symptoms. Additionally, elderly patients often express mistrust in medication changes, especially when previous prescriptions seemed effective. The PMHNP should use motivational interviewing and shared decision-making to navigate these concerns. Providing psychoeducation on the risks associated with long-term benzodiazepine use—especially in older adults—is essential. Offering non-pharmacological interventions such as Cognitive Behavioral Therapy for Insomnia (CBT-I), relaxation techniques, and sleep hygiene education can also empower the patient and reduce resistance to change (Wang et al., 2022).
To educate the patient about the Beers Criteria, which lists medications potentially inappropriate for older adults, the PMHNP should explain that Halcion (triazolam) and clonazepam are included due to their long half-lives, high potential for confusion, dependence, and falls. The clinician can use simple language and visual aids or handouts to describe how the brain processes these medications differently with age, leading to a greater risk of adverse events. This discussion should be framed around the patient’s goals for maintaining independence and safety at home.
One safer pharmacologic alternative for insomnia in geriatric patients is ramelteon, a melatonin receptor agonist. Unlike benzodiazepines, ramelteon does not cause dependence, cognitive impairment, or significant sedation, making it suitable for elderly populations (Zhou et al., 2021). It mimics the body’s natural melatonin to help regulate the sleep-wake cycle, particularly useful in patients with difficulty initiating sleep. The typical dose is 8 mg taken 30 minutes before bedtime, and it has a favorable side effect profile. When combined with CBT-I, it offers a comprehensive and low-risk treatment plan.
In summary, managing insomnia and anxiety in geriatric patients requires a patient-centered, safety-focused approach. By discontinuing high-risk medications, addressing fears and barriers to change through education, and introducing safer alternatives, the PMHNP can significantly enhance the patient’s quality of life and reduce fall risk.
References
American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. https://doi.org/10.1111/jgs.15767
Boyle, L. L., Seaman, C., & Hill, K. (2021). Benzodiazepines and Z-drugs in older adults: A review of risks and benefits. Drugs & Aging, 38(9), 735–747. https://doi.org/10.1007/s40266-021-00884-4
Wang, Y., Gooneratne, N., & Troxel, W. M. (2022). Behavioral and pharmacologic treatments for insomnia in older adults. Journal of Clinical Sleep Medicine, 18(4), 1205–1213. https://doi.org/10.5664/jcsm.9850
Zhou, E. S., Gardiner, P., Bertisch, S. M., & Legedza, A. T. R. (2021). Non-benzodiazepine pharmacologic treatment for insomnia in older adults: A review. The Permanente Journal, 25, 1–7. https://doi.org/10.7812/TPP/20.090