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Hip Fracture
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?
o Comprehensive assessment, OLD CARTs, Psychiatric and psychosocial history- past diagnosis’s, who he lives with
o Fall history
o h/o family dementia or Alzheimer’s
o hydration status, UTI?
o Medication review
o Sleep asst
o Functional and cognitive status with screening tools
o ADL for function- bathing, toileting, eating
• What is the primary goal for the treatment of this patient?
o Safety
Sleep, sedation, ambulating, and ADLS- can these be done?
• 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.
o Melatonin- paired with a consistent slee, wake schedule, reduced day time naps, light therapy
o Evaluate for depression and anxiety that could impact sleep patterns
o Avoid: benzodiazepines, anticholinergics like Benadryl or other antihistamines
o Avoid zolpidem, temazepam, and other like drugs due to sedating factor and reduced kidney clearance in elderly
Sample Answer
This 71-year-old widowed male patient presents a complex clinical picture, highlighting the challenges of managing chronic conditions like insomnia and anxiety in older adults, especially when compounded by polypharmacy and adverse drug events. As an advanced practice registered nurse, particularly a PMHNP, a comprehensive and patient-centered approach is critical.
1. Critical Information to Collect in the First Visit:
In the initial visit, the most critical information to collect would be aimed at rapidly identifying reversible causes of his acute symptoms (confusion, falls) and comprehensively assessing the long-term contributors.
- Comprehensive Clinical Assessment (Focused on New Symptoms):
- Neurological Assessment: Mental status examination (orientation, attention, memory), cranial nerves, motor and sensory function, gait and balance assessment (Romberg test, tandem gait, “Timed Up and Go” test). Assess for signs of stroke or transient ischemic attack (TIA).
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