NUR 650

NUR 650

 

Peer 1. Joshua Perez

 

Hip Fracture

This 71-year-old widower's anxiety and persistent insomnia are being treated with clonazepam (Klonopin) and triazolam (Halcion). In addition, he recently had a hip injury and is experiencing increasing disorientation. The most crucial thing to gather on the first visit is a complete medication history, including dosage, frequency, length of usage, and whether he takes any over-the-counter medications, alcohol, or other sedatives. It would also be critical to evaluate how drug use or dose changes relate to the start of disorientation and falls. A thorough cognitive assessment is required to determine his level of concentration, memory, and orientation. A fall risk evaluation must also include questions regarding blood pressure, mobility, home safety, dizziness, and changes in vision. Information on his sleep patterns, anxiety triggers, mood symptoms, and day-to-day functioning would need to be gathered in order to assess if his current medications are still appropriate. Given that he is a widower, it is especially important to assess his social support system because loneliness can make anxiety and insomnia worse. The primary goal of the patient's treatment is to effectively manage his anxiety and insomnia while enhancing his safety and cognitive capacities. Preventing more falls and injuries is critical, especially after a hip fracture. Benzodiazepines, such as clonazepam and triazolam, have been demonstrated to increase the risk of sleepiness, falls, disorientation, and memory loss in older adults.

A higher risk of 6-month death was linked to the prescription of benzodiazepines at the time of hospital discharge; however, deprescription may reduce this excess risk (Bellelli et al., 2026). Consequently, a major focus of treatment would be to offer safer substitutes while appropriately decreasing off these drugs. There could

be several obstacles to change. The patient may be concerned that stopping his medication may exacerbate his anxiety or sleeplessness. He may also feel dependent on these drugs because he has been using them for a long time. Additionally, rebound anxiety or insomnia brought on by benzodiazepine withdrawal might make tapering challenging. When these drug classes' inhibitory effects are abruptly stopped, the central nervous system experiences an overall excitatory reaction (Regina et al., 2024). To overcome these challenges, the PMHNP should use an educational and patient-centered approach. Motivational interviewing would be helpful to look into his concerns and build trust. Because of his misconception, instruction should be clear-cut, simple, and repeated as needed. Including family members or caregivers in the discussion can improve understanding and promote plan adherence, if at all possible. Teaching the patient about the Beers Criteria is essential. The Beers Criteria, a list of medications that may be harmful or unsuitable for elderly people, was developed by the American Geriatrics Society. To put it simply, older bodies have a harder difficulty absorbing certain medications, and they can cause side effects including confusion and falls.

Halcion is on this list because it can stay in the body longer in elderly people and increase their risk of fractures, vertigo, and memory problems. A safer medication option for older persons with insomnia is low-dose doxepin. At very low doses, doxepin has modest anticholinergic effects and mainly supports sleep maintenance by acting on histamine receptors. Compared to benzodiazepines, it is not associated with the same level of cognitive impairment and fall risk. Another option is melatonin, which can help regulate the sleep-wake cycle and has fewer side effects. In addition to medication modifications, cognitive behavioral therapy which is considered a first-line treatment for insomnia and is safe for older adults, should be recommended. In general, the primary goals of care should be safety, education, supportive follow-up, and a gradual drug transition. By addressing the risks associated with benzodiazepines and providing safer alternatives, the patient's risk of falls and confusion can be reduced while still safely managing his anxiety and insomnia.

Peer 2. Sergio Pereira

Hip Fracture

In older adults, hip fractures are often a sign of a cocktail of medication, risk, cognitive impairment, and frailty that needs urgent medical care. The case of a 71-year-old divorced man with a history of insomnia, anxiety, falls, and confusion is a multifaceted presentation related to benzodiazepines. Benzodiazepines are known to increase the fall risk in older adults (Na et al. 2022). In addition, confusion post-fall may be a sign of delirium, which is a sign of frailty in older people, and as a result, an approach that is medical and psychiatric is crucial.

Critical Assessment

The initial consultation should focus on collecting information to guide diagnosis and safety strategies. Information about the medication history, dose, and adherence to triazolam and clonazepam is important, as inappropriate prescribing is common in older people (Bidarolli et al. 2026). Cognitive screening is also important to identify the presence of delirium or dementia, as acute confusion may be due to stress response (Bellelli et al. 2021). Balance and falls history will cover physical factors. Collateral information from family and/or carers may improve symptom and disability reporting.

Treatment Goals

The goal of treatment is to reduce falls, preserve cognitive function, and treat insomnia. It is important to wean benzodiazepines, as these cause ataxia and falls in the elderly (Na et al., 2022). Intervention for possible delirium is also crucial, as it is associated with worse outcomes and increased death. Non-pharmacological strategies for sleep should be emphasized, such as sleep hygiene. Drug therapies can be introduced with a change in cognition or function assessed.

Barriers and Education

There are many barriers to treatment, such as benzodiazepine addiction and the fear of worsening insomnia. Dementia may reduce the patient's understanding of risk and the ability to follow through on new instructions (Sharma et al. 2025). Social supports may also impact change. The PMHNP should educate simply by repeating instructions with motivational interviewing strategies. Linking medication use to the fall will increase insight and motivation. Involving the caregiver and providing written instructions will enhance education and medication compliance when adjustments are made.

Beers Criteria Education

Beers Criteria education should include the fact that some medications are high risk in the elderly due to side effects. Triazolam is listed because of its potent hypnotic effect and risk for confusion and falling (Bidarolli et al. 2026). The PMHNP should point out that these are significant and the reason for the falls. Short statements and images will help the patient to better understand. Encouraging the patient to ask questions and the teach-back method will confirm that the patient understands the need to change medication and is empowered to do so.

Medication Alternative

An alternative medication to treat insomnia in the elderly is low- dose melatonin, which allows normal sleeping patterns without too much sedation and confusion (Sharma et al. 2025). It is less likely to cause falls than benzodiazepines, which may cause dizziness and falls (Na et al. 2022). The drug should be used with care in persons with cognitive impairment to avoid worsening confusion (Sharma et al. 2025). Melatonin could be combined with behavioral approaches, and regular follow-up will maximize effectiveness, enhance safety, and allow an effective shift to the new medication.

NUR 650-CL

Peer 1. Jessica Bruceta

Module 7 Discussion

The group observed was the Alcoholics Anonymous Sabal Palm Group, attended on April 27, 2026, through a Zoom meeting based in the Kendall area of Miami, Florida. I chose this specific meeting because it was accessible virtually, local to Miami-Dade County, and offered an opportunity to observe peer recovery support in a familiar community setting. Alcoholics Anonymous has been helping individuals with alcohol-related problems for more than 80 years and describes its model as one alcoholic helping another, with recovery supported through shared lived experience and mutual support. Entrance into the group appeared simple and low-barrier: individuals needed only a desire to address alcohol use or maintain sobriety; no payment, referral, diagnosis, insurance, or formal intake was required. The group demographics appeared mixed, with approximately 15–20 members, including adults ranging from young adulthood to older adulthood, both men and women, and a racially and ethnically diverse membership reflective of the Kendall/Miami community. The organization’s goal was to provide a safe, confidential, supportive space where members could discuss recovery, maintain abstinence, reduce isolation, and receive encouragement from others with lived experience. Objectively, the group appeared effective in meeting client needs because it offered structure, emotional support, accountability, and immediate access, which are important because mutual-help groups remain an integral and free recovery resource within the U.S. substance use treatment system (Hai et al., 2022). Two therapeutic factors observed were universality and instillation of hope. Universality was evident when members shared similar struggles with cravings, relapse fears, shame, and rebuilding relationships, helping others feel less alone. Instillation of hope was present when members with longer sobriety encouraged newer

participants by sharing realistic examples of recovery progress. The group process was effective because the leadership style was calm, peer- led, respectful, and structured, with clear norms around confidentiality, taking turns, and avoiding judgment. No major patient management issues were observed; when one participant became emotional, the group responded supportively without interrupting or trying to “fix” the person. I felt the group was welcoming, humble, and surprisingly powerful in its simplicity. It enriched my understanding of recovery by showing that peer connection can sometimes reach people in ways formal treatment cannot. I would refer future clients to this group as an adjunct to clinical care, especially because online recovery meetings may improve access and appeal to individuals earlier in recovery (Timko et al., 2022).

Peer 2. Geslande Dessalines

I attended the Hope for Newcomers Al-Anon Family Group via Zoom on April 26, 2026, at 11:00 AM. I chose this meeting because, among the various support groups I explored this semester, Al-Anon resonated most deeply with my personal experiences related to the substance use of my ex-fiancé and my brother. While I had previously attended a different Al-Anon meeting, I wanted to broaden my perspective by observing another group. Al-Anon is a mutual support program founded in 1951 for individuals affected by another person’s alcohol use, emphasizing shared experiences, coping strategies, and emotional support (Al-Anon Family Groups, 2026). Membership is open to anyone concerned about another person’s drinking, regardless of whether the individual with alcohol use disorder is actively seeking treatment, making the program highly accessible and inclusive (Al-Anon Family Groups, 2026).

The meeting I attended included approximately 30 participants from diverse geographic regions, including the United States, Canada, Puerto

Rico, and Bermuda. The group appeared to include a mix of adults in their 20s-60s, mostly women, and fairly diverse in ethnic backgrounds. The primary goal of Al-Anon is to help members develop healthier coping mechanisms, reduce emotional distress, and foster personal growth despite living with or being affected by someone else’s substance use (personal communication, April 26, 2026). One participant shared that the program helped them “focus on what I can control, like my reactions and my peace, rather than trying to fix my loved one” (personal communication, April 26, 2026), which aligns with the organization’s emphasis on detachment with love and self-care.

From an objective standpoint, the group appeared effective in meeting participants’ emotional and psychological needs. The structured yet supportive environment allowed members to share openly without fear of judgment, which is consistent with therapeutic group principles (Tusaie & Fitzpatrick, 2016). The meeting fostered a sense of safety and consistency, both of which are essential for individuals coping with chronic stressors like a loved one’s addiction. Additionally, the virtual format increased accessibility, which is particularly relevant in modern mental health care delivery (Wheeler, 2020).

Two key therapeutic factors observed during the session were universality and instillation of hope. Universality was evident as participants shared similar struggles, reducing feelings of isolation and stigma. Hearing others articulate nearly identical emotional experiences, such as guilt, frustration, and helplessness, helped normalize these feelings, a process known to be therapeutic in group settings (Wheeler, 2020). Instillation of hope was also prominent with several long-term members sharing their progress in setting boundaries and achieving emotional stability. These testimonies appeared to encourage newer members by demonstrating that change and personal growth are possible over time. Such factors are foundational to effective group psychotherapy and are associated with improved coping outcomes (Tusaie & Fitzpatrick, 2016).

The group process itself was well managed. There was a clear leader who maintained structure, guided discussion, and ensured

adherence to group norms. This was particularly important given the relatively large number of participants. The leader effectively addressed minor patient management issues, such as multiple individuals speaking simultaneously, by reminding participants to remain muted until it was their turn. This demonstrated appropriate limit-setting and helped maintain a respectful and organized environment, which is critical in large therapeutic groups (Wheeler, 2020).

Personally, I found the experience both meaningful and enriching. Listening to others describe how they learned to live without being consumed by worry or judgment toward their loved ones was especially impactful. One participant shared that they “finally feel free to live my own life without guilt” (personal communication, April 26, 2026), which resonated deeply with my own journey. This perspective helped me reframe my understanding of support, not as control or sacrifice, but as maintaining personal boundaries while still caring for others.

Overall, I would confidently refer future clients to Al-Anon. The program offers a supportive, accessible, and evidence-informed approach to coping with the challenges of a loved one’s substance use. Its emphasis on shared experience, emotional validation, and personal growth aligns well with psychiatric nursing principles and provides meaningful adjunctive support to formal treatment modalities.