Patient 4: A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia. He is forgetful and seems to be tripping on things or walking into walls, although he has lived in the same home for the past 35 years. The patient does not agree with his daughter but does admit he has had a “few stumbles and falls” lately. Medication reconciliation shows the following medications: metoprolol ER 50mg q day, omeprazole 20mg q day, clonazepam 1mg TID, levothyroxine 75mcg q am. His daughter is wondering if he should be started on a “dementia medication.”
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Patient 4
Review potential side effects for elderly on benzodiazepines providing education to both the patient and the patient’s daughter. What are the risks of continuing the benzodiazepine for this patient?
How would you evaluate the patient for these side effects?
The patient and daughter agree he will need to taper off the clonazepam given the risks of continuing this medication. How would you recommend tapering off this medication?
Review with the patient and daughter potential side effects of tapering off the medication. Review with them common side effects to more serious side effects and when to seek medical attention.
Patient 4 Solved
The case involving a 71-year-old male with potential cognitive decline and a history of falls presents a critical change for a medication review and de-prescribing. The use of benzodiazepines among the elderly population has been associated with significant risks that may be contributing to the patient’s current symptoms. Benzodiazepines have been known to contribute to significant risks for elderly patients, such as fall risk and sedation. Benzodiazepines have also been shown to contribute to an increased risk of addiction and cognitive decline, including a decline in memory, attention, and executive function (Horowitz et al., 2021). In their study by Edinoff et al. (2021), the risk of falls contributes to injuries among elderly patients. Other notable side effects include paradoxical reactions, such as increased agitation or confusion and increased risk of motor vehicle accidents.
Evaluating the patient for side effects will require the use of a comprehensive geriatric assessment will be used. This will include a cognitive assessment tool called a mini-mental state examination. In their study by Su et al. (2021), MMSE is an instrument used to evaluate cognitive functioning. It measures aspects including orientation to time, orientation to place, registration, attention and calculation, recall, and language. The balance and gait assessment will use the Time Up and Go (TUG) test, a reliable, cost-effective, safe, and efficient to assess overall functional mobility (Klotzbier et al., 2021). The patient’s fall history will be reviewed to understand the scenarios and frequency of falls. The assessment will also include a medication review to identify potential drug interactions or other medications that may contribute to increased fall risk or cognitive impairment.
Based on the patient’s risk and current symptoms, it is important to taper off clonazepam. Among elderly patients, a gradual taper of the clonazepam medication is recommended due to their heightened sensitivity to withdrawal symptoms (Edinoff et al., 2021). The plan will include using a slow taper of a 5% reduction every two weeks. The slow taper process will be vital in reducing withdrawal symptoms and the risk of symptom recurrence.
References
Ait-Daoud, N., Hamby, A. S., Sharma, S., & Blevins, D. (2018). A review of alprazolam use, misuse, and withdrawal. Journal of addiction medicine , 12 (1), 4-10. https://doi.org/10.1097/ADM.0000000000000350
Baldacci, A., Saguin, E., Balcerac, A., Mouchabac, S., Ferreri, F., Gaillard, R., … & Bourla, A. (2023). Pharmacogenetic Guidelines for Psychotropic Drugs: Optimizing Prescriptions in Clinical Practice. Pharmaceutics , 15 (11), 2540. https://doi.org/10.3390/pharmaceutics15112540
Boon, M., van Dorp, E., Broens, S., & Overdyk, F. (2020). Combining opioids and benzodiazepines: effects on mortality and severe adverse respiratory events. Annals of Palliative Medicine , 9 (2), 54257-54557. https://doi.org/10.21037/apm.2019.12.09
Brandt, J., Bressi, J., Lê, M. L., Neal, D., Cadogan, C., Witt-Doerring, J., … & Wright, S. (2024). Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review. Clinical medicine , 70 . 10.1016/j.eclinm.2024.102507
Chang, Y., Xie, X., Liu, Y., Liu, M., & Zhang, H. (2024). Exploring clinical applications and long-term effectiveness of benzodiazepines: An integrated perspective on mechanisms, imaging, and personalized medicine. Biomedicine & Pharmacotherapy , p. 173 , 116329. https://doi.org/10.1016/j.biopha.2024.116329
Edinoff, A. N., Nix, C. A., Hollier, J., Sagrera, C. E., Delacroix, B. M., Abubakar, T., … & Kaye, A. D. (2021). Benzodiazepines: uses dangers and clinical considerations. Neurology International , 13 (4), 594-607. https://doi.org/10.3390/neurolint13040059
Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of anxiety disorders: current and emerging treatment options. Frontiers in psychiatry , p. 11 , 595584. https://doi.org/10.3389/fpsyt.2020.595584
Horowitz, M. A., Wright, J. M., & Taylor, D. (2021). Risks and benefits of benzodiazepines. Jama , 325 (21), 2208-2209. https://doi.org/10.1001/jama.2021.4513
Klotzbier, T. J., Korbus, H., Johnen, B., & Schott, N. (2021). Evaluation of the instrumented Timed Up and test as a tool to measure exercise intervention effects in nursing home residents: results from a PROCARE substudy. Ger J Exerc Sport Res 51, 430–442 (2021). https://doi.org/10.1007/s12662-021-00764-0
Maust, D. T., Petzold, K., Strominger, J., Kim, H. M., & Bohnert, A. S. (2023). Benzodiazepine Discontinuation and Mortality Among Patients Receiving Long-Term Benzodiazepine Therapy. JAMA network open , 6 (12), e2348557-e2348557. https://doi.org/10.1001/jamanetworkopen.2023.48557
Reid Finlayson, A. J., Macoubrie, J., Huff, C., Foster, D. E., & Martin, P. R. (2022). Experiences with benzodiazepine use, tapering, and discontinuation: an Internet survey. Therapeutic advances in psychopharmacology , p. 12 , 20451253221082386. https://doi.org/10.1177/20451253221082386
Su, Y., Dong, J., Sun, J., Zhang, Y., Ma, S., Li, M., … & Zhu, P. (2021). Cognitive function assessed by Mini-mental state examination and risk of all-cause mortality: a community-based prospective cohort study. BMC geriatrics , 21 , 1–10. https://doi.org/10.1186/s12877-021-02471-9
Wang, X., Zhang, T., Ekheden, I., Chang, Z., Hellner, C., Hasselström, J., … & Sidorchuk, A. (2022). Prenatal exposure to benzodiazepines and Z-drugs in humans and risk of adverse neurodevelopmental outcomes in offspring: A systematic review. Neuroscience & Biobehavioral Reviews , 137 , 104647. https://doi.org/10.1016/j.neubiorev.2022.104647
NURS_6630_Week5_Assignment_Rubric
NURS_6630_Week5_Assignment_Rubric
Criteria
Ratings
Pts
This criterion is linked to a Learning Outcome Patient 1: Describes concerns for patient remaining on the medication and how these risks and concerns will be addressed to the patients. Describes how to assist Patient 1 in tapering medication, as well as what other medication might be prescribed with considerations of legal, ethical, or social considerations to the plan NURS-6630 Week 5: Assignment De-Prescribing – A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia.
20 to > 18.0 pts Excellent The response comprehensively describes medication risks and concerns. The response comprehensively and clearly explains how the patient will be educated. The response comprehensively and clearly explains considerations for medication tapering. The response comprehensively and clearly reflects on legal, ethical, or social considerations of the plan.
18 to > 15.0 pts Good The response clearly describes medication risks and concerns. The response clearly explains how the patient will be educated. The response clearly explains considerations for medication tapering. The response clearly reflects on the legal, ethical, or social considerations of the plan.
15 to > 10.0 pts Fair The response inaccurately or vaguely describes medication risks and concerns. The response inaccurately or vaguely explains how the patient will be educated. The response inaccurately or vaguely explains considerations for medication tapering. The response inaccurately or vaguely reflects on legal, ethical, or social considerations of the plan.
10 to > 0 pts Poor The response vaguely or inaccurately describes medication risks and concerns, or it is missing. The response includes inaccurate and vague examples that does not explain how the patient will be educated, or it is missing. The response vaguely or inaccurately explains considerations for medication tapering, or it is missing. The response includes inaccurate and vague examples that does not reflect on legal, ethical, or social considerations of the plan, or it is missing.
20 pts
This criterion is linked to a Learning Outcome Patient 2: Describes common withdrawal symptoms and patient education information. Describes which benzodiazepine might be prescribed to convert the patient, as well as the specific dosing and tapering information.
20 to > 18.0 pts Excellent The response comprehensively and clearly explains withdrawal symptoms. The response comprehensively and clearly provides patient education information. The response comprehensively and clearly identifies a benzodiazepine for the patient. The response comprehensively and clearly details dosing and tapering information.
18 to > 15.0 pts Good The response clearly explains withdrawal symptoms. The response clearly provides patient education information. The response clearly identifies a benzodiazepine for the patient. The response clearly details dosing and tapering information.
15 to > 10.0 pts Fair The response inaccurately or vaguely explains withdrawal symptoms. The response inaccurately or vaguely provides patient education information. The response inaccurately or vaguely identifies a benzodiazepine for the patient. The response inaccurately or vaguely details dosing and tapering information.
10 to > 0 pts Poor The response vaguely or inaccurately explains withdrawal symptoms, or it is missing. The response includes inaccurate and vague examples that does not provide patient education information, or it is missing. The response vaguely or inaccurately identifies a benzodiazepine for the patient, or it is missing. The response includes inaccurate and vague examples that does not detail dosing and tapering information, or it is missing.
20 pts
This criterion is linked to a Learning Outcome Patient 3: Describes potential risks, benefits and side effects of lorazepam, as well as alternative medications that might be prescribed for the patient. Describes how the patient might discontinue lorazepam, with necessary patient education regarding discontinuing medication and patient/fetus needs.
20 to > 18.0 pts Excellent The response comprehensively and clearly describes risks, benefits and side effects of lorazepam. The response comprehensively and clearly identifies potential alternative medications. The response comprehensively and clearly describes how the patient might discontinue the medication. The response comprehensively and clearly provides necessary education for discontinuing the medication for patient and fetus.
18 to > 15.0 pts Good The response clearly describes risks, benefits and side effects of lorazepam. The response clearly identifies potential alternative medications. The response clearly describes how the patient might discontinue the medication. The response clearly provides necessary education for discontinuing the medication for patient and fetus.
15 to > 10.0 pts Fair The response inaccurately or vaguely describes risks, benefits and side effects of lorazepam. The response inaccurately or vaguely identifies potential alternative medications. The response inaccurately or vaguely describes how the patient might discontinue the medication. The response inaccurately or vaguely provides necessary education for discontinuing the medication for patient and fetus.
10 to > 0 pts Poor The response vaguely or inaccurately describes risks, benefits and side effects of lorazepam, or it is missing. The response includes inaccurate and vague examples that does not identify potential alternative medications, or some or all are missing. The response vaguely or inaccurately describes how the patient might discontinue the medication, or it is missing. The response includes inaccurate and vague examples that does not provide necessary education for discontinuing the medication for patient and fetus, or some or all are missing.
20 pts
This criterion is linked to a Learning Outcome Patient 4: Describes potential risks and side effects of continuing benzodiazepine. Describes how to taper the medication and education regarding the tapering NURS-6630 Week 5: Assignment De-Prescribing – A 71-year-old-male who comes to see you at the insistence of his daughter. His daughter expresses concern of memory loss and is wondering if he has the beginning stages of dementia.
20 to > 18.0 pts Excellent The response comprehensively and clearly describes potential side effects and risks. The response comprehensively and clearly describes how to taper the medication. The response comprehensively and clearly provides necessary patient education for tapering.
18 to > 15.0 pts Good The response clearly describes potential side effects and risks. The response clearly describes how to taper the medication. The response clearly provides necessary patient education for tapering.
15 to > 10.0 pts Fair The response inaccurately or vaguely describes potential side effects and risks. The response inaccurately or vaguely describes how to taper the medication. The response inaccurately or vaguely provides necessary patient education for tapering.
10 to > 0 pts Poor The response vaguely or inaccurately describes potential side effects and risks, or it is missing. The response vaguely or inaccurately describes how to taper the medication, or it is missing. The response includes inaccurate and vague examples that does not provide necessary patient education for tapering, or some or all are missing.
20 pts
This criterion is linked to a Learning Outcome Paper demonstrates critical thinking and synthesis of literature with five (5) evidence-based, peer reviewed scholarly references
5 to > 4.0 pts Excellent Paper demonstrates critical thinking and synthesis of literature with five (5) evidence-based, peer reviewed scholarly references outside of course resources.
4 to > 3.0 pts Good Paper demonstrates some critical thinking and/or vague synthesis of literature with four (4) evidence-based, peer reviewed scholarly references outside of course resources.
3 to > 1.0 pts Fair Paper demonstrates vague critical thinking and/or little synthesis of literature with three (3) evidence-based, peer reviewed scholarly references.
1 to > 0 pts Poor Paper demonstrates no critical thinking and/or synthesis of literature with two (2) or less evidence-based, peer reviewed scholarly references.
5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting—Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction is provided, which delineates all required criteria.
5 to > 4.0 pts Excellent Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion is provided which delineates all required criteria.
4 to > 3.0 pts Good Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the Assignment is stated yet is brief and not descriptive.
3 to > 1.0 pts Fair Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the Assignment is vague or off topic.
1 to > 0 pts Poor Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. No purpose statement, introduction, or conclusion was provided.
5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and proper punctuation
5 to > 4.0 pts Excellent Uses correct grammar, spelling, and punctuation with no errors.
4 to > 3.0 pts Good Contains one or two grammar, spelling, and punctuation errors.
3 to > 1.0 pts Fair Contains several (three or four) grammar, spelling, and punctuation errors.
1 to > 0 pts Poor Contains many (five or more) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning Outcome Written Expression and Formatting: The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, parenthetical/in-text citations, and reference list.
5 to > 4.0 pts Excellent Uses correct APA format with no errors.
4 to > 3.0 pts Good Contains one or two APA format errors.
3 to > 1.0 pts Fair Contains three or four APA format errors.
1 to > 0 pts Poor Contains many (five or more) APA format errors.
5 pts
Total Points: 100
