Geriatrics 2023

Ensuring adequate nutrition is an important part of pressure injury care. You ask the dietitian to make recommendations for her overall nutrition. Question What types of interventions would be appropriate to aid in healing Mrs. Jones's pressure ulcer? Select all that apply. A. Arginine/glutamine/antioxidant supplementation B. Protein supplementation C. Removing her dentures when eating so she doesn't accidentally choke on them D. Supplements such as vitamin C and Zinc E. Tube feeding, if a patient is unable to take in enough calories and protein

A. Arginine/glutamine/antioxidant supplementation B. Protein supplementation

Which of the following is the least acceptable translation method for communicating with Mr. Wang? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. His son B. Qualified medical interpreter C. Telephone interpretation services D. Video interpretation services E. Yourself, if you speak Mandarin fluently

A. His son

A 74-year-old patient comes to the clinic with her daughter because of a 6 month history of hoarding behaviors. The daughter is concerned the patient's apartment is not a safe place to live. The patient has fallen 3 times in the last month and had been falling 1-2 times a month before that. The patient recognizes that her frequent falls are a concern, however she does not want to live in a nursing home and wants to maintain her independence. Medical history is significant for hypertension, heart failure with preserved ejection fraction, and mild dementia. Medications are carvedilol, lisinopril, and donepezil. Social history is notable for 1-2 glasses of wine a week. She is a retired psychologist, and her highest level of education is a doctorate. Vital signs are normal. Physical examination shows a neatly dressed older woman, with kyphosis and multiple bruises. Cardiopulmonary exam is unremarkable. She is alert and oriented to self and place, but is off by a month on the date. Mini-Cog demonstrates normal clock drawing, but she is only able to recall two of the three words. Results of laboratory tests are unremarkable. Which of the following should be considered in determining the patient's capacity regarding whether she can safely stay at home? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Patient's alcohol intake B. Patient's understanding of the risks and benefits of living at home C. Patient's highest level of education D. Patient's history of dementia E. Patient's hoarding behaviors

Answer Comment The correct answer is B. While the patient's falls and hoarding behavior are concerning, capacity is determined for individual decisions and requires that she appreciate the options (and associated risks/benefits) and communicate a choice based on her values. In this case, the patient understands that her home is becoming unideal but has stated a preference in line with her values: to maintain independence. Her level of education, hoarding, alcohol intake, and history of mild dementia do not affect her capacity to make this decision. Patients who are acutely intoxicated or patients who have dementia may or may not have capacity, depending on the complexity of the decision and severity of dementia. An assessment of capacity must be made for each individual situation.

Medicare provides federally funded health insurance for disabled adults, those over 65, and dialysis patients. What percentage of Medicare patients are readmitted to the hospital within 30 days of discharge for any reason? Choose the single best answer. A. < 10% B. 15% C. 25% D. 30% E. 35%

B. 15%

Older patients are more likely than younger patients to be discharged to a subacute rehabilitation facility than to their homes after an acute care hospital stay. What percentage of hospitalized older patients is likely to experience functional decline at the time of hospital discharge? Choose the single best answer. A. < 10% B. 10% to 25% C. 30% to 40% D. 50% to 60%

C. 30% to 40%

Which of the following have been shown to improve as a result of feeding tube placement in patients with advanced major neurocognitive disorder? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Incidence of aspiration B. Malnutrition/weight loss C. Palliation (improved comfort/lessening of pain) D. Pressure injuries E. Survival prognosis F. None of the above

F. none of the above

An 88-year-old independent and healthy male is brought to the clinic to discuss his memory. Medical history includes mild Alzheimer disease, diagnosed one year ago. His only medication is donepezil. His daughter reports that she sees her dad once a month and is worried that he is becoming a bit more forgetful. He has forgotten to pay his bills for the past two months. She has no safety concerns. The patient feels well and doesn't agree with his diagnosis; he often gets angry when told he has dementia. He continues to manage his medication and drive independently. He received a traffic citation a month ago for failing to yield to oncoming traffic. He continues to exercise on his stationary bicycle daily and routinely goes to the local senior center for social events and card tournaments. He sleeps well, has a good appetite, and has not lost any weight. His vitals are normal. Neurological examination is unremarkable. His score on the mini-mental status exam today is 20/30. His score six months ago was 23/30. What recommendation should you give this patient at this time? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Driving evaluation B. Increased cardiovascular exercise C. Meals on Wheels program D. Melatonin at bedtime E. Psychology referral SUBMIT

The correct answer is A. Most dementia is progressive, and symptoms such as memory loss, visual-spatial disorientation, and decreased cognitive function will worsen over time. This patient has been noted to have cognitive decline objectively and subjectively and he has had a driving citation. As a general rule, persons with early or mild dementia who wish to continue driving should get their driving skills evaluated, in order to maintain their independence and safety. Increased cardiovascular exercise, while appropriate for most people, is not specifically pertinent at this time. Psychology referral might be appropriate for patients with depression or other mood issues. Melatonin may be appropriate for certain types of insomnia and even in dementia patients with sleep-wake cycle problems, however, this patient has not endorsed sleeping problems. He also does not have any problems with his weight or with procuring meals.

A 78-year-old female comes to the clinic along with her daughter. The daughter is concerned that her mother seems slower in her thinking lately and appears more unsteady when walking. Her mother doesn't have any concerns for any pain or other symptoms. She has been generally active and enjoys daily card games and evening social events in her senior living facility. Last evening, when gathering her things to go back to her apartment, she lost her balance and fell. She was helped to her feet by a friend. Medical history is significant for osteoarthritis of the knees, non-insulin-dependent diabetes, temporal lobe epilepsy, and hypertension (HTN). Medications are acetaminophen, metformin, lamotrigine, and hydrochlorothiazide. Vital signs, including pulse and blood pressure, are normal. Blood glucose is 145 mg/dl. Physical examination is unremarkable except for bruises at the knees, bilaterally, and abrasions on the palmar aspects of her hands. The patient appears alert and able to ask and answer questions clearly and appropriately. What is the next best step in your approach to the patient's care? A. Apply antibiotic ointment to abrasions B. Ask the patient about alcohol use C. Assess the patient's cognition D. Order an electroencephalogram E. Perform a gait and balance evaluation

The correct answer is B. Evaluation of falls in older adults requires careful history taking that includes the circumstances at the time of the fall. Alcohol use may impair balance and gait in older adults, leading to an increased risk of falling.

A 90-year-old female and former physician is seen in the memory care clinic for cognitive evaluation. She is accompanied by her healthy 88-year-old spouse. She is unsure why she has an evaluation today. Her spouse notes that over the last three years she has had a slow decline in memory and orientation. She often repeats herself and has lost interest in most of her hobbies. She is easily irritated. Over the last six months, she has made several mistakes when cooking and often doesn't remember to take her medications. She states she has not made these mistakes and reports that it is her spouse who is having difficulty with his medications. She has a medical history of hyperlipidemia and essential hypertension. She is on simvastatin and lisinopril. Her vitals are normal except for a 3.6 kg (8 lb) weight gain in the last six months. She appears depressed and withdrawn. She exhibits word-finding difficulty and she is easily frustrated when asked to perform various tasks; she requires repeated instructions. Otherwise, her examination is unremarkable. She has not had head imaging. Her thyroid-stimulating hormone (TSH) is 12.6 ulU/mL, vitamin B12 is 500 pg/ml, and rapid plasma reagin (RPR) screen is negative. Her physician makes the diagnosis of cognitive impairment. What medication should be started at this time? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Donepezil B. Levothyroxine C. Methylphenidate D. Sertraline E. Vitamin B12 SUBMIT

The correct answer is B. It is possible this patient has a diagnosis of cognitive impairment; however, hypothyroidism could be contributing to her presentation and should be treated. She should then have cognition and function reevaluated after therapeutic treatment of thyroid disease.

A 92-year-old female was admitted to the hospital four days ago because of an aspiration event and is being treated for aspiration pneumonia. She was initially febrile, hypotensive, and had leukocytosis, which all improved with intravenous (IV) antibiotics. She started tolerating a soft modified diet, so IV fluids were stopped two days ago. Medical history is significant for Alzheimer disease, depression, hypertension (HTN), and osteoarthritis. Medications are acetaminophen as needed (PRN), amlodipine, donepezil, and sertraline. This morning, her vital signs are normal. Physical examination shows an older female lying in bed with no facial grimacing, but with blankets over her head and lights out in her room. She is awake but minimally responsive to verbal or tactile stimuli. She has dry mucous membranes, a non-tender abdomen, and no leg edema. Cardiac and lung examinations are normal. Skin examination reveals erythema and skin tear over sacrum. Laboratory studies are within normal limits except for her blood urea nitrogen (BUN) of 40 mg/dL and creatinine (Cr) of 1.4 mg/dL (baseline creatinine is 0.6 mg/dL), and her serum sodium has increased to 148 mEq/L. Which of the following is the most likely cause of her increased lethargy? Choose the single best answer. A. Anorexia B. Dehydration C. Medication side effects D. New Infection E. Pressure Injury

The correct answer is B. Patient's hypoactive delirium is likely precipitated by reduced fluid intake, predisposed given her underlying dementia, infection, and being in an unfamiliar environment. She has hypoactive delirium as she is lethargic and unresponsive, which increases her mortality risk. Even though vital signs may appear within normal limits, it is important to pay close attention to BUN trend, creatinine, and sodium levels, and to clinical findings of dehydration. While appetite can decrease with an infection and anorexia can cause lethargy, the acuity of this patient's lethargy is likely to be from lack of fluids and dehydration, rather than anorexia. Medication side effects are important to think about in a hospitalized patient with lethargy. She has not had any new medications or is on any medications that would cause increased lethargy. While an acute infection is possible in the hospital, labs are within normal limits, vital signs are normal, and there are no focal findings on exam of a new infection. While this patient does have a skin tear and erythema over her sacrum, there are no signs of this pressure injury being infected or causing pain. This skin tear would not explain her increased lethargy.

A 90-year-old female comes to the clinic with her son for a routine follow-up appointment. She offers no concerns and says she has "no medical problems." Her son tells you that she has been falling at home and he is worried. She usually uses a cane for ambulation. Medical history is significant for moderate stage Alzheimer disease, coronary artery disease (CAD), arthritis, hypertension (HTN), macular degeneration, and hearing loss. Medications include metoprolol, lisinopril, aspirin, tramadol, donepezil, and ophthalmologic drops. You attempt to measure orthostatic vital signs but she is unable to lie supine for five minutes due to kyphosis and pain. Blood pressure is 125/70 mmHg while seated and 105/60 mmHg after standing for one minute. Pulse remains constant between 70 to 74 beats/minute. Physical examination is significant for marked thoracic kyphosis, a grade 3/6 systolic ejection murmur at the right-upper-sternal border, normal pulmonary findings, and 2+ pedal edema. Her memory is poor and she is unable to stand unassisted to complete the Timed Up and Go (TUG) test. What is the best approach in the management of this patient's complex medical situation? Choose the single best answer. A. Frequent clinic follow-up B. Hospital admission C. Medication review D. Multidisciplinary intervention E. Referral for a wheelchair

The correct answer is D. In an older adult living at risk for future falls a multidisciplinary intervention around the management of orthostatic hypotension, medication review, gait and balance, and strength training can reduce future falls. The other options may be of benefit to this patient, however, isolated interventions have not been shown to be effective in fall reduction. In this case, medication review, regular ophthalmologic evaluation, hearing aids, checking for postural hypotension, and physical therapy can be considered to reduce falls risk. Wheelchair referral is not appropriate at this time.

Which of the following could help you in the role of cultural broker for Mr. Wang? Select all that apply. A. A nurse practitioner in the clinic who was born and raised in China and speaks Mandarin B. Leaders in the Chinese community center C. Mr. Wang's grandchildren D. Mr. Wang's son

The correct answers are A, B, C, D. All of the above would be good choices. If you wish to ask a medical colleague, it is best to choose another physician or nurse practitioner, with the understanding that they may decline if they do not feel comfortable with the task, rather than a medical student who might feel undue pressure to comply. One caveat when using a cultural broker is that two people with a similar cultural background may not have identical beliefs. Speak to the patient first to elicit their personal explanatory model, before using a cultural broker. For more information and examples of successful brokering in community health initiatives, visit Bridging the Cultural Divide in Health Care Settings: The Essential Role of Cultural Broker Programs.

Based on this history, you would like to perform cognitive testing on Mr. Wang. Question What methods or tests might be appropriate? Select all that apply. The best options are indicated below. Your selections are indicated by the shaded boxes. A. Mini-Cog B. Mini-Mental State Exam (MMSE) in English, administered via interpreter C. MoCA translated and validated in Mandarin D. Saint Louis University Mental Status (SLUMS) exam in English, administered via interpreter E. Time and change test

The correct answers are A, C, E. For reasons other than cognitive impairment, culturally diverse patients may score falsely positive on commonly used cognitive screening tools. Perhaps the most obvious reason for this is the language barrier; it is inappropriate to administer a test such as the Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA), or Saint Louis University (SLU) Mental Status exam to Mr. Wang in English, as he speaks limited phrases and may answer incorrectly due to miscommunication rather than cognitive impairment. It is not appropriate to directly translate a cognitive test in English via an interpreter, as it may not have been validated for non-English speakers; certain elements of the test do not effectively translate into other languages (e.g., "no ifs, ands, or buts," spell WORLD backwards). Even patients who are fluent in English as their second language may perform worse on an English language test, as language skills for a second language are impaired early in cognitive decline. Keeping linguistic and cultural factors in mind, cognitive assessments such as the MMSE and MoCA have been translated, modified, and validated in a number of other languages. For Mr. Wang, you may administer a Mandarin language MoCA (C) if a Mandarin interpreter is available who has been trained to administer the test appropriately. The MoCA is available in over 100 languages, including several Chinese languages, at www.mocatest.org. As an interpreter might be difficult to arrange, another option is to administer a cognitive assessment that is closer to being "culture-free." These assessments tend to be shorter in length, with less emphasis on language or education-based skills and include the Mini-Cog (clock drawing with three-item recall) and the time and change test (telling time from a clock and making change with money). These tests tend to show more equivalent performance across cultures and can be useful screening tools. When using cognitive testing tools with any patients, remember that you are gathering supportive information. The diagnosis of dementia is made clinically, based upon the entire picture including the history, physical exam, and supporting data, not just a score on a single test. TEACHING POINT

Which of the following statements is most accurate about elder abuse or mistreatment? Select all that apply. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Caregiver stress has little connection to elder mistreatment. B. Most abusers are known to their victims. C. Most cases are reported to authorities. D. Most instances of elder mistreatment occur in nursing facilities.

The correct answer is B. Most abusers are known to their victims (B). Many abusers are first-degree relatives. This caregiver relationship is the reason most instances of elder mistreatment occur in non-institutional settings (D), and is likely why most cases are not reported (C). Caregiver stress is a known risk for elder abuse (A).

A 78-year-old female has been hospitalized for a week with a myocardial infarction, now status post a percutaneous coronary intervention with the placement of three stents. Post-infarction, she is noted to have new heart failure and is started on an angiotensin-converting enzyme inhibitor (ACE-I) and beta-blocker in addition to dual antiplatelet therapy. The patient is tolerating all of her new medications well and has no acute cardiac concerns. Medical history is significant for diabetes and hyperlipidemia. Other medications include glargine every evening, humalog before every meal, and atorvastatin. The patient lives at home with her daughter, son-in-law, and two grandchildren. Prior to hospitalization, she ambulated with a one-point cane. She was independent in activities of daily living (ADLs), and her daughter assisted with her finances and medications. During her hospitalization, she and her daughter were seen by a social worker. The daughter said she would be able to care for her mother if she were discharged home. Vital signs are normal. Physical examination shows an older female in no acute distress and she appears euvolemic. Cardiac and lung examinations are normal. She is alert; oriented to time, place, and person; and engages with the medical team. The patient is seen by physical therapy who recommends that she use a walker and be discharged home with PT. At this point in the patient's discharge planning, which member of the inpatient interdisciplinary team should meet with the patient and her family next? Choose the single best answer. A. Chaplain B. Occupational therapist C. Pharmacist D. Social Worker

The correct answer is C. This patient has had many medications added to her home regimen during this admission. To ensure a smooth transition from the hospital, it would be most appropriate to have the pharmacist explain the new medications to both the patient and her daughter, who helps to manage the patient's medications. The patient is not showing any signs of spiritual distress that may benefit from the chaplain at this time. This patient has no indication for occupational therapy at this time. The patient's insurance has been reviewed, and she has been seen by the social worker during her hospitalization so there is no immediate need for another meeting. It is possible that the daughter has changed her mind, and feels that her mother's mobility difficulty precludes her from going home, If this is the case, the physical therapist would need to reevaluate the patient to see if she qualifies for subacute rehabilitation.

A 72-year-old female was admitted to the hospital eight days ago for rectal bleeding. She was found to have a mass in the descending colon and underwent surgical resection with creation of a colostomy. She was discharged from the hospital with close follow-up with a medical oncology clinic. Medical history is significant for osteoarthritis, hypertension (HTN), and hyperlipidemia. Medications are lisinopril and atorvastatin. She is widowed and lives alone in an apartment complex with an elevator. Her two adult children live out of state. Prior to hospitalization, the woman did not have any professional caregivers. She is independent with all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She goes out to lunch once or twice a week with friends. Physical therapy assessed the woman post-operatively and recommended no additional equipment or services. Vital signs are normal. Physical examination shows a female who appears her age in no acute distress. She is able to ambulate to and from the bathroom without assistive devices. She is alert; oriented to time, place, and person; and engages with the medical team. Her patient health questionnaire (PHQ2) is negative. What outpatient referral or home service would best address this woman's risk for readmission? Choose the single best answer. A. Referral to adult daycare B. Referral to geriatric psychologist C. Referral to home health aide agency D. Referral to home physical therapy services E. Referral to visiting nurse services SUBMIT

The correct answer is E. This patient lives alone with no informal (family) or formal caregivers. While she is independent of ADLs/iADLs, the new ostomy bag requires specialized nursing care and training for the patient to become comfortable with exchanging the bag on her own. VNS referral will provide this. Referral to adult daycare is incorrect because the patient is independent of ADLs and iADLS. She does not need assistance with meals or medications that would be provided by an adult daycare. She also has regular contact with friends so is less likely to need the social benefit of an adult daycare. Referral to a geriatric psychologist is incorrect because while psychological factors like depression increase a patient's risk for readmission, her PHQ2 is negative. Patients with cancer are at risk for depression so it is important to routinely screen for depression. Referral to a home health aide agency is incorrect because home health aides predominantly assist with ADLs. At discharge, this patient has maintained function and is independent of all ADLs. Referral to home physical therapy services is incorrect because this patient is able to ambulate independently of assistive devices and was assessed by the inpatient physical therapist as having no further physical therapy needs. After a major operation, prolonged hospitalization, and in older adults, it is important to involve the physical therapy team in assessing discharge needs.

A 70-year-old patient comes to the clinic because of a three-month history of abdominal pain. He also has noticed increasing constipation with thin stools, nausea, and weight loss of 4.5 kg (10 lbs) over that period of time. - Medical history is significant for past treatment of colon cancer status post colonic resection and chemotherapy two years ago. Since then, the patient has not followed up with his gastroenterologist or his oncology team as he believes that his cancer is "cured." - He takes no medications but tells you he has increased his vegetables and fruits in order to help with his constipation. - Vital signs are normal. Weight is 59 kg (130 lbs). Height is 175 cm (5ft 9 in). Body mass index is 19.2 kg/m2. - Physical examination shows a man who is thin in appearance, with a normal examination except for a non-distended abdomen, with decreased bowel sounds, and some fullness and tenderness to palpation across the left lower quadrant. You suggest next steps to more fully determine the etiology of the patient's weight loss, abdominal pain, and constipation. The patient replies that he plans to instead treat his symptoms with a variety of natural laxatives that he has obtained from the local health and supplements store. Which of the following is your best initial response to the patient? Choose the single best answer. A. Can you tell me more about what you think is happening in your body? B. I'm concerned that this may be cancer, and we need to investigate this more fully. C. Let's look at trying some more traditional laxatives to relieve your constipation. D. We really need to refer you back to the oncologist to manage your cancer. E. Why haven't you followed up with your health care team?

A. Can you tell me more about what you think is happening in your body?

A 91-year-old female is found down at home, and brought to the emergency department after EMS accurately diagnoses a stroke. Her last known well time is unknown, so she is not a candidate for thrombolytic therapy. Due to a low Glasgow coma scale score at time of presentation, she is urgently intubated and transferred to the intensive care unit. As part of standard of care, a nasogastric tube is placed and she is started on enteral nutrition. You review her advance directive, which lists her adult son as her surrogate decision-maker. Your communication with family in the initial days of her admission center around her ventilator settings, sedation medication, and updates on her blood pressure management. You continue to reassure her family that you are providing necessary care. After five days in the intensive care unit, the patient remains minimally responsive without sedation, and she requires minimal ventilator settings. She continues to receive enteral nutrition. Due to her inability to meaningfully respond to commands, she has not received any rehabilitative therapies. She begins to experience agitation overnight, requiring antipsychotic medications for safety. You consult palliative care to elicit the patient's goals of care, as you fear that the patient's son has unrealistic expectations for his mother's recovery and you question how long to continue her care in the intensive care unit. Palliative care recommends a family meeting, which is scheduled the next day. During the family meeting, you learn from her son that prior to her stroke she was living independently at home, capable of managing her activities of daily living. Her son assisted her multiple days a week with shopping, cleaning and finances. He explains how important her two cats are to her, and that they provided significant companionship for her since her husband died a few years ago. He further shares that the activities that provided greatest joy in her life include quilting and cooking specialty dishes. Lastly, he tells you that she "never wanted to be a burden" on others. When asked what he wants for his mom, he states he wants her to live as long as possible. Based on what you learned about her during the family meeting, you explain to him that her chance of meaningful recovery is limited. Rather than a life of quilting, cooking, and seeing her cats, it is more likely that her life would involve months-to-years in nursing facilities, with a surgically placed feeding tube, and worst case scenario with a tracheostomy. He tearfully acknowledges that this is not a life his mother would want, and he asks what the alternative care option(s) include. You explain that she could be transitioned to a comfort-focused plan of care, and admitted to hospice, with death expected in days. He agrees to this plan, the patient is extubated, and she dies a couple days later at a hospice facility. Her son receives bereavement support from the hospice agency after her death. Which of the following is true about exploring a patient's goals, values and preferences in serious-illness care? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Families experience more complicated bereavement following a patient's death B. Health care systems spend more money coordinating care C. Patients and families experience higher anxiety and difficulty coping D. Patients and families understand expected outcomes from their medical treatments E. Providers suffer higher rates of burnout from emotionally challenging conversations

Answer Comment The correct answer is D. Although prognostication in acute stroke is extremely challenging, it is pertinent for providers to "tell a story" about the most likely outcome a patient may experience. The patient's son/surrogate wants her to "live as long as possible," but the treatments required to maintain her survival (e.g., prolonged ventilation +/- tracheostomy, permanent feeding tube with artificial nutrition) are not acceptable to him because they cannot guarantee her ability to enjoy the activities she did before her stroke. Quite often in critical care settings, the day-to-day care and updates overwhelm any conversations about a patient's big picture morbidity and mortality. When families receive our best prediction of prognosis and clinical outcomes, it is much easier to align treatment care goals with patient/family values and preferences (C). Despite the emotional distress experienced by families and/or clinicians during these conversations, research shows that the overall emotional toll from serious illness is lessened for both patients/families and clinicians (A, E). Having goals of care conversations and providing goal-concordant care reduces health care spending at the end of life (B). This is an important reason to have these conversations, but it should not be the primary or sole reason that these conversations take place.

You perform the Get-Up and Go Test on Mrs. Purcell and note that she needs to use the arms of the chair to get up, takes time to steady herself, and then walks slowly. It takes her 20 seconds to do the test. What does the abnormal Get Up and Go test put the patient at risk for in the future? Select ALL that apply. The best options are indicated below. Your selections are indicated by the shaded boxes. A. Cognitive Impairment B. Falls C. Myocardial Infarction D. Urinary incontinence SUBMIT

Answer Comment The correct answers are B, D. Impaired gait is a risk factor for future falls. Functional impairment can place patients at increased risk for functional urinary incontinence as it takes longer for patients to get to the bathroom.

An 86-year-old patient comes to the clinic with her daughter for follow-up. Medical history is significant for advanced dementia, osteoarthritis, hypertension, and diet-controlled diabetes mellitus. Medications are memantine, acetaminophen, and amlodipine. Vital signs are normal but notable for a 2.3 kg (5 lb) weight loss in the last three months. Physical examination shows an older woman, seated in a wheelchair, appearing comfortable. She smiles when greeted but does not answer any questions. At a prior visit, when discussing the progression of the patient's dementia and reviewing the patient's advance directives, the daughter requested comfort feedings and wanted to prioritize the patient's comfort and quality of life. She notes she gives very small bites of food because the patient can sometimes pocket food or tire with chewing. Meals take approximately an hour and seem to be increasing in length and decreasing in intake. The daughter states that the patient seems to enjoy certain foods more than others but she worries about the patient's history of diabetes. Which of the following would help increase the patient's nutritional intake? Choose the single best answer. A. Begin calorie count B. Give larger bites of food C. Increase patient's preferred foods D. Initiate supplement shakes E. Start megestrol acetate

C. Increase patient's preferred foods

As you examine Mrs. Jones, her daughter walks in. She says hello to her mother, looks over your shoulder, and asks you how long this wound has been there. You review the chart and cannot find any documentation of a skin exam in the nursing home, ED, or inpatient medicine notes. Skin exams can be overlooked in the hospital setting. Question At a minimum, how often should skin exams be performed in the inpatient hospital setting? Choose the single best answer. A. On admission and every 2 hours B. On admission and every 8 hours C. On admission and every 24 hours D. On admission and every 48 hours E. On admission and every time patient status changes SUBMIT

C. On admission and every 24 hours

Which of the following is the usual result of patient/family goals-of-care discussions? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Delay in providing treatment B. Early discharge to home C. Higher cost of care D. Higher patient satisfaction E. Increase in family distress

D. Higher patient satisfaction

Question: What is Adult Protective Services? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. A police force B. A prosecutorial agency of the government C. A social services agency

The National Adult Protective Services Association (NAPSA) is a social service agency (C). All United States jurisdictions have an Adult Protective Service (APS) agency. The size of APS jurisdictions vary state by state and county by county. APS is not a police force (A) or a prosecutorial agency (B). It has no power to arrest people but may report suspected dangerous situations and possible criminal activity to the police. If an APS worker suspects that an older or vulnerable adult is in danger, the worker may call the police and ask the officers to conduct a "welfare check." APS may give information to prosecutorial agencies such as the local district attorney's office regarding evidence of suspected criminal activity, but APS does not determine if someone will be charged with a crime. APS protocol and scope of practice may vary from one jurisdiction to another. In this circumstance, a vulnerable adult is defined as a person who is unable to care for themselves, and/or is unable to protect themselves from abuse, exploitation, or neglect by others.

For which of these three disease trajectories was the Medicare hospice benefit designed? (picture on back of card) The dementia patient The organ failure patient (such as Mrs. Fields with her COPD) The cancer patient

The cancer patient

A 78-year-old patient comes to the clinic because he fell yesterday. He is worried he will fall again since he is not sure why he fell in the first place. Prior to his fall, he reports feeling weak and dizzy. Medical history is significant for atrial fibrillation, diabetes, hypertension (HTN), coronary artery disease (CAD), chronic kidney disease (CKD), and spinal stenosis. Medications are acetaminophen as needed, apixaban, carvedilol, insulin glargine, and nifedipine. Physical examination shows a well-groomed man in no acute distress. His hearing is intact with bilateral hearing aids, vision is 20/20 with corrective lenses and dentition. He has normal heart and lung exams. He has a normal gait without using any assisted devices. Get-up and go test is normal with no use of arms to help him stand up. He is alert and oriented to person, place, and time and has no focal neurological deficits. Results of laboratory/diagnostic studies include normal electrocardiogram (ECG), complete blood count (CBC) is normal, sodium (Na) is 136 mEq/L, creatinine (Cr) is 1.7 mg/dL, estimated glomerular filtration rate (eGFR) is 40 ml/min, glucose is 70 mg/dL, and hemoglobin A1C (HbA1c) is 6.5%. What is the best next step to prevent another fall in this man? Choose the single best answer. A. Change A1C target to 7% B. Follow up with an audiologist C. Recommend use of a walker D. Referral for physical therapy E. Start meclizine for his dizziness SUBMIT

The correct answer is A The best next step to prevent a future fall is to reduce the likelihood of hypoglycemia. Insulin is renally excreted and patients often need lower doses as they age and renal function declines. This patient's Hemoglobin A1C goal should be 7% at the lowest and maybe even 8% if the patient has significant comorbidities and limited life expectancy. The patient's dizziness prior to his fall is likely due to hypoglycemia and not from vertigo; starting a new medication, like meclizine, is not needed and could lead to an increase in symptoms. The patient's hearing is intact with his current hearing aids, so he does not need to see an Audiologist at this point. After a fall, physical therapy can be helpful to improve balance; however, that would not be the next best step. Given that the patient's Get Up and Go Test is normal and his gait is intact, he does not need a walker at this time.

A 78-year-old patient comes to the clinic with concerns of feeling tired and sad. She recently moved into an assisted living facility. She tells you she feels depressed and isn't interested in making new friends or joining any of the group activities. She states no suicidality. Her past medical history includes hypertension (HTN) and diabetes. Her medications include lisinopril 5 mg daily, hydrochlorothiazide 25 mg daily, and metformin 500 mg twice daily. Her physical examination and laboratory studies are unremarkable. The PHQ-9 score is 12. The patient is referred for psychotherapy and started on sertraline for her depression. What is the best next step at her one-month follow-up visit? Choose the single best answer. A. Basic chemistry B. Blood glucose level C. Complete blood count D. Echocardiogram E. Sertraline level SUBMIT

The correct answer is A. A potential side effect of SSRI medications, such as sertraline, may be hyponatremia. This patient is also taking hydrochlorothiazide which may also decrease serum sodium levels. Hyponatremia is more likely in older patients and in those taking other drugs associated with hyponatremia, such as diuretics. In such patients, serum sodium should be checked before and several weeks after starting an SSRI. An SSRI does not affect blood glucose or blood counts. Unlike some other SSRIs, sertraline is not known to cause QT prolongation, hence, ECG or echocardiogram is not recommended. Sertraline cannot be measured by blood levels.

An 82-year-old female is brought to the emergency department (ED) because of a two-day history of rash and pruritus. The rash is along her arms and upper chest. She recently started taking a three-day course of trimethoprim-sulfamethoxazole for a urinary tract infection (UTI). Medical history is significant for type 2 diabetes, hypertension, and hyperlipidemia. She drinks one to two glasses of wine a night. She does not have tobacco or recreational drug use. Medications are metformin, simvastatin, and lisinopril. The patient appears uncomfortable, but is pleasant and easily engages with you. Skin exam is notable for a diffuse maculopapular rash along the upper extremities and upper chest. The patient is given intravenous (IV) diphenhydramine for pruritus. When you check on the patient in one hour, they are difficult to arouse and are confused. The nurse notes normal vital signs. A brief physical examination shows an older female in mild distress. Cardiac and pulmonary examinations are unremarkable. Complete blood count (CBC) and chemistry panels are normal. Your resident suggests you screen for delirium. Which of the following information do you need to complete the confusion assessment method (CAM)? Choose the single best answer. A. Whether the patient can list days of the week or months of the year backward B. Whether the patient can state their name, the date, and the name of the hospital C. Whether the patient has a history of alcohol misuse or alcohol withdrawal D. Whether the patient has baseline cognitive impairment E. Whether the patient has had a similar reaction to diphenhydramine before

The correct answer is A. Days of the week or months of the year backward are tests of attention. The patient's acute change and altered level of consciousness provide two of the three components needed for a positive CAM. Evidence of inattention, which can be assessed with serial sevens, spelling "world" backward, or days of the week backward, can confirm delirium. Whether the patient can state thier name, the date, and the name of the hospital is incorrect because, questions about orientation are part of a thorough neurological assessment and are part of the Abbreviated Mental Test of the 4AT, not a part of the CAM. The purpose of the CAM is to screen for delirium, not to identify predisposing or precipitating factors. It is important to assess the risk of alcohol withdrawal and alcohol use as a cause of altered mental status; however, it is not part of the CAM. Furthermore, patients with alcohol withdrawal typically present with additional abnormal physical exam findings such as tachycardia, diaphoresis, and anxiety. Similarly patients with cognitive impairment are at increased risk of delirium, but this doesn't provide information needed to complete the CAM. Whether the patient has had a similar reaction to diphenhydramine would also signal a possible precipitating factor, but a history of delirium or of adverse reactions to deliriogenic medications are not a part of the CAM. Medications such as antihistamines, anticholinergics, benzodiazepines, and muscle relaxants are all deliriogenic.

A 78-year-old patient is brought to the emergency department (ED) by the local police after being called by the neighbor about an overgrown and unkempt lawn. The neighbor notes that the man has lived alone since his daughter moved out six months ago, and now she visits "once a month to collect the check." Upon entering the home, the police found the patient disheveled and soiled with urine and feces and the house in disarray with spoiled food and garbage throughout. On contact with the daughter, the listed health care power of attorney, she states that she drops off groceries and medications monthly but she "can't help someone who won't help himself." Medical history is significant for dementia, depression, osteoarthritis, and hypothyroidism. Medications include acetaminophen and levothyroxine. The man has missed his last two appointments with his primary care provider (PCP) with prior notes stating his daughter demonstrated symptoms of significant caregiver stress. Vital signs are normal. Weight is 53.5 kg (117.9 lbs). Height is 175 cm (5 ft 9 in). Body mass index (BMI) is 17.5 kg/m2. Physical examination shows a cachectic older adult with strong odor noted. He has evidence of multiple dental caries. Nails are long on hands and feet. There is scattered bruising on forearms. He has abrasions on his knees but cannot explain where they came from. Osteoarthritis changes are noted in many joints, and his gait is slow and unsteady. Results of laboratory studies are normal except for an elevated thyroid-stimulating hormone (TSH) of 18 µIU/L. Which of the following is the next best step for care of this man? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Assess decision-making capacity B. Get a court-appointed guardian C. Order whole body imaging D. Refer to Adult Protective Services (APS) E. Transfer to a nursing home SUBMIT

The correct answer is A. Decision-making capacity should be assessed. This patient's history and physical exam findings are most consistent with self-neglect, likely due to dementia. Assessment of cognition and decision-making ability is the first step in moving forward to help the patient. Decisional patients may decline adult protective Services Contact and assistance. The exam findings are consistent with self-neglect, not physical abuse, as forearm bruising is not uncommon in older adults. The neighbor is not legally responsible for the care of this patient.

A 70-year-old patient comes to the clinic because she is worried about her memory. She worries that she is having more difficulty with remembering names and feels like her thinking is "clouded and slower." She has been noticing these changes for the past three months. She is the caregiver for her mother, who has dementia and is concerned that she may also have the disease. She tells you that her mother is requiring much more care now and that it is getting harder to manage everything. She isn't able to visit friends or be part of her book club. She is tired and feels like "everything hurts." She is having trouble sleeping and feels anxious, but doesn't feel depressed. Medical history is significant for hypertension, gastroesophageal reflux disease, and cataracts. Medications are hydrochlorothiazide and famotidine. Vital signs are normal. The patient is alert, but appears to have a flat affect and speaks in a low and quiet voice. Physical examination shows an alert but anxious female with early cataracts bilaterally. Her cardiopulmonary examination is normal and her abdominal examination shows mild tenderness in the epigastric region. Her neurological examination is normal. Results of laboratory/diagnostic studies show mildly decreased vitamin B12 and an elevated methylmalonic acid level. What is your next step in caring for this patient? Choose the single best answer. A. Administer the Geriatric Depression Scale B. Consult psychiatry C. Order computed tomography (CT) scan of the head D. Prescribe cyanocobalamin E. Prescribe donepezil

The correct answer is A. Depression in older adults may present atypically, with symptoms of fatigue, weight change, memory complaints, and multiple somatic complaints. As older adults may not endorse feelings of depression, formal screening using the Geriatric Depression Scale may be helpful in diagnosis. Further evaluation of the patient's memory and cognition is warranted but the first step is office-based screening using a tool such as the MoCA or mini-mental state examination (MMSE). Psychiatric referral may be needed in complex or atypical cases. Imaging is not the first step in the clinical evaluation of depression or memory loss when the neurological examination is normal. Low B12 may contribute to, or cause, memory loss and cognitive decline but a diagnosis is the first step in management. While the patient has subjective memory loss complaints, they have not yet completed a cognitive evaluation. In older adults, mood and cognitive concerns may sometimes mimic each other. The next step is to further assess for depression before starting pharmacotherapy.

A 74-year-old patient comes into the clinic by himself and is not sure why he is there. He said his son is parking, and he is feeling scared. Halfway through the appointment, his son joins the appointment and says the man is there for a wellness visit. The man has missed his last three appointments. Since his last clinic visit eight months ago, he looks like he lost weight, and he is now using a walker. Medical history is significant for atrial fibrillation, coronary artery disease (CAD), hyperlipidemia, hypertension (HTN), osteoarthritis, osteoporosis, and vascular dementia. Patient and son are unsure which medications he is taking at home. Based on the last clinic visit, medications are acetaminophen, alendronic acid, amlodipine, apixaban, atorvastatin, and metoprolol succinate. Vital signs are normal. Weight is 54 kg (120 lbs). Height is 173 cm (5 ft 8in). Body mass index (BMI) is 18.2kg/m2. The man appears disheveled with dirty clothes that smell like tobacco. He has bilateral temporal wasting and poor dentition with plaque over his teeth. Lung and cardiac exams are normal. He has a hesitant, slow gait with a walker. He is alert to self, but not to date or location. He appears withdrawn and has a flat affect. His skin is diffusely dry. Long, thick toenails are noticed on his foot exam. Results of laboratory/diagnostic studies show a normal urinalysis, normal complete blood count (CBC), sodium (Na) of 141 mEq/L, blood urea nitrogen (BUN) of 35 mg/dL, creatinine (Cr) of 1.3 mg/dL (baseline creatinine is 0.8 mg/dL), and albumin (Alb) of 2.5 g/dL. Which of the following is the best next step in the management of this man? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Call Adult Protective Services (APS) B. Order a computed tomography (CT) scan of the head C. Refer him to home care services D. Refer him to the emergency department (ED) E. Schedule follow-up in one week

The correct answer is A. The next best step is to call Adult Protective Services (APS) due to concern for elder neglect in this patient. Although it would be a good idea to have a close follow-up in a week and consult a home visit to assess his safety, the best next step would be to call APS due to high suspicion for elder abuse and neglect. Suspicions of abuse or neglect do not have to be confirmed; any suspicion is enough grounds to contact APS. There is no acute indication for this patient to be admitted to the hospital. Given his WBC is normal and his urinalysis is normal, an acute infection is unlikely the cause of his confusion. Given the history of Atrial Fibrillation, an acute stroke is possible, though less likely given that he has many reasons for being confused, including malnutrition, acute kidney injury, Vascular Dementia, and neglect from his caregiver/son. A CT head would not be the most appropriate next step.

A 78-year-old female is admitted to the hospital after a fall. She is found to have a femoral neck fracture and undergoes surgical repair by orthopedic surgery. You are seeing her post-op day one as part of geriatrics co-management of her medical problems. Medical history is significant for hypertension (HTN), diabetes, insomnia, and anxiety. Medications are aspirin, lisinopril, metformin, and sertraline. Vital signs are normal. Physical examination shows a thin female in no apparent distress. She is restless and occasionally inattentive. Cardiac examination is unremarkable. Lungs are clear to auscultation bilaterally. Skin is dry. Neurologic examination is without focal deficits. Results of laboratory studies show elevated blood urea nitrogen (BUN) of 45 mg/dL and creatinine (Cr) of 1.5 mg/dL. White blood count (WBC) is 6,400/mm3, and hemoglobin (Hb) is 10.2 g/dL. Which of the following interventions would be your next best step in the management of this patient? Choose the single best answer. A. Get the patient up out of bed every shift B. Oral diphenhydramine 12.5 mg at night to help with sleep C. Oral lorazepam 0.5 mg every six hours as needed for anxiety D. Strict bed rest to minimize post-op pain E. Two-liter fluid restriction

The correct answer is A. Encouraging physical activity and time out of bed is helpful for maintaining a patient's sleep-wake cycle and preventing delirium. Physical activity should be encouraged even in the acute postoperative time. Benzodiazepines and antihistamines should be avoided in older adults as they can precipitate delirium. Dry skin and a BUN of 45 indicate possible dehydration. In the absence of a history of heart failure, fluid restriction is not needed and should be avoided as dehydration is a precipitating factor for delirium. Oral and/or intravenous fluids should be encouraged in the post-operative period to prevent delirium.

Older patients have a lower hypothalamic set point resulting in a lower body temperature. For this reason, fever is defined as a rise in temperature of two degrees Fahrenheit or 1.1 degrees celsius from baseline. This lower set point can result in older patients not being identified with having a fever as they do not have a temperature of 101.5 °F or 38.6 °C. For example, for a patient with a baseline temperature of 97 °F a temperature of 99 °F would be a fever but go unrecognized. In addition to the lower set-point, older patients, especially frail older patients, are less likely to have a rise in temperature when they have an infection. Which of the following best explains the reason for this? Choose the single best answer. A. Immunosenescence B. Inflammaging (chronic inflammation of aging) C. Less body fat D. Less muscle/sarcopenia

The correct answer is A. Immunosenescence (A) is correct. Immunosenescence refers to the declining strength of the aging immune system's ability to fight off infection. Due to the decline in the innate and adaptive immune system, there is less response to the bacterial infection and less release of cytokines, like Interleukin-1, Interleukin-5, and TNF. Inflammaging (B) refers to a chronic inflammatory state more common in older adults typified by higher levels of inflammatory cytokines and is not the major contributor to the absence of fever. Sarcopenia (D) may contribute to the inability to raise temperature through shivering, but is not the major contributor. Changes in thermogenic brown fat that accompany aging may also play a role in a blunted fever response in animal studies, but that is also not the dominant reason for less fever. Most older individuals have more body fat rather than less as they age (C).

A 79-year-old male comes to the clinic for a preoperative evaluation for his upcoming elective right total hip arthroplasty. The surgeon requested labs: complete metabolic panel (CMP), complete blood count (CBC), and international normalized ratio (INR), and a "clearance" form be filled out and note sent from his visit with you. The patient has had chronic right hip osteoarthritis that has become progressively more painful and now limits his ability to complete his daily two-mile walk around the neighborhood for the past three months. Medical history is significant for hypertension (HTN), hearing impairment, mild cognitive impairment, and osteoarthritis. Medications are acetaminophen three times a day, amlodipine, and lisinopril. Vital signs are normal. Physical examination shows a kyphotic male who is well-groomed, in no acute distress and wearing bilateral hearing aids. Cardiac, pulmonary, and abdominal examinations are normal. There is tenderness over the right hip to palpation that radiates to his groin. He has an antalgic gait with the aid of a walker. There is decreased range of motion of the right lower extremity. Results of laboratory studies are normal. Right hip x-ray, from a month ago, shows severe osteoarthritis. Which of the following should also be completed as part of this preoperative evaluation? Choose the single best answer. A. Assess baseline cognitive and functional status B. Complete skin examination C. Obtain a magnetic resonance imaging (MRI) of the pelvis and right hip D. Order a chest x-ray E. Order a wheelchair for the man to have after surgery

The correct answer is A. Most preoperative evaluations include a physical exam, laboratory assessment, and comprehensive medication reconciliation, including over-the-counter medications and supplements. As part of a preoperative evaluation for an older adult, the following assessments should also be done: baseline cognitive and functional status, home supports, and advance care planning to help further risk stratify patients as well as make recommendations for intra-operative and postoperative care. Those with baseline cognitive deficits are at higher risk of developing delirium in the immediate postoperative period, and those with functional limitations may need consideration from social work and physical therapy during discharge planning. A chest x-ray is not clinically indicated as part of the pre-operative evaluation. Recent x-rays were done and further imaging was not requested by the surgeon, so an MRI is not the correct answer. It is too early to know if the patient will need a wheelchair after his surgery; however, asking about home support, potential barriers (e.g. stairs to get in the home to get to a bathroom), and what equipment that patient already has at home is helpful as some of these things can be addressed prior to surgery and ready when the patient comes home. A complete skin examination is indicated upon admission and frequently during hospitalization for early identification and prevention of pressure injuries, but it is not indicated in the preoperative assessment for an ambulatory patient.

A 75-year-old patient is seen in the clinic with a concern of depressed mood. He has had depression in the past, which was successfully treated with paroxetine. He now reports sadness, lack of energy, feelings of helplessness, and apathy. Past medical history is significant for depression (age 45), coronary artery disease (CAD), hypertension (HTN), and chronic kidney disease (CKD) stage 2. Medications include ASA 81 mg daily, metoprolol 25 mg twice daily, lisinopril 10 mg daily, and simvastatin 20 mg daily. His vital signs are within normal limits and his physical examination is unremarkable. What medication would you recommend to treat this patient's depression? Choose the single best answer. A. Sertraline B. Lorazepam C. Methylphenidate D. Mirtazapine E. Paroxetine

The correct answer is A. SSRIs, examples of which include sertraline and escitalopram are a first-line pharmacologic treatment for elderly patients with depression. Fluoxetine is not recommended for use in the elderly because of its long half-life and prolonged side effects. Paroxetine is also not recommended for use in older patients as it has the greatest anticholinergic effect of all the SSRIs, similar to that of the tricyclic antidepressants desipramine and nortriptyline. SNRIs, examples of which include duloxetine, venlafaxine, and desvenlafaxine, are a reasonable choice, especially if the patient has coexisting pain—in particular, neuropathic pain. However, most physicians would use an SSRI first and large trials do not show increased efficacy of the SNRIs versus the SSRIs. Lorazepam is a benzodiazepine that may contribute to falls and delirium. Methylphenidate is a stimulant medication that is not used as a first-line antidepressant medication unless rapid results are needed for depression towards the end of life. Mirtazapine is a non-SSRI antidepressant that is best used in situations of insomnia and low appetite, as it can specifically help both of these symptoms as well as depression.

Older adults are more likely to have symptomatic hypoglycemic episodes than younger people. Which of the following symptoms of hypoglycemia is less common in older than in younger adults? Choose the single best answer. A. Anxiety B. Delirium C. Dizziness D. Seizures E. Weakness

The correct answer is A. Symptoms of hypoglycemia are grouped into neurogenic and neuroglycopenic. Adrenergic neurogenic symptoms like anxiety (A) and tremor are less common in older adults, whereas neuroglycopenic symptoms which arise from the brain's lack of glucose tend to be the presenting symptoms for older adults, like seizures (D), delirium (B), weakness (E) and dizziness (C).

A 79-year-old patient is seen in primary care for follow-up. She has osteoarthritis, hypertension, elevated cholesterol, and diabetes. For many years she has been obese and ambulated slowly with the help of a cane for stability. In the past year her 4 m gait speed measured in clinic was 0.8 m/s. Six months after undergoing a knee replacement and working with physical therapy she has lost 20 lbs and increased her exercise capacity, now walking 1 mile every day. At her most recent clinic visit her 4 m gait speed was 0.95 m/s. Which of the following is most strongly associated with a reduction in mortality in older adults? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Improving gait speed by 0.1m/s B. Taking a daily aspirin C. Taking a daily multivitamin D. Walking every day

The correct answer is A. The correct answer is improving gait speed by 0.1m/s (A), which is associated with a 12% reduction in mortality risk in one year (pooled hazard ratio per 0.1 m/s, 0.88; 95% CI, 0.87-0.90; P < .001, from Studenski et al., JAMA 2011) This is true regardless of the reason for why walking speed improves. For some patients it is because they are now using a walker and feel more sure of their steps. For others, a knee replacement to treat severe OA is needed to improve mobility and function. And for others decreasing polypharmacy and avoiding orthostasis and hypoglycemia may make all the difference. Gait speed should be considered a vital sign that can be monitored over time for improvement or worsening. Simple daily walking (D) has not been strongly associated with a reduction in mortality; however, a structured walking/exercise program may be one component of a multipronged effort to improve gait speed. A daily multivitamin (C) is not recommended for reducing mortality in the general population. After age 70, a daily aspirin (B) is not recommended for primary prevention due to the increased risk of bleeding. U.S. Preventive Services Task Force. Final Recommendation Statement: Vitamin, Mineral, and Multivitamin Supplements for the Primary Prevention of Cardiovascular Disease and Cancer. February 2014. https://www.uspreventiveservicestaskforce.org/uspstf/announcements/final-recommendation-statement-vitamin-mineral-and-multivitamin-supplements-primary-prevention-cardiovascular-disease-and-cancer. Accessed April 1, 2022. U.S. Preventive Services Task Force. Final Recommendation Statement: Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication. April 2016. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/aspirin-to-prevent-cardiovascular-disease-and-cancer. Accessed April 1, 2022.

n 80-year-old patient comes to the clinic for a routine follow-up appointment. He has a two-month history of increased fatigue and reports feeling as if he has "no energy at all." He had been the caregiver for his wife, who died one month ago. He is eating less and while he doesn't know how much weight he has lost, he tells you that his pants are too loose now. He hasn't felt like going out for coffee with his usual bunch of friends and prefers staying in the house "watching TV." Through your review of systems, you find that he is having more knee and hip pain and is sleeping poorly. He is drinking two beers daily to help decrease his pain and while he manages his diabetes, he hasn't been checking his blood glucose levels lately. Medications are acetaminophen, lisinopril, atorvastatin, metoprolol, and metformin. Vital signs are normal. Physical examination shows an alert male, oriented to person, place, and time. His mood is "here and there," with a dysphoric affect. His physical examination is within normal limits except for osteoarthritis findings in knees and hands, including crepitus in his knees. Cognitive screening using the Montreal Cognitive Assessment (MoCA) Tool shows a score of 27/30 and the Geriatric Depression Scale screen reveals a score of 9/15. Results of laboratory/diagnostic studies show normal complete blood count (CBC), chemistry panels, and thyroid-stimulating hormone (TSH). His hemoglobin A1C (HbA1C) is 7.5%. What is the next best step in caring for this patient? Choose the single best answer. A. Ask the patient if they are having any thoughts of self-harm or suicide B. Order imaging C. Prescribe an antidepressant D. Refer the patient to psychology E. Screen for alcohol withdrawal SUBMIT

The correct answer is A. The patient demonstrates risk factors for suicide, including being an older adult, living alone, male gender, alcohol use, comorbid illness and pain, and depression. It is important to directly ask about suicidal ideation. In a grieving and depressed patient with weight loss but no worrisome findings on history, physical examination, and labs, imaging is not indicated. While an antidepressant may be of benefit for this patient the first step is to assess whether the patient is a risk to themself or others. While the patient is likely grieving and depression is a concern and psychological care is key, the first step is to assess whether the patient is a risk to themself and others. While the patient is demonstrating at-risk drinking behaviors, the first step is to assess the risk for self-harm.

An otherwise healthy 37-year-old male presents with abdominal pain, nausea, vomiting, and no bowel movement in 7 days; He receives a computed tomography scan of his abdomen/pelvis in the emergency department, which reveals a circumferential mass in the sigmoid colon with partial obstruction. He is admitted to the hospital for urgent workup of suspected cancer and management of his symptoms. Gastroenterology is consulted and performs a colonoscopy, taking local biopsies of the mass, which are suggestive of malignancy. Computed tomography scan of chest/abdomen/pelvis with contrast is performed for staging purposes which reveals no regional lymph node metastasis and no evidence of tumor in distant sites or organs. He is discharged home with moderate improvement in symptoms, with scheduled colorectal surgery follow-up. While he is waiting for follow-up appointment, the biopsy confirms primary colon cancer with high-risk genetic features. At home he continues to experience pain, as well as constipation from opioid medications. He returns to colorectal surgery clinic and is counseled about diagnosis of stage II colon cancer. Surgery is planned a few weeks later, and referral is made to medical oncology to discuss adjuvant chemotherapy. Twoweeks later, he undergoes sigmoid colectomy. Based on conversation with medical oncology, he receives three months of adjuvant chemotherapy. He develops chemotherapy-induced nausea and vomiting, resulting in hospitalization for dehydration and acute kidney injury. One year following completion of treatment, he receives carcinoembryonic antigen testing, surveillance computed tomography scans and colonoscopy. Post-treatment surveillance renders him cancer-free at one year Is palliative care appropriate for this patient, and at what point in his serious-illness trajectory? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Yes - at time of initial hospital presentation B. Yes - when diagnosis of colon cancer is confirmed C. Yes - when he develops symptoms from cancer-directed treatments D. No - he is too young to receive palliative care E. No - his disease is considered curable F. No - he lacks palliative care needs

The correct answer is A. The patient presented with uncontrolled symptoms (pain, nausea, vomiting, constipation). Although cancer is not yet confirmed at time of presentation, it is appropriate to provide palliative care since serious illness is suspected (and, one could argue, his hospitalization alone is "serious" for an otherwise-healthy 37 year old). Additionally, the process of diagnostic procedure, waiting for diagnosis, and fear of a cancer diagnosis often leads to emotional/psychological stress. Coping with this stress (emotional well-being) and starting to support his medical decision-making (communication) are also focuses of palliative care. In general, earlier palliative care intervention leads to improved quality of life for patients. Choice B: Although not inappropriate, the "need" for intervention may be less by this point, as he was discharged from the hospital with improvement in symptoms. Choice C: He presented to the hospital with physical symptoms, and developed emotional/psychological needs as well prior to starting cancer-directed treatments. Choice D: Palliative care is appropriate at any age Choice E: Palliative care is appropriate at any stage of a serious-illness Choice F: He has physical symptoms, emotional/psychological needs (coping with stress of work-up and waiting for diagnosis), and likely communication needs (counseling about treatment options).

An 88-year-old female is seen in consultation for memory loss by a geriatrician. She lives alone in her own home. She is noted to have had short-term memory issues over the past year but has always been independent in her IADLs. Her daughter notes that her memory loss has significantly progressed over the last month, during which period she has had a weight loss of 3.2 kg (7 lbs), with a baseline weight of 54.4 kg (120 lbs), three to four falls, and increased paranoia. She can no longer operate her television or telephone. She has a history of osteoporosis, spinal stenosis, and essential hypertension (HTN). She takes amlodipine, vitamin D3, and alendronate. Her daughter sets up her pillbox weekly and notes her mother having increasing difficulty with this. On examination, her vitals are normal. She has a kyphotic posture and appears thin. She maintains good eye contact, hearing is normal. Her speech is coherent and intelligible. There are no focal deficits. She is forgetful, and oriented to place and person but not to date/month. You complete a lab workup for any possible reversible cause of dementia; all results are normal. Depression screen is negative. Her score on the Montreal Cognitive Assessment (MoCA) is 18/30 (normal ≥ 26). What is the best next step? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Brain imaging B. Recommend increased supervision in assisted living C. Referral to neurology D. Referral to physical therapy E. Start donepezil SUBMIT

The correct answer is A. This patient has a fast progression of cognitive decline over the last month in the context of several falls and significant weight loss. This requires brain imaging to rule out acute infarcts, mass, or hematoma. The patient may need increased supervision but would first require more workup to rule out reversible causes of her decline. A referral would be inappropriate when the immediate workup is not yet complete. The patient may benefit from physical therapy but first, a brain MRI would be needed as she may have had TBI from her falls. Donepezil would be appropriate management for dementia, but first intracranial pathology should be ruled out when fast progression is present, as well as other possible red flags, such as significant weight loss and falls.

A 93-year-old male comes to the clinic accompanied by his spouse for a preoperative comprehensive geriatrics assessment before an elective total hip replacement surgery. Medical history is significant for mild aortic stenosis, atrial fibrillation, chronic kidney disease (CKD) stage 3, hypertension (HTN), heart failure with reduced ejection fraction (HFrEF) with EF 40%, depression, insomnia, severe osteoarthritis, and osteoporosis. Medications are apixaban, atorvastatin, carvedilol, diazepam, furosemide, paroxetine, and acetaminophen as needed. Vital signs are normal. Physical examination shows a male in no acute distress. Cardiac examination reveals a systolic murmur best heard over apex, irregularly irregular rhythm, and trace lower-extremity edema bilaterally. Pulmonary and abdomen examinations are normal. The patient has kyphosis and decreased range of motion of bilateral lower extremities, and walks with an antalgic gait. There are no focal neurological deficits. Results of laboratory studies are normal except for a creatinine (Cr) of 1.4 mg/dL. Which of the following medications should be held prior to surgery? Choose the single best answer. A. Apixaban B. Atorvastatin C. Carvedilol D. Diazepam E. Paroxetine

The correct answer is A. This patient needs to hold apixaban, an anticoagulation medication, at least 48 hours prior to his hip surgery in order to safely be able to operate and not have bleeding complications. There are no contraindications for the patient to continue atorvastatin or carvedilol before or after surgery. Depending on his fluid status, his furosemide could be continued or held; either way, monitoring his kidney function will be important. The patient should take paroxetine on the day of surgery and restart as soon as medically possible post-surgery to prevent paroxetine related discontinuation syndrome. This patient likely should not be on diazepam as it is on the AGS Beers criteria and can lead to increased delirium and falls. However, it would be important to assess the chronicity of the medication use in order to prevent benzodiazepine withdrawal; a slow taper of diazepam may be required.

A 70-year-old patient comes to the clinic with his wife for a wellness visit. His wife asks whether her husband should have a "screening test to be sure he doesn't have colon cancer." The patient has not had blood in his stools, constipation, diarrhea, abdominal pain, or weight loss. Medical history is significant for moderate stage Alzheimer dementia diagnosed four years earlier. His wife helps with his medications, finances, and all household tasks. The man is starting to require more assistance with dressing and with showering himself. He is able to feed himself independently and speaks with one-word answers. Medications are donepezil 5 mg daily and a multivitamin. Vital signs are within normal limits and his physical examination is unremarkable. His cognitive examination is notable for a Montreal Cognitive Assessment score of 15/30 (normal score ≥ 26). You discuss the patient's disease process and ascertain his goals of care from him and his wife. His wife asks you for your recommendation of whether a screening colonoscopy will benefit her husband. You advise against the procedure based on what principle? Choose the single best answer. A. Lag time to benefit B. Lead time bias C. Medical futility D. Test sensitivity E. Test specificity

The correct answer is A. You advise against the screening procedure based on the principle of lag time to benefit. In a patient with moderately advanced dementia the average added life the patient would need to live to benefit from the procedure is (in this case), 7-10 years, which is longer than the estimated lifespan of a patient with moderate stage dementia. Lead time bias refers to the perceived added lifespan of a patient due to an earlier diagnosis time. Medical futility is invoked at the end of life when determining that further medical efforts will not extend life. Dementia does not change test sensitivity or specificity.

An 80-year-old male is brought to his primary care clinician by his daughter, who is visiting from out of state, with memory concerns. The patient has a history of hypertension (HTN) and hyperlipidemia. He hasn't seen his clinician in over a year. He is prescribed losartan and atorvastatin, but his daughter is concerned because she noticed unopened prescription bottles in his apartment that were filled two months ago. She also noted that his apartment was unkempt and there were several new dents and a broken mirror on his car. He doesn't know how the damage happened to his car. He has been in good spirits. On examination, vital signs are significant for a blood pressure of 155/85 mmHg, otherwise normal. His weight has gone from a baseline of 81.6 kg (180 lbs) one year ago to 77.1 kg (170 lbs). He appears well-nourished. Hygiene is appropriate. He is unable to name the month, year, or date. Laboratory results show a normal urinalysis, basic chemistry, and complete blood count (CBC). The Geriatric Depression Scale is normal. He is given the Montreal Cognitive Assessment (MoCA). A normal score is ≥ 26/30. His score is 22/30. In addition to his abnormal cognitive screening test, which finding reinforces the diagnosis of dementia in this patient? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Hypertension B. Loss of ability to manage medications C. Normal depression screen D. Short-term memory loss E. Weight loss SUBMIT

The correct answer is B. Abnormal cognitive screening in addition to loss of major daily function (IADLs) is required in the diagnosis of dementia. If a patient only has measured cognitive impairments without loss of function, the diagnosis is mild cognitive impairment (MCI). Chronic hypertension is a risk factor for vascular dementia but not required for diagnosis. Normal depression screening is not included in a dementia diagnosis, although it is valuable information. Short-term memory loss can occur in dementia but is not required for diagnosis. A 10 lb. weight loss is significant enough (> 5% over 6-12 months) to warrant intervention and can occur in dementia. However, it is not included in a diagnosis.

A 68-year-old female presents to primary care clinic for a yearly physical. You last saw her a year ago, and have been following her for the past decade. During the visit she endorses a months-long history of fatigue, poor appetite, and weight loss. In the past couple of weeks she noticed her urine getting darker, and she developed epigastric pain three days ago. You refer her for an abdominal computed tomography scan, which shows a mass in her pancreas with occlusion of her superior mesenteric artery, as well as numerous peripancreatic lymph nodes. You refer her to gastroenterology, which performs endoscopic ultrasound with fine needle aspiration. Biopsy confirms pancreatic cancer. You next refer her to medical oncology and surgical oncology, who both discuss potential treatment options for her cancer. Since you are her most trusted provider, she makes an appointment with you to help with her medical decision-making. Prior to her appointment, you reach out to oncology to better understand her prognosis, medical options and timeline for a decision. On returning to your office, she appears emotionally distressed. She tells you she has been in tears daily since learning about her diagnosis, and she is struggling to manage day-to-day. She expresses significant fear about her future, about her family and whether she is "strong enough" to pursue treatment. She says, "I know I'm going to die," and "I've been praying every day." When a patient presents in emotional or spiritual distress about their serious illness, the appropriate first step is to: Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Ask them to meet with their spiritual leader B. Explore their spiritual beliefs C. Reassure them that everything will be okay D. Refer them to psychology for help with coping E. Tell them God will give them strength

The correct answer is B. Although you may eventually refer the patient for supportive therapy (D) and it is always beneficial to involve a patient's personal spiritual support systems (A), a core palliative care skill is the ability and willingness to make an initial attempt to explore a patient's spiritual and cultural beliefs, and find out how these beliefs may or may not affect their experience of serious illness. While there is no expectation that a provider will engage the patient in a deep spiritual conversation or debate, the act of openly listening to the patient engenders an environment of openness and trust between the patient and their provider. There are different tools that can be used to complete this assessment (e.g., the FICA spiritual history tool). Answer (C) is not correct, as you need to explore a patient's spirituality and emotion before providing reassurance so you can correctly address their needs. Additionally by simply telling them "everything will be okay," you risk diminishing their emotions and experience. Answer (E) is incorrect, as you must explore their faith before imposing any personal theology or beliefs on them. This response may be the appropriate one if it is already known that you and the patient share similar beliefs, or if you've previously shared spiritual discussions.

A 78-year-old patient is awaiting a kidney transplant for end-stage renal disease from advanced diabetes. She is independent in her ADLs but does need assistance with driving due to vision loss from diabetic retinopathy and help with her IADLs. Her A1C is 7.1% on most recent labs and her blood pressure is 130/60. Which of the following is most likely to optimize her frailty status prior to surgery? Choose the single best answer. A. Controlling her AIC to < 6.5% B. Exercise program under the guidance of a physical therapist C. Protein supplementation D. Social work consultation for ride services due to patient's inability to drive E. Vitamin D supplementation SUBMIT

The correct answer is B. An exercise program under the guidance of a physical therapist (B) is likely to improve her frailty status, especially if it includes a multi-component program that combines aerobic and balance training along with resistance training. "Prehabing" a patient prior to surgery can be extremely helpful in improving their ability to recover. Although addressing her challenges with driving (D) and vitamin D (E) are important, they are not as likely to impact frailty. Protein supplementation (C) has not been shown to improve frailty by itself. Control of her A1c to < 6.5% (A) is contraindicated as it would increase the risk for hypoglycemia and potentially increase her mortality.

An 88-year-old patient comes to the clinic with her son, who is her primary caregiver, with progressive hallucinations, wandering at night, trying to open the front door, and not letting anyone brush her hair. A month ago, the patient and her son came to the clinic due to these behaviors and were told to place additional locks on the doors, try aromatherapy and music therapy, and that things should get better. A week ago, her son was called by the police when his mother was found in a park. Today, the son brought the patient to the clinic because her behaviors have not improved; he reports being exhausted. Medical history is significant for vascular dementia, diabetes (diet controlled), gastroesophageal reflux disorder (GERD), hypothyroidism, and spinal stenosis. Medications are acetaminophen as needed, levothyroxine, and pantoprazole. Vital signs are normal. Physical examination shows a kyphotic older female with knotted hair, slightly disheveled appearance, but in good spirits. Normal lung, cardiac, and abdominal examinations. The patient knows she is at the doctor, but does not know why or the date. Speech is tangential but coherent. No gross neurological deficits are noted. Results of laboratory studies are within normal limits. The son inquires about medication options. Which of the following should you tell the son before prescribing antipsychotics? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Antipsychotics are FDA approved in patients with dementia. B. Antipsychotics increase the mortality risk in those with dementia. C. There are few cardiovascular risks for dementia patients taking antipsychotic medications. D. There is a black box warning for typical antipsychotics, but not for atypical antipsychotics.

The correct answer is B. Antipsychotic medications are known to have a number of adverse effects. The clinician must educate patients and caregivers about the risks and side effects of antipsychotic medications. Antipsychotic medications should be the last resort but are sometimes necessary for treating behavioral disturbances. Before starting a patient on antipsychotic medications for dementia with behavioral manifestations, the patient and/or caregiver should know the black box warning. Antipsychotic medications, both atypical and typical, are off-label use (not FDA approved) and have been shown to increase the mortality risk in patients with dementia. Most deaths are due to cardiovascular or infectious events when taking antipsychotic medications in patients with dementia.

A 66-year-old patient with a history of cognitive delay and blindness since childhood is brought to see a new primary care physician to establish care. He was accompanied by his paid private-hire caregiver. His family pays for him to live in a senior apartment with 24/7 supervision as he needs assistance with IADLs and some ADLs. He has a history of anxiety, hypothyroidism, and hyperlipidemia. His medications include levothyroxine, lorazepam, and simvastatin. He reports no complaints today. Vital signs are normal except for a Body Mass Index of 17.6. He appears thin and pale. His hygiene is poor, hair is unkempt and he has a strong odor. His clothing is covered in food stains. Dentition is poor. Halitosis is present. His fingernails are long, uneven, and dirty. He has dry, scaly skin on his arms and legs. There is faint bruising on his bilateral wrists. His cardiac and respiratory exams are normal. He speaks only in short sentences and doesn't act appropriately in simple commands. He is oriented only to self. Results of laboratory studies show hemoglobin of 8.5 with mean corpuscular volume of 101. His sodium is 131 and creatinine 1.5. Which of the following is the most significant risk factor of elder abuse for this patient? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Blindness B. History of cognitive delay C. Low body mass index D. Non-family caregivers E. Residence in a senior apartment SUBMIT

The correct answer is B. Elder abuse is common and underreported. Vulnerable older adults more likely to experience abuse are those with a history of mental illness or cognitive impairment. Additionally, it is more likely that elders are abused by family members who are known to the victim. Elder abuse is more likely to happen in group homes or long-term care settings.

A 85-year-old patient comes to the clinic he asks you to be sure to "do all recommended screening tests." Medical history is significant for hypertension, hypercholesterolemia, COPD, and chronic kidney disease stage 4. Social history includes no current alcohol use and a history of smoking 1 pack of cigarettes daily from age 25 to present. Vital signs show blood pressure reading of 160/84, heart rate 84 beats/min, respiratory rate 16/min, afebrile. What key factor must be considered as you weigh whether low-dose pulmonary CT scanning is appropriate screening for this patient? Choose the single best answer. A. Diagnosis of COPD B. Expected longevity C. Family history of lung cancer D. Pulmonary function test results E. Smoking history SUBMIT

The correct answer is B. Expected longevity due to age 85. The USPSTF recommends screening for adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. His age of 85 is the key factor to consider as you weigh the appropriateness of a screening low-dose pulmonary CT scan for this patient. COPD and prior history of tobacco use are important risk factors, but even with these risk factors, screening for age > 80 is not recommended. Pulmonary function tests do not indicate the likelihood of pulmonary malignancy and are not relevant here.

A 90-year-old patient comes in to the clinic for a follow-up visit. She has a history of hypertension and osteoarthritis and takes amlodipine and acetaminophen. Prior surgeries include an appendectomy and total abdominal hysterectomy for fibroids. She was recently admitted to the hospital after developing acute abdominal pain and vomiting. She was diagnosed with a small bowel obstruction, which was managed medically. Prior to this hospitalization, she was independent in ADLs and needed assistance with some IADLs such as grocery shopping and house cleaning. She often felt fatigued and reported slowing in completing tasks. After the hospital stay, she noted that she was considerably weaker and required increased assistance with ambulation, bathing, and dressing. She was subsequently transferred to a subacute rehab for two weeks, and then recently discharged to home. Which of the following terms best describes the syndrome of decreased physiological and functional reserve/resilience present in this individual during her hospitalization? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Disability B. Frailty C. Functional impairment D. Multimorbidity

The correct answer is B. Frailty (B) is correct. Frailty is defined as a syndrome of decreased physiological and functional reserve and resilience that leads to an increased risk of adverse outcomes among older adults. In this case, the patient describes slowing, fatigue, weakness, and needing assistance with some IADLs. Based on the Clinical Frailty Scale, she would be mildly-moderately frail (CFS 5-6). Frailty increases the risk of adverse outcomes, which include increased mortality and morbidity. Due to the decreased physiological and functional reserve and resilience, this patient experienced a decline after an acute illness. Frailty can increase the risk of discharge to an institution after a hospital stay, which occurred in this case. Disability (A) is incorrect. Disability is a broad term that indicates impairment that limits activity or restricts participation. Functional impairment (C) is incorrect. Functional impairment more specifically indicates a limitation in a person's ability to perform an activity independently. While this patient does have functional impairment as well, this does not indicate the underlying decreased physiological and functional reserve, defined as frailty, that led to an increased risk of adverse outcomes during her hospitalization. Multimorbidity (D) is incorrect. Multimorbidity is commonly defined as the presence of multiple chronic conditions in an individual. While there is considerable overlap between individuals with multiple chronic conditions and those with frailty, multimorbidity alone does not necessarily portend decreased physiological and functional reserve and resilience.

Based on your understanding of the pharmacodynamics of diabetes medications, which of the following, when used as monotherapy, is least likely to cause hypoglycemia? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Glipizide B. Metformin C. NPH Insulin 10 units subcutaneously QHS D. Repaglinide E. None of the above SUBMIT

The correct answer is B. Metformin is the least likely to cause hypoglycemia due to its mechanism of action. It decreases gluconeogenesis in the liver. Insulin, glipizide, and repaglinide all increase the risk of hypoglycemia. In addition to metformin, there are other medication options that are unlikely to cause hypoglycemia. The table below details mechanisms of action, hypoglycemia risks, and other prescribing considerations for diabetes medications.

An 86-year-old patient presents to the emergency department after her family found her down in her home. She lives alone; her fall was unwitnessed. Prior to this, she was able to do her usual activities. The last time anyone had spoken to her was 36 hours before. She has a history of type 2 diabetes mellitus and chronic kidney disease (CKD) stage 2. For the past 15 years, she has taken glimepiride, hydrochlorothiazide, metoprolol, aspirin, and rosuvastatin. Her family has recently been worried that her memory has worsened. They don't think she checks her blood sugars regularly. Her pulse is 107 beats/minute. Blood pressure is 106/54 mmHg. Weight is 45.3 kg (100 lbs). Height is 162 cm (5 ft 4 in). Her body mass index (BMI) is 17.3 kg/m2. Other vitals are normal. Physical examination shows a thin, lethargic female. There is temporal wasting and proximal muscle bulk is decreased. Mucous membranes are dry. Cardiovascular exam shows sinus tachycardia. Lungs are clear to auscultation. Abdominal exam is benign. There is no edema. Skin is dry. Today, laboratory/diagnostic studies show serum glucose of 40 mg/dL, potassium (K) of 5.0 mEq/L, BUN of 30, creatinine (Cr) of 1.5 mg/dL. Creatinine kinase is mildly elevated at 200 U/L. Which of her chronic medications is most likely responsible for this event? Choose the single best answer. A. Aspirin B. Glimepiride C. Hydrochlorothiazide D. Metoprolol E. Rosuvastatin SUBMIT

The correct answer is B. Of this list of medications, it is the sulfonylurea that is particularly concerning and a possible cause of her presentation. Sulfonylurea medications stimulate insulin release and hence, can lead to hypoglycemic events. Glimepiride (B) is renally excreted, leading to an increased likelihood of dangerous side effects in older adults, due to age-related reduction in renal function over time. The patient likely became hypoglycemic, fell, and then became dehydrated and went into acute renal failure and mild rhabdomyolysis. The dehydration was probably secondary to an inability to hydrate during the time she was on the floor, not a primary result of the HCTZ.

An 82-year-old patient was admitted to the hospital after a fall at home four days ago. He recently had an open reduction internal fixation (ORIF) of his right femur two days ago and is currently being evaluated for new-onset lethargy this morning. Medical history is significant for hypertension, dementia, and benign prostatic hyperplasia. He drinks on average one to two beers daily. Medications are amlodipine, tamsulosin, and vitamin D. Since surgery, the patient has been getting oxycodone as needed for pain. Temperature is 36.1 °C (97 °F), pulse is 110 beats/minute, respiratory rate is 12 breaths/minute, and blood pressure is 110/83 mmHg. Oxygen saturation is 99% on room air. Physical examination shows an older man who appears stated age, lying in bed with difficulty waking up despite tactile and verbal stimuli. He has dry mucous membranes, no oropharyngeal exudate. Lungs are clear to auscultation bilaterally; he has tachycardia, regular rate and rhythm, and no murmurs. Abdomen is soft with no facial grimacing to palpation, no suprapubic tenderness, and his dressing over the right surgical site is clean, dry, and intact without any tenderness. Results of laboratory studies show white blood cell count (WBC) of 6,400/mm3, hemoglobin (Hb) of 11.2 g/dL, sodium (Na) of 149 mEq/L, blood urea nitrogen (BUN) level of 41 mg/dL, and creatinine (Cr) of 1.5 mg/dL. Post-void residual bladder scan showed 75 ml of urine. Which of the following is the most likely cause of his delirium? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Alcohol withdrawal B. Dehydration C. Infection D. Uncontrolled pain E. Urinary retention

The correct answer is B. Patient is most likely dehydrated given his tachycardia, dry mucous membranes, and elevated sodium, urea nitrogen, and creatinine. Given his underlying dementia, the patient is at higher risk for delirium, which can worsen with dehydration. Alcohol withdrawal symptoms usually occur within 12-48 hours after a person's last drink, so being in the hospital for four days does not fit the timeline. Also, with alcohol withdrawal, a patient would be anxious, shaky, sweating, and can have seizures, which is not the case with the patient. Alcohol withdrawal can present as hyperactive delirium. While postoperative infections can happen, this patient is afebrile (though older adults may not become febrile), does not have an elevated white blood cell count, and his surgical site is nontender and without exudate. Infection can cause delirium and is less likely in his patient. While uncontrolled pain can cause delirium in someone with baseline dementia, the patient does not have any facial grimacing to palpation over his surgical site or abdomen. If someone cannot share if they have pain, it is important to look for nonverbal cues for pain, such as clenched fists, facial grimacing, moaning, and tachycardia. While the patient does have benign prostatic hyperplasia (BPH), his bladder scan showed < 200 ml of urine post void, which means he does not have acute urinary retention. He has no suprapublic tenderness, which makes urinary retention less likely the cause of his delirium.

An 88-year-old patient was admitted to the hospital after having an acute stroke four days ago. Prior to admission, the patient was independent with activities of daily living (ADLs) and most of her instrumental activities of daily living (IADLs). She used a cane when walking outside, and her son, who lives 10 minutes away from her, helped her with the heavier groceries and household work such as cleaning. Since her stroke, she has dysarthria and dysphagia, requiring a pureed diet with nectar thick liquids. Physical and occupational therapy recommend discharge to a skilled nursing facility (SNF) for subacute rehabilitation. Medical history is significant for atrial fibrillation, hypertension (HTN), hyperlipidemia, and osteoarthritis. Medications are acetaminophen as needed, apixaban, atorvastatin, and nifedipine. Vital signs are normal. Physical examination shows a female sitting up in bed with no acute distress. Cardiac examination reveals irregular rhythm, normal rate, and no murmurs. Pulmonary and abdominal examinations are normal. Muscle strength over right-upper and lower extremities is 2/5 and left-upper and lower extremities is 5/5. Speech is slowed and at times mumbled; patient is alert and oriented to time, place, and reason for admission. She needs moderate assistance to sit at the edge of the bed. Laboratory results are normal. Her echocardiogram shows normal ejection fraction with diastolic dysfunction. The patient's son is worried his mother will not get the care she needs at a skilled nursing facility. How would you counsel the son regarding the type of care provided when getting subacute rehabilitation in a skilled nursing facility (SNF)? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Most SNFs have a physician on-site 24 hours a day. B. SNFs have on-site physical therapy, occupational therapy, and speech-language therapy. C. The nursing care at a SNF is done mainly by registered nurses (RNs). D. The nursing to patient ratio at a SNF is similar to that in the hospital. E. The SNF is able to order stat labs and imaging if needed. SUBMIT

The correct answer is B. Subacute rehabilitation SNFs usually have on-site physical therapists, occupational therapists, and speech-language pathologists. In subacute rehab, there is 24-hour nursing care, but not 24-hour physician care. A physician is available by telephone 24 hours. The nursing care in subacute rehab can be provided by a licensed professional nurse (LPN) or a registered nurse (RN). Most of the bedside care is provided by certified nursing assistants (CNAs). The nurse to patient ratio in the hospital ranges from 1:2 (ICU) to 1:5 (medical-surgical floors); in a subacute rehab, the nurse to patient ratio can average 1:15.

Choose the test below that is most specific for identifying patients with delirium. Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Clock Draw Test B. Confusion Assessment Method (CAM) C. Mini-Cog D. Montreal Cognitive Assessment (MoCA) E. Trail Making Test, Part B

The correct answer is B. The Confusion Assessment Method (CAM) (B). MoCA (D) and Mini-Cog (C) are screening tools for dementia. Clock Draw Test (A) and Trail Making Test, Part B (E) are screening tools for cognitive dysfunction. All of these tests (A, C, D, E) might be abnormal in a delirious patient but are not designed to screen for delirium. When using these tests to screen for dementias and other cognitive problems, delirium must first be excluded. Please see Geriatrics 04: 85-year-old woman with dementia for further description of evaluations for dementia. (Also see Geriatrics Glossary for descriptions of evaluations/assessments.)

An 85-year-old male patient comes to the clinic for a wellness visit. Medical history is significant for hypertension, type 2 diabetes mellitus, and peripheral neuropathy. Medications are lisinopril, metformin, gabapentin, amlodipine, and levothyroxine. Vital signs are normal, including a blood pressure of 128/76 mmHg. Weight is 52 kg (114.6 lbs). Height is 150 cm (4 ft 11 in). Body mass index (BMI) is 23.1 kg/m2. Physical examination is unremarkable. Results of laboratory/diagnostic studies show creatinine (Cr) = 1.3 mg/dL, blood urea nitrogen (BUN) = 18 mg/dL, glucose = 172 mg/dL and the rest of the basic metabolic panel (BMP) is normal. Hemoglobin A1c (HbA1c) = 7.5%. Using the CKD-EPI equation, calculate the patient's eGFR. Use an online calculator such as the one here. Which of the patient's medications need to be adjusted because of the patient's renal function? Choose the single best answer. A. Amlodipine B. Gabapentin C. Levothyroxine D. Lisinopril E. Metformin

The correct answer is B. The dosage of many drugs needs to be modified for renal function. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation provides the most accurate GFR estimation (compared to a renal-clearance "gold standard") and is the formula advocated by contemporary consensus. Variables include age, weight, serum creatinine, and sex. In this patient, the CKD-EPI creatinine clearance (GFR), determined by using an online calculator, is 54. Resources such as drug indexes or built-in references in the EMR can be used to review what medications need to be adjusted for a patient's GFR. For this patient, gabapentin, lisinopril, and metformin are renally excreted. Using a drug reference, you will note that gabapentin (B) doses should be decreased when GFR < 60 ml/min, while lisinopril (D) and metformin (E) doses do not need to be reduced until GFR < 30 ml/min. Neither amlodipine (A) nor levothyroxine (C) are renally excreted as active drugs.

A 97-year-old patient with a history of osteoporosis and essential hypertension is seen in clinic for hospital follow-up after a fall with pelvic fracture. She has been home in her senior apartment for one week. She is tearful and reports a fear of falling, so she is barely leaving her recliner. She hasn't had any falls in the last week but has significant pelvic pain that she has had since her fracture and notes increased soreness to her sacral area. Medications she is taking include acetaminophen, oxycodone, alendronate, and amlodipine. On exam, her vital signs are normal. She has maintained her normal weight of 45.4 kg (100 lbs) since discharge to home. She appears frail, and her cardiac, respiratory, and abdominal exams are normal. She has dry skin without a rash. On her sacral prominence, there is an area of red-maroon coloration that is not blanchable with an overlying intact blister. There is no granulation tissue noted. What stage pressure injury does this patient have? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Stage 5

The correct answer is B. The epidermis and dermis are involved, as identified by the blister formation which makes this injury greater than stage 1. As there is no eschar, granulation, or adipose tissue involved, this pressure injury remains at stage 2. This patient is at risk for a pressure injury as she is frail with low body mass and has been sedentary since her fall and pelvic fracture. Pressure injury staging increases in severity from 1 to 4. There is no stage 5.

An 85-year-old male comes to the clinic for a routine checkup. As part of the Medicare Annual Wellness Visit, you ask him if he has had any falls. He reports that he had two falls over the past year, slipping once on a wet floor and tripping once on a throw rug. He reports no neurological or cardiovascular symptoms at the time of the falls, and he sustained no injuries. Medical history is significant for gout, osteoporosis, and bilateral cataracts. Medications are allopurinol, vitamin D, and calcium citrate. His vital signs and physical examination are unremarkable except for significant thoracic kyphosis and mild cataracts bilaterally. What is your next step in the evaluation and management of this patient? A. Assess for undiagnosed alcohol use disorder B. Check a Timed Up and Go (TUG) test C. Consult ophthalmology D. Order hip protectors E. Refer to physical therapy

The correct answer is B. The first step is to further assess the patient's gait and balance. This may be done in the office using the Timed Up and Go Test. The test is designed to assess the patient's level of fall risk. Ask the patient to stand from a chair, without using their arms, walk 10 feet, turn around, and return to sit in the chair, again without using their arms. Allow them to use their assistive device when doing this. Completion of the task in > 12 seconds indicates an increased fall risk. Assessment of alcohol use, referral to ophthalmology, or physical therapy may be done after gait and balance assessment. Hip protectors have not been found to reduce falls or fractures in community-dwelling older adults.

A 72-year-old patient is admitted to the hospital because of a seven-month history of weight loss, decreased ability to care for herself, increased fatigue, and family concerns for self-neglect. Her dementia was diagnosed five years ago when the family noted declines in short-term memory and errors in her finances and medications. She now needs assistance with her medications, finances, house cleaning, and meal preparation. She is having difficulty dressing and is refusing to bathe, as she seems afraid of the shower. Medical history is significant for hypertension (HTN), diabetes mellitus, chronic obstructive pulmonary disease (COPD), anemia, coronary artery disease (CAD), Parkinson disease, and dementia. Medications include metformin, glipizide, lisinopril, hydrochlorothiazide, and carbidopa/levodopa. She has a 100-pack-year smoking history. Vital signs are remarkable for a sitting pulse of 96 beats/minute and blood pressure of 124/70 mmHg; with a standing pulse of 110 beats/minute and blood pressure of 102/58 mmHg. Weight is 86 kg (189.6 lbs). Six months ago weight was 90 kg (198.4 lbs). Body mass index (BMI) is 30 kg/m2. Exam is notable for a distinct body odor and long, broken fingernails. There are several scratch marks on her skin. She has a stooped posture, slow shuffling gait with absence of arm swing, and a pill rolling tremor. Results of laboratory/diagnostic studies are remarkable for a hemoglobin (Hb) of 10 g/dL, creatinine (Cr) of 1.4mg/dL, and a sodium (Na) of 147 mEq/L. The family is concerned about her overall health and requests your opinion on her condition and prognosis. What historical or clinical features are most significant in determining her prognosis? Choose the single best answer. A. Anemia B. Difficulty with self-care C. Smoking history D. Tremor and bradykinesia E. Weight loss

The correct answer is B. The patient has several factors that would impact her prognosis. The greatest factor is her functional decline and difficulty with self-care. Functional decline is a marker of poorer prognosis regardless of the underlying cause of the decline. Impairments in basic activities of daily living, particularly movement, bathing, and strength, are surrogate markers of global decline. Her weight loss, while worrisome, is less than 10%, and her overall BMI is greater than 25 (lower than 25, even though considered "normal weight", may be associated with higher morbidity and mortality in older adults). Her anemia is not physiologically dangerous and her abnormalities in heart rate and blood pressure are explained by potential dehydration. Tremor and bradykinesia are not independently linked with prognosis. Smoking history increases her probability for medical comorbidities but is not the greatest prognostic factor in this case.

A 77-year-old male comes to the clinic because of four weeks of increased aggressive behavior at home. He has hit his primary caregiver, yells when his daughter tries to bathe him and has been waking up many times during the night. He moved in with his daughter two years ago when she noticed he could not cook for himself, pay his bills, and take his medications as prescribed. Today, his daughter brought him to the clinic, since she is having caregiver distress and is not sure what to do. Medical history is significant for chronic obstructive pulmonary disease (COPD), hypertension (HTN), osteoarthritis, and vascular dementia. He currently smokes three to five cigarettes a day. Medications are acetaminophen as needed, albuterol, nifedipine, and tiotropium. Vital signs are normal. Physical examination shows a calm, older man with kyphosis who has a few stains on his shirt. Fair dentition. Normal heart and lung examinations. He is alert and oriented to self, doctor's office, and season. Speech is coherent and clear and there are no gross neurological deficits. Results of laboratory/diagnostic studies are within normal limits. Which of the following is the best next step for this patient's agitation? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Admit to the hospital B. Evaluate for depression B. Order brain imaging D. Refer to a psychotherapist E. Start an antipsychotic medication

The correct answer is B. This patient is having behavioral disturbances due to his dementia. His vital signs are stable, labs and diagnostic testing are within normal limits, and there are no focal deficits on the exam to need further brain imaging, especially since his symptoms have been going on for four weeks (no acute changes). He also has no indication for being admitted to the hospital. The next step is to make sure there is no treatable cause such as depression or sleep deprivation that is contributing to his agitation. While he may need an antipsychotic medication in the future, it would not be the best next step. Due to his progressive dementia, psychotherapy would not be effective, as the patient would not be able to retain learning.

A 75-year-old patient is seen via video clinic appointment. Her main concern is fatigue. She has been isolating herself from family and friends in efforts to protect herself against a virus which has been spreading through her community. She is tearful and admits to "feeling down." She used to enjoy her book club and activities at church, but tells you she just "has no interest in getting out anymore." Medical history is significant for cataracts, lumbar spinal stenosis with sciatica to bilateral legs, osteoporosis, and falls. Medications are acetaminophen 1000 mg twice daily, calcium supplement 500 mg twice daily, vitamin D 1,000 IU daily, and alendronate 70 mg weekly. You are unable to check vital signs. The patient appears tired and sad. She looks away from the video monitor during the visit and apologizes to you for her "messy room with all this clutter." Physical examination shows downcast eyes and head, some redness to her sclera bilaterally. Respirations appear comfortable and unlabored. What is your next step in caring for this patient? Choose the single best answer. A. Begin treatment with low-dose SSRI B. Order a thyroid-stimulating hormone (TSH) level C. Order an echocardiogram D. Refer for counseling E. Schedule a follow-up appointment in four weeks

The correct answer is B. Thyroid-stimulating hormone (TSH) levels should be checked in patients with fatigue, joint aches, memory impairment, and symptoms of depression. Hypo- or hyperthyroidism can present atypically and cause these symptoms. CBC, BMP, B 12/folate, vitamin D levels, and liver function tests (LFTs) are reasonable to further evaluate complaints of fatigue and are important baseline tests for starting medications. The patient screens positive for depression by PHQ-2 criteria. She endorses symptoms of depression/sadness and of anhedonia. When possible, a PHQ-9 or other extended depression screen may be helpful in identifying symptom burden of depression and its impact on daily life. Prior to considering medication, it is important to assess for causative or contributing factors. It is reasonable to check thyroid function, CBC, basic chemistry, LFTs, B12, Folate, and 25 OH vitamin D levels. An electrocardiogram could be done to obtain baseline data prior to beginning medication. After these factors are evaluated, counseling sessions and a low dose of an antidepressant would be a good approach to help improve her depression. Waiting four weeks without any action is unlikely to improve the situation.

You are working in an oncology clinic when an 86-year-old male arrives with his wife for routine follow-up of advanced prostate cancer metastatic to bone, which was diagnosed four years ago following biopsy of a spine lesion. He was started on androgen deprivation therapy at that time, with regular follow-up in oncology clinic. Over the past six months, the bone pain related to his metastatic cancer has increased, at one point leading to hospitalization for acute pain crisis. In addition, he has a history of heart failure with reduced ejection fraction, coronary artery disease, hypertension and type 2 diabetes. He has experienced one heart failure exacerbation in the past year and his other medical conditions are well-managed by his primary care physician. Despite his multiple medical conditions, he remains physically active, riding a stationary bicycle daily in his home. He is able to use the toilet without assistance, shower and dress with no help, and he prepares meals for himself and his wife. He still manages the household bills, but his daughter helps with grocery shopping and his son drives him to appointments. He continues to meet a group of friends for lunch every Friday, and completes small woodworking projects in his garage. In clinic today he expresses a desire for "comfort," as his pain is starting to affect his quality of life. He has constipation from the opioids you previously prescribed, and some days he doesn't feel like eating as much for meals as he has in the past. He shares that he wants to stay at home as long as possible, hoping to avoid any future hospitalizations. You discuss with him a plan for medication titration for his pain, and a bowel regimen to prevent opioid-induced constipation. You tell him you would not be surprised if his function continues to decline, but that you anticipate his prognosis to be long months to short years. He asks you whether hospice is appropriate for him. You counsel him that a palliative care referral is appropriate, but that he does not yet qualify for hospice. All of the following are part of hospice care, except: Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Focus on comfort rather than cure B. Physical, emotional, spiritual symptoms requiring specialized interdisciplinary care C. Prognosis of long months to short years D. Support to manage your care at home E. Terminal Illness diagnosis SUBMIT

The correct answer is C. Hospice care is both a philosophy and an insurance benefit. It is insurance coverage that dictates when/whether a patient is eligible for hospice. Based on the Medicare hospice benefit, patients are not eligible for hospice until their provider certifies that their prognosis is estimated to be six months or less if the disease runs its natural course. This prognostic estimate may be difficult in certain conditions (e.g., heart failure, COPD, and some metastatic cancers). Often it is a patient's functional status that is the best predictor of prognosis. The overlap between palliative care and the philosophy of hospice care is difficult to ascertain. Both seek to improve the quality of life for patients with a terminal illness (E), and both aim to provide comfort (A) under the care of trained interdisciplinary team members (B). If a patient identifies being at home is important, then both palliative care (through home health care) and hospice care may contribute to helping maintain living in the home (D).

An 82-year-old female is admitted to the hospital for fever and shortness of breath. She is diagnosed with aspiration pneumonia and is transitioned to oral antibiotics on hospital day three. Her hospitalization was complicated by mild delirium. You are helping the team prepare her discharge to a nursing facility for rehabilitation. Medical history is significant for early dementia, hypertension (HTN), urinary incontinence, and depression. Medications are amlodipine and sertraline; she will need an additional four days of amoxicillin and clavulanic acid (Augmentin) to complete treatment of her pneumonia. During this admission, the patient was evaluated by the speech and language pathology team and recommended to have a mechanical soft diet. She was also seen by physical therapy with recommendations for one hour of therapy a day and a walker for safety. Vital signs are normal. Physical examination shows an older female in no apparent distress. Pulmonary examination is notable for crackles in the right-lower lobe. Abdomen is soft. She is alert and oriented to self, but not place and time. Results of laboratory/diagnostic studies show white blood cell count (WBC) of 5,700/mm3 and a chest x-ray (CXR) is read as a "right-lower lobe consolidation with possible nodule obscured by area of consolidation." Which of the following reflects appropriate wording of instructions/clinical information in the discharge summary? Choose the single best answer. A. "Activity as tolerated." B. "Follow up repeat chest x-ray." C. "Patient is alert and oriented to person, but not place and time." D. "Regular diet." E. "Resume home medications and complete Augmentin."

The correct answer is C. It is important to have an updated physical exam, including baseline mental status, in the discharge summary. With regards to medications, it is important to specify which home medications to resume and which ones to discontinue; furthermore, for antibiotics, it is helpful to specify the stop date. Physical therapy had left specific instructions to the amount of daily exercise as well as durable medical equipment to use. While many patients with dysphagia benefit from thickened liquids, "regular diet" is not equivalent to the recommendation "mechanical soft diet." Given the possible nodule, the discharge summary should specify what the repeat chest x-ray would be evaluating and at what time interval. It would be more appropriate to write, "Follow-up repeat chest x-ray in 4 weeks to evaluate for resolution of possible right lower lobe nodule."

An 80-year-old female comes to the clinic because of a one-month history of "feeling weak." The patient was admitted to the hospital one month ago for treatment of pneumonia. While her breathing has returned to her baseline, she admits that last week she fell in her bathroom while getting up from the toilet. She did not hit her head or get "hurt," but she is worried that she might fall while walking. Medical history is significant for coronary artery disease (CAD), hypertension (HTN), osteoarthritis of the knees and hips, and early-stage cataracts. Medications include metoprolol, lisinopril, hydrochlorothiazide, and naproxen cream. Temperature, oxygenation level, and respiratory rate are all normal. Blood pressure taken in the supine position is 132/60 mmHg with a pulse of 60 beats/minute. Blood pressure taken in the standing position after a three-minute wait is 125/58 mmHg with a pulse of 64 beats/minute. Physical examination shows normal cardiopulmonary and abdominal examinations and vertebral kyphosis. Results of electrolytes, blood cell counts, and thyroid studies are all normal. What is the best next step in the care of this woman? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Discontinue lisinopril B. Order a home safety evaluation C. Order a physical therapy referral D. Perform a gait and balance evaluation E. Prescribe a walker

The correct answer is D. The gait and balance evaluation is a key physical examination assessment in a patient who has fallen or is at risk for falls. This assessment demonstrates the neurologic, musculoskeletal, and ophthalmologic systems' ability to function in an integrated manner. The patient did not demonstrate orthostatic hypotension and her antihypertensive and cardiac medications do not need to be adjusted. Home safety evaluations done by physical or occupational therapy may be helpful but should be ordered after the patient's gait and balance are assessed. Physical therapy should be ordered after the assessment of gait, balance, strength, and other factors. Evaluation of gait and balance is needed prior to any determination of an aid for ambulation.

A 99-year-old female was admitted to the hospital five days ago because of fevers and dyspnea. She was diagnosed with aspiration pneumonia and has been getting antibiotics. She has been immobile since admission, and is being repositioned by medical staff every two hours. She has been nothing-by-mouth (NPO) since admission, and is being evaluated by a speech language pathologist. On hospital day 5 she was noted to have a stage I sacral pressure injury. It is now day 9 and there is evidence of further breakdown to a stage II ulcer. Medical history is significant for chronic obstructive pulmonary disease (COPD), constipation, depression, and mild cognitive impairment. Medications are albuterol inhaler as needed (PRN), escitalopram, senna PRN, and tiotropium inhaler. Vital signs are normal. Weight is 61 kg (135 lbs). Height is 165 cm (5 ft 5 in). Body mass index (BMI) is 22.5 kg/m2. Physical examination shows an older woman lying in bed with a regular hospital mattress who is arousable but appears fatigued. She has dry mucous membranes; scant wheezes over bilateral lower posterior lung fields; and a soft, nontender abdomen with normoactive bowel sounds. She has a sacral pressure injury that measures 2 cm by 3 cm that is erythematous with scant exudate and no odor. She knows she is in the hospital getting antibiotics. She forgot the date but demonstrates no inattention. Which of the following is the most likely reason this patient is not healing her pressure injury? A. Delirium B. Infection C. Malnutrition D. Medications E. Regular mattress

The correct answer is C. Malnutrition (C) is the most likely reason this patient's pressure injury is progressing. Injury due to inadequate oral intake, decreased protein, and being nothing by mouth (NPO) for the first few days of the hospitalization are risk factors for developing a pressure injury, and are a major factor in their healing. Adequate nutrition is essential in preventing and treating pressure injuries. While delirium can lead to further immobilization and anorexia, delirium is an indirect cause of a pressure injury and therefore not the most likely reason for a pressure injury. There is no clear evidence on how often to turn a patient (between 2-4 hours). This patient was turned every two hours, which makes inadequate repositioning less likely to be the cause of her pressure injury. The repositioning must be sufficient to off-load the wound area, and other areas prone to pressure injury, from weight for an extended period of time. Care must also be taken that the patient is not sliding down in the bed, or that surfaces are not providing sufficient friction to induce sheer injuries to underlying tissue. While infections can lead to decreased mobilization and delay wound healing, it is less likely to be the cause of developing a pressure injury. While there are many different types of mattresses a patient can use in the hospital, there is inconsistent evidence on the best mattress to use, and if different mattresses truly prevent pressure injuries. This patient's malnutrition is more likely to be the cause of her pressure injury.

An 85-year-old community-dwelling patient with a history of hypertension and chronic kidney disease is admitted to the hospital with streptococcal pneumonia. At baseline, he walks with a walker and has a slow gait speed of 0.6 m/s. Which is likely to be the biggest predictor of whether he is likely to require rehabilitation after hospitalization? Choose the single best answer. A. Age B. Chronic kidney disease C. Gait speed D. Hypertension E. Streptococcal pneumonia SUBMIT

The correct answer is C. The correct answer is gait speed (C). This patient has a slow gait speed of 0.6 m/s, which indicates that he may be frail and have limited physiological reserve; he is likely to need rehabilitation after a pneumonia serious enough to require hospitalization. Hypertension (D) and chronic kidney disease (B) are incorrect, although measures of blood pressure and kidney function are both included in the CURB-65 score for pneumonia severity. In this patient, his slow gait speed, a marker of frailty, may be a better predictor of his need for rehabilitation rather than his specific comorbidities. His age (A) and the type of pneumonia (E) are incorrect.

Question: What is the primary purpose of APS? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. To assist with home cleanup and repairs B. To arrange temporary housing C. To investigate allegations of elder mistreatment D. To provide assistance with utility bills E. To provide referrals for medical assessment

The correct answer is C. The primary purpose of APS is to investigate allegations of elder mistreatment (C). If the allegations of elder mistreatment are found to be unsubstantiated, APS ends its involvement in the case. When such allegations are substantiated, however, APS can provide a variety of services to clients in need, including: Home cleanup or repairs (A) Temporary emergency housing (B) Bill payments on a short-term basis (D) Referrals for medical assessment (E) Temporary medications Food Clothing Transportation If necessary, placement in long-term care to stop mistreatment

An 89-year-old patient comes to the clinic from home because her family noticed she was not herself for a few days per family and tried to hit her private home health aide (who is also present) a few hours prior to presentation. In the past two days, when prompted to eat or drink, she put her hand in front of her mouth. According to her aide, there have been no reported changes in medications and no changes in urinary patterns. Medical history is significant for hypertension, hyperlipidemia, diabetes, vascular dementia, and gait instability with her last fall one month ago. Medications include lisinopril, atorvastatin, mirtazapine, and senna as needed. Vital signs are normal, except for a blood pressure of 92/60 mmHg and pulse of 112 beats/minute. Weight is 48.5 kg (107 lbs). Height is 157.5 cm (5 ft 2 in). Body mass index (BMI) is 19.6kg/m2. Physical examination shows a cachectic older adult wearing corrective lenses, sitting in a chair with her rollator walker in front of her. She has dry mucous membranes with no oropharyngeal exudate. Cardiac and pulmonary exams are unremarkable. Her abdomen is distended, tender to palpation over left-lower quadrant (LLQ) and right-lower quadrant (RLQ), and with hypoactive bowel sounds. There is no suprapubic tenderness and no joint tenderness over bilateral upper and lower extremities. Which of the following is the most appropriate next step to help identify the cause of her agitation? Choose the single best answer. A. Complete a comprehensive medication reconciliation B. Complete a hearing exam C. Complete a rectal exam D. Obtain an ankle x-ray E. Obtain a urine sample SUBMIT

The correct answer is C. This patient has decreased oral intake based on history and dry mucous membranes on exam and lower abdominal tenderness. She takes senna as needed, so she likely has a history of constipation. A detailed history of recent bowel habits and a rectal exam may help identify stool impaction or severe constipation, which can cause agitation and delirium in older adults. While medications can definitely cause agitation, there are no reported changes in her medications. A comprehensive medical reconciliation is helpful at every clinical visit; however, this would not be the most appropriate next step. There is no identified hearing or overall sensory impairment on history or exam. Hence, there is a lower likelihood of sensory impairment causing her agitation. Even though the patient had a fall a month ago, there are no reported injuries and no joint tenderness on physical exam. Given no reported or visible sign of pain, pain is less likely the cause of her agitation. There are no reported changes in urinary patterns or suprapubic tenderness, so there is low suspicion for urinary retention as the cause of her agitation.

An 82-year-old male is admitted to the hospital for delirium. His family reports that the patient is normally alert and independent in all activities of daily living (ADLs). He eats a fairly balanced diet though he has had decreased food and fluid intake in the week leading up to admission. He has a witnessed fall, with no head injury, in the hospital on the day of admission. Medical history is significant for benign prostate hyperplasia, hypertension (HTN), mild cognitive impairment, and presbyopia. Medications are tamsulosin and nifedipine. He drinks one to two glasses of wine socially with friends. He does not partake in tobacco or illicit drug use. Vital signs are normal. Physical examination shows a well-nourished older gentleman who falls asleep when not stimulated and is easily distracted when awake. Head is normocephalic and atraumatic, and the patient is wearing reading glasses. Cardiopulmonary examination is unremarkable. Abdomen is distended with decreased bowel sounds and mildly tender in the left-lower quadrant. No costophrenic tenderness. Neurologic examination is without focal deficits. Results of the laboratory workup show normal white blood cell count (WBC), and normal renal and liver functions. Which of the following most likely precipitated the patient's delirium? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Alcohol withdrawal B. Concussion C. Constipation D. Sensory deficits E. Vitamin B12 deficiency

The correct answer is C. This patient has multiple predisposing factors (mild cognitive impairment, male sex) for delirium. While all of the answers are possible precipitating factors, the history of decreased oral intake and the LLQ tenderness and abdominal distention on physical exam make constipation most likely. The patient's balanced diet makes vitamin B12 deficiency unlikely, and his social drinking does not place him at high risk for alcohol withdrawal. While he does have a history of presbyopia, the patient has appropriate visual aids (ie., glasses). Despite having an in-hospital fall, the fall was witnessed and without trauma to the head, making concussion also less likely. Delirium is associated with increased morbidity and may be associated with the fall experienced by this patient.

A 75-year-old male is brought to the emergency department (ED) after a fall while going down the stairs to his basement. He said that he just "missed" the edge of the stairs and his foot slipped. He was wearing slippers and his glasses at the time. The lighting was dim and he said he was tired. He has not had any falls in the past. Medical history is significant for hearing loss and macular degeneration. He wears bilateral hearing aids and glasses with bifocal lenses. He has a recent diagnosis of osteoporosis. Vital signs are normal. Physical examination and radiographs reveal a left hip fracture. Which one of the factors listed below is an intrinsic risk factor predisposing this patient toward future falls? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Bifocal lenses B. Loose-fitting slippers C. Macular degeneration D. Poor lighting E. Stairs to basement

The correct answer is C. Visual loss is due to the patient's macular degeneration and is an intrinsic risk factor inherent to an individual. Bifocal lenses are an extrinsic risk factor as they interact with the patient's body (eyes/vision). Slippers and shoes may pose an extrinsic risk factor for falls. Poor lighting is an environmental risk factor in the patient's surroundings. Stairs are an environmental risk factor in the patient's surroundings.

A 73-year-old patient comes to the clinic for an annual follow-up exam. Patient has had two hospitalizations in the past year for confusion and UTIs. Caregiver reports that patient's disinhibited and compulsive behaviors have lessened considerably, but he is less verbal and requires increasing assistance with activities of daily living, and is now only independent in feeding himself. He is eating less and has lost 4.5 kg (10 lbs) over the last year. Medical history is significant for frontotemporal dementia, former tobacco use, and adenocarcinoma of lung s/p radiation with no current evidence of disease. Medications are citalopram. Vital signs are normal. Weight is 69 kg (152 lbs). Height is 173 cm (68 in). Body mass index is 23.1 kg/m2. Physical examination shows the patient seated in a wheelchair and in no distress. With minimum assistance of caregiver and gait belt, the patient can stand and transfer to the exam table. Cardiac and lung exam are normal. Patient is largely apathetic and answers only yes and no with variable accuracy to direct questioning. The caregiver notes that the patient is due for colorectal cancer screening due this year and is worried about the patient completing the bowel prep. The ePrognosis site is used and based on the Lee Index, the patient's life expectancy is 2.9 years. Continued screening is not recommended. Which of the following principles best guides this recommendation? Choose the single best answer. A. Heterogeneity of aging B. Lead time bias C. Length time bias D. Shared decision making E. Time to benefit

The correct answer is E. All of these are important concepts when considering a decision to screen for cancer, but the recommendation is based on the patient's life expectancy (2.9 years) being less than the time to benefit for colorectal cancer screening (7-10 years). Though this patient does not have multiple medical diagnoses, his poor functional status secondary to his dementia is predictive of high mortality over the next five years.

A 73-year-old patient comes to the clinic for an annual follow-up exam. Patient has had two hospitalizations in the past year for confusion and UTIs. Caregiver reports that patient's disinhibited and compulsive behaviors have lessened considerably, but he is less verbal and requires increasing assistance with activities of daily living, and is now only independent in feeding himself. He is eating less and has lost 4.5 kg (10 lbs) over the last year. - Medical history is significant for frontotemporal dementia, former tobacco use, and adenocarcinoma of lung s/p radiation with no current evidence of disease. Medications are citalopram. - Vital signs are normal. Weight is 69 kg (152 lbs). Height is 173 cm (68 in). Body mass index is 23.1 kg/m2. - Physical examination shows the patient seated in a wheelchair and in no distress. With minimum assistance of caregiver and gait belt, the patient can stand and transfer to the exam table. Cardiac and lung exam are normal. Patient is largely apathetic and answers only yes and no with variable accuracy to direct questioning. - The caregiver notes that the patient is due for colorectal cancer screening due this year and is worried about the patient completing the bowel prep. The ePrognosis site is used and based on the Lee Index, the patient's life expectancy is 2.9 years. Continued screening is not recommended. Which of the following principles best guides this recommendation? Choose the single best answer. A. Heterogeneity of aging B. Lead time bias C. Length time bias D. Shared decision making E. Time to benefit

The correct answer is E. All of these are important concepts when considering a decision to screen for cancer, but the recommendation is based on the patient's life expectancy (2.9 years) being less than the time to benefit for colorectal cancer screening (7-10 years). Though this patient does not have multiple medical diagnoses, his poor functional status secondary to his dementia is predictive of high mortality over the next five years.

A 79-year-old patient presents to the clinic for a wellness visit. He is accompanied by his teenage grandson who lives with him. The man says very little during the interview and answers with single words. He has a medical history of hyperlipidemia and essential hypertension (HTN). He is unable to tell you what medications he is currently taking, and his grandson is unaware if he is taking his medications. Vital signs are normal. His weight has decreased by 6.8 kg (15 lbs) in the last year. On exam, you notice he has a smell of urine, is wearing dirty clothing, and his walker is missing a wheel. There is temporal wasting present. You notice a stage II pressure wound on his buttocks. His skin is very dry. His toenails are thick, yellow, and curling. His strength testing of proximal muscle groups is significantly below normal. When asked to stand up from sitting in a chair, he is able to get up with considerable effort and pushes off with his arms. He is unable to complete a gait exam safely. What is the next best step in the management of this man? Choose the single best answer. A. Check a urinalysis B. Complete a depression screen C. Determine decision-making capacity D. Referral to physical therapy E. Referral to podiatry SUBMIT

The correct answer is C. When elder abuse or neglect is suspected, it is important to assess the safety of their living situation, including their capacity to live independently without supervision.

A 85-year-old patient is admitted to the hospital with septic shock secondary to E. coli bacteremia from a urinary infection. She is started on broad spectrum antibiotics, fluid resuscitated, and placed on high-flow nasal cannula. Despite appropriate treatment, four days into her hospitalization, her oxygen saturation continues to trend down, and she remains obtunded. Her daughter is her medical Durable Power of Attorney (DPOA). Her daughter notes that her mom has had increasing weakness when at home. The patient lived on her own and had always maintained that she would not want to be institutionalized. The ICU attending is called to evaluate the patient as there is concern she may need to be intubated given increased work of breathing. Given the patient's frailty, the intensivist is worried the patient may need prolonged mechanical ventilation or be unable to wean off the ventilator. Medical history is significant for mild cognitive impairment, hypertension, and congestive heart failure. Medications are aspirin, lisinopril, carvedilol, and furosemide. Physical examination shows a frail, older woman in moderate respiratory distress. She does not respond to verbal or tactile stimuli; moans occasionally but is not able to engage with the examiner. Tachycardic with 3/6 systolic murmur. Bibasilar crackles are present and she is using accessory muscles. Abdomen is soft. Which of the following statements by the ICU attending would be most consistent with informed assent? Choose the single best answer. A. As the medical DPOA, what do you think your mom's code status should be? B. Does your mom have a living will outlining her preferences for resuscitation? C. Given your mom's values of maintaining independence, I recommend she be DNR/DNI. D. If your mom was able to speak with us now, what would your mom say she would want? E. I recommend your mom be DNR/DNI because she is not doing well.

The correct answer is C. While it is important to have goals of care conversations with the legal medical decision maker and helpful to review a patient's advance directives if available, informed assent is when a medical provider makes recommendations based on patient values. Asking what this patient would want to say is an open-ended way to explore values. Given concern she is at high risk of prolonged intubation or may not be able to wean off the ventilator due to her frailty, the ICU attending can make a recommendation based on patient values of maintaining independence and not being institutionalized. It is important to give specific recommendations based on values assessed instead of a patient merely not doing well.

A 85-year-old patient is admitted to the hospital with septic shock secondary to E. coli bacteremia from a urinary infection. She is started on broad spectrum antibiotics, fluid resuscitated, and placed on high-flow nasal cannula. Despite appropriate treatment, four days into her hospitalization, her oxygen saturation continues to trend down, and she remains obtunded. Her daughter is her medical Durable Power of Attorney (DPOA). Her daughter notes that her mom has had increasing weakness when at home. The patient lived on her own and had always maintained that she would not want to be institutionalized. The ICU attending is called to evaluate the patient as there is concern she may need to be intubated given increased work of breathing. Given the patient's frailty, the intensivist is worried the patient may need prolonged mechanical ventilation or be unable to wean off the ventilator. Medical history is significant for mild cognitive impairment, hypertension, and congestive heart failure. Medications are aspirin, lisinopril, carvedilol, and furosemide. Physical examination shows a frail, older woman in moderate respiratory distress. She does not respond to verbal or tactile stimuli; moans occasionally but is not able to engage with the examiner. Tachycardic with 3/6 systolic murmur. Bibasilar crackles are present and she is using accessory muscles. Abdomen is soft. Which of the following statements by the ICU attending would be most consistent with informed assent? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. As the medical DPOA, what do you think your mom's code status should be? B. Does your mom have a living will outlining her preferences for resuscitation? C. Given your mom's values of maintaining independence, I recommend she be DNR/DNI. D. If your mom was able to speak with us now, what would your mom say she would want? E. I recommend your mom be DNR/DNI because she is not doing well. SUBMIT

The correct answer is C. While it is important to have goals of care conversations with the legal medical decision maker and helpful to review a patient's advance directives if available, informed assent is when a medical provider makes recommendations based on patient values. Asking what this patient would want to say is an open-ended way to explore values. Given concern she is at high risk of prolonged intubation or may not be able to wean off the ventilator due to her frailty, the ICU attending can make a recommendation based on patient values of maintaining independence and not being institutionalized. It is important to give specific recommendations based on values assessed instead of a patient merely not doing well.

A 72-year-old patient is brought to the emergency department because of a recent seizure witnessed by her son. Her son told EMS that just prior to her seizure his mother had appeared confused, slow, and "shaky." Medical history is significant for diabetes, hypertension, and retinopathy. She was seen in the local urgent care this week and is being treated with trimethoprim-sulfamethoxazole antibiotic for a urinary tract infection. Her usual medications include glyburide 5 mg daily and lisinopril 5 mg daily. The patient received care in the EMS ambulance and arrived at the ED with normal vital signs. The paperwork of what was done for her on the ambulance is not available. She is no longer experiencing a seizure, but her cognition remains slow and she is uncertain of the day and year. She can not recount what occurred. Her examination, EKG, and basic laboratory studies are within normal limits on arrival. Reviewing the patient's history and recent events, which of the following best explains the precipitating factor for her recent seizure? Choose the single best answer. A. Amplified side effect B. Disease-disease interaction C. Drug-disease interaction D. Drug-drug interaction E. Physiologic change with aging SUBMIT

The correct answer is D. Drug-drug interaction. Trimethoprim-sulfamethoxazole was used to treat this patient's urinary tract infection. Glyburide has a long half-life of 10 hours. The addition of trimethoprim-sulfamethoxazole further increases the unbound active concentration of glyburide which then increase the hypoglycemic effect of glyburide, leading to hypoglycemia causing a seizure. The patient's glucose was treated urgently in the ambulance by the EMS team. Her medical conditions and aging physiology are not strong enough factors to cause hypoglycemia in this case.

An 82-year-old male comes to the clinic for a post-hospitalization follow-up appointment. He was discharged from the hospital three days ago after being hospitalized for a week for a fall-related injury at home where he hit his head and reported right knee pain. He has not started home physical therapy yet. Since his last clinic visit two months ago, he appears more tired, is now using a walker, and came to his appointment with a caregiver. He used to come to his appointments by himself. Medical history is significant for heart failure with preserved ejection fraction (HFpEF), hypertension (HTN), and osteoarthritis. Medications are acetaminophen as needed (PRN), amlodipine, furosemide, and lisinopril. Vital signs are normal. Weight is 68 kg (150 lbs). Height is 172 cm (5 ft 8 in). Body mass index is 22.8 kg/m2. Physical examination shows a cachectic, well-groomed male who appears fatigued. Normal cardiac and lung examinations. His gait is slow but steady using a walker. Right knee is tender to palpation. He is alert and oriented to place, but knows the month and year, and the reasons for his appointment, however, he does not know the day of the week or the date. No other neurological changes are identified. There are faint ecchymoses over his right forehead and right knee. Results of hospital laboratory studies are within normal limits; basic chemistry panel, complete blood count (CBC), and urinalysis. His head computed tomography (CT) scan was negative for acute infarct or hemorrhage. Right knee x-ray showed evidence of osteoarthritis. Which of the following is the most likely reason this man is now using a walker? Choose the single best answer. A. Decreased confidence B. Delirium C. Depression D. Prolonged immobility E. Weight loss SUBMIT

The correct answer is D. Falls and hospitalizations often lead to bed rest, which leads to deconditioning marked by a loss of muscle strength, muscle mass, and decreases in aerobic capacity. Within a week after a fall and with decreased mobilization, this patient is now requiring a walker and help from a caregiver. While a fall and a hospitalization can decrease one's confidence, it is not the most likely reason he now needs to use a walker and has a new caregiver. It is notable that fear of additional falls is a major barrier to full and successful participation in physical therapy. While delirium can often happen after hospitalization and can have long-term cognitive effects, he likely does not have acute delirium. After a hospitalization, forgetting the date can happen. Delirium would not explain why this patient needs a walker now. While depression can happen after a fall or exacerbate by a hospitalization, it is unlikely the reason for this patient now using a walker. Weight loss is common during hospitalization due to plasma volume loss, poor oral intake, and a decrease in muscle mass. While a patient may have some weight loss, this would not explain why he needs to use a walker.

A 78-year-old male is admitted to the hospital because of a three-day history of worsening confusion and urinary frequency. He is started on broad-spectrum antibiotics for a urinary tract infection (UTI). Medical history is significant for vascular dementia, hypertension (HTN), and diabetes. Medications are losartan, aspirin, and metformin. The nurse calls for an assessment of the patient for agitation. Vital signs are normal. Physical examination shows a confused male, lying in bed with one leg hanging over the bed rail. Cardiopulmonary and abdominal examinations are unremarkable. He is oriented to self, but inattentive and repeatedly tries to get out of bed. Neurological examinations are without focal deficits. Results of laboratory/diagnostic studies show white blood cell count (WBC) of 12,800/mm3, basic metabolic panel (BMP) is unremarkable, urine culture growing E. coli, and a normal chest x-ray. What would be the next most-appropriate step to order in managing this patient's agitation? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Bed rails raised and locked B. Bilateral posey mitts C. Haloperidol 0.5 mg D. One-to-one sitter E. Quetiapine 12.5 mg SUBMIT

The correct answer is D. First-line management for agitated delirium includes non-pharmacological interventions, such as a sitter to reorient and redirect the patient. Physical (e.g., mitts, vests) and chemical (e.g., pharmacological interventions) restraints should only be utilized if a patient poses a threat to self or others. Raising both bed rails is a form of physical restraint. Should a patient require pharmacological interventions, it is important to always start with the lowest dose as above and discuss relevant black box warnings for use of antipsychotics in patients with dementia.

A 76-year-old male was admitted 12 days ago for sepsis secondary to a urinary tract infection (UTI). He was initially admitted to the intensive care unit (ICU) before being transferred to the regular medicine floor. Medical history is significant for benign prostate hypertrophy, hypertension (HTN), and diabetes. Medications are tamsulosin, lisinopril, and metformin. He lives with his wife in a one-story house. His wife uses a walker to ambulate and is currently undergoing treatment for lung cancer. They have no children. Prior to admission, the patient used a cane when outside the home and was independent in all activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Vital signs are normal. Physical examination shows a frail, older male in no distress. He is able to lift all extremities against gravity and requires a one-person assist to transfer from bed to chair. He is able to ambulate 20-30 feet with a walker. He is alert and oriented to time, place, and person and follows multi-step commands. Physical therapy assessed the patient and stated he is able to tolerate one to two hours of therapy a day. What is the most appropriate post-discharge location for this man? Choose the single best answer. A. Acute rehabilitation B. Home with family support C. Home with home health care D. Long-term care facility E. Subacute rehabilitation

The correct answer is E. This patient is able to participate in 2 hours of physical therapy a day and would hopefully regain independence after a few weeks of subacute rehabilitation. For Medicare to cover acute rehabilitation, a patient must have certain qualifying diagnoses (ie., stroke, spinal cord injury, amputation, hip or femur fracture, burns, brain injury). This patient's debility is secondary to prolonged hospitalization and sepsis so he would not qualify for acute rehabilitation. He would also need to be able to tolerate 3 hours daily of physical therapy. The patient's wife is elderly with her own mobility limitations and acute health issues. As such, she is unlikely able to provide adequate support for her husband post-discharge. Home health care is able to provide limited home physical therapy. However, this patient can tolerate and would benefit from the more intensive therapy offered in subacute rehabilitation. Long-term care is for patients who are unable to regain function and independence with ADLs. This patient is able to participate in physical therapy as evidenced by his ability to follow commands and retain teaching. As such, he should be discharged to subacute rehabilitation.

A 77-year-old female with history of type 2 diabetes mellitus, chronic kidney disease, and heart failure with reduced ejection fraction is admitted to hospital medicine after presenting to the emergency department with fluid overload, acute kidney injury, and hypoxemia. She requires intravenous diuretic medications and supplemental oxygen via nasal cannula. At time of admission to the hospital, the patient expresses a wish for full resuscitation in the event of cardiopulmonary arrest. Cardiology is consulted to assist with heart failure management and nephrology is consulted for diuretic management. Forty-eight hours after admission, the patient's GFR continues to worsen, and her oxygen requirements have increased from nasal cannula to face mask to noninvasive positive pressure ventilation (e.g., BiPAP). Considering her age and chronic medical conditions, an urgent goals-of-care conversation occurs and she expresses desire for a time-limited trial of ICU-level care. She is transferred to the medical intensive care unit, where she is intubated and a hemodialysis catheter is placed preemptively by the ICU team. She requires sedation in order to allow for appropriate ventilation, and is no longer able to express her own care preferences. The ICU team diagnoses the patient with type 1 cardiorenal syndrome, which portends a poor prognosis. Nephrology is willing to provide continuous renal replacement therapy, although the patient had not previously expressed a preference for or against hemodialysis, and the consult team questions the benefit of long-term hemodialysis. Cardiology is hopeful that the patient's fluid status can be optimized to allow for left and right heart catheterization, as they are considering mechanical circulatory support (e.g., left ventricular assist device, or LVAD). The ICU social worker is approached to arrange a family meeting, and is asked to have the appropriate surrogate decision maker(s) present. Which intervention/procedure warrants specialty-level palliative care? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Counseling patient/family about prognosis of worsening renal function in heart failure B. Determining whether patient accepts transfer to intensive care unit for life-sustaining treatments C. Discussing medical need for life-sustaining treatments and potential risk/benefit and outcomes with and without intervention D. Eliciting resuscitation preferences (i.e., code status) at time of admission E. Helping a surrogate decision-maker decide whether the patient would choose to pursue life-sustaining treatments among conflicting opinions from different medical teams F. Identifying appropriate surrogate decision-maker for incapacitated patient

The correct answer is E. This patient is experiencing serious illness in multiple ways—both the acute exacerbation of her chronic medical problems and acute decompensation during hospitalization leading to a need for intensive care. Although she presents as a complex patient, her constellation of diagnoses and presentation is a common one. Her case follows a relatively familiar course until she reaches the ICU, where the multiple provider teams participating in her care have differing opinions about the best plan of care going forward. Up to this point, her primary (and consulting) team(s) have been able to provide primary palliative care (whether or not they recognize they're doing so!). It is reasonable for any hospital-based provider to have some comfort in asking a patient's code status (D), discussing ICU transfer (B), talking about prognosis in a common setting (cardiorenal syndrome) (A), and counseling the patient/family about hemodialysis (C). It is important to note that this is not necessarily completed by a single clinician—rather, the cardiology and nephrology consultants most likely support the primary service in these tasks. Similarly, the identification of the legally appropriate surrogate decision-maker is a task that all care team members should be familiar with (F), barring significant ethical or legal challenges. Once a family meeting is needed/anticipated, this may be a time to involve specialist-level palliative care. Specifically, there is "conflict" present between medical teams (e.g., ICU team sees a poor prognosis, whereas cardiology is hopeful to provide an LVAD, and nephrology is on the fence). The presence of conflict does not necessarily imply hostile interaction. The role of a palliative care clinician will be to counsel the patient's surrogate to help make sense of the complexity of medical care being provided, and to support substituted decision-making on behalf of the patient.

A 92-year-old female comes to the clinic after being discharged last week for a heart failure exacerbation. The patient states that she has no symptoms except occasional dizziness and a near fall two days ago. Her daughter, who is her primary caregiver, accompanies her to the visit and brings discharge instructions. The discharging team had discussed the care plan with the daughter. The instructions read: "Increase your furosemide to 80 mg daily, continue your carvedilol 25 mg twice a day, and start melatonin 4 mg nightly as needed for insomnia. Continue a low-salt diet and record your daily weight; see below for further guidance about lifestyle modification. You have an appointment with your PCP next Thursday at 2 p.m." Medical history is significant for heart failure and hypertension (HTN). Home medications were 40 mg furosemide daily and carvedilol 25 mg twice a day. Vital signs are notable for orthostatic hypotension. Physical examination shows an older female in no apparent distress. Lungs are clear to auscultation bilaterally. There is trace pitting edema bilaterally to mid-shin. Results of laboratory/diagnostic studies show creatinine (Cr) 1.2 mg/dL and blood urea nitrogen (BUN) 45 mg/dL. (Baseline creatinine is 0.8 mg/dL). Which of the following is most likely to improve the smooth transition of care from the hospital? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Discuss discharge instructions with the patient's other children B. Include additional instructions about cardiopulmonary rehabilitation C. Place a referral to a nutritionist for ongoing lifestyle modification D. Schedule a follow-up appointment within two days of discharge E. Specify what changes in weight or symptoms should prompt a call to a primary care physician (PCP)

The correct answer is E. This patient presents with orthostatic hypotension in the setting of increased diuretics. In older adults, this can be an important risk factor for falls and hospital readmission. It is important to discuss potential complications or side effects of medication changes so that the family/patient is aware when they should notify a health professional. While the patient may benefit from further rehab therapy or education by a nutritionist, those interventions would not address the issue of over-diuresis. The team did involve the patient's primary caregiver (daughter) so while it may be helpful to include other family members, that is unlikely to be as useful as proper education around side effects/complications. A follow-up within one week was scheduled upon discharge and with proper return precautions and education around side effects, the patient/family could always call the clinic for an earlier appointment if needed.

A 75-year-old male is found on the floor of his home by his family. He is admitted to the hospital for acute kidney injury and rhabdomyolysis. During his admission, the cause of his fall is evaluated, but no specific etiology identified. The patient does not remember why he fell and states he has been healthy and independent. He is then transferred to a subacute rehabilitation facility for physical therapy. He has not seen a physician in several years. He lives alone in a ranch home. His son notes that his father recently started forgetting his medications and recently overdrafted his checking account. His past medical history is significant for osteoarthritis, cerebrovascular accident, and coronary artery disease (CAD). His medications include aspirin, fish oil, and acetaminophen. He has an allergy to statins. On examination, vitals are normal. He has decreased strength and movement in his right upper extremity. His gait is slow with decreased arm swing. On cognitive testing, his Montreal Cognitive Assessment (MoCA) score is 17/30. A normal MoCA score is ≥ 26/30. His labs are unremarkable. On head imaging, there is evidence of several cerebral infarctions and moderate volume loss. What is the most likely diagnosis? Choose the single best answer. The best option is indicated below. Your selections are indicated by the shaded boxes. A. Alzheimer disease B. Lewy body dementia C. Normal pressure hydrocephalus D. Parkinson disease E. Vascular dementia SUBMIT

The correct answer is E. Vascular dementia is associated with stepwise decline and a history of vascular disease like stroke and coronary artery disease. Radiologic findings of multiple white matter lesions or cortical infarcts are also common in vascular dementia.

A 68-year-old patient comes to the clinic for an annual wellness visit accompanied by her home attendant. - Medical history is significant for severe osteoarthritis requiring a wheelchair, diabetes, end-stage renal disease (ESRD) on hemodialysis, hyperlipidemia, hypertension, and vascular dementia. Medications are acetaminophen as needed, aspirin, atorvastatin, epoetin alfa, nifedipine, and sevelamer. - Vital signs are normal. Physical examination shows a frail female sitting in a wheelchair. Palpable thrill and audible bruit over right arm fistula. No lower extremity edema bilaterally. Alert to self, clinic, but not date. Speech is tangential but mostly coherent. She needs full assistance moving from her wheelchair to the exam table. - Results of laboratory studies are within normal limits except for the following: Hemoglobin 8.4 g/dL and Creatinine of 5.2 mg/dL, both unchanged from a year ago. - After reviewing her chart further, you realize she is up to date on vaccinations. Her mammogram six months ago was normal, and her colonoscopy five years ago was also normal. She has never had a pap smear. Other than recommending age-appropriate immunizations, which of the following is the next best step for this patient in terms of primary prevention? Choose the single best answer. A. Order a colonoscopy B. Order a mammogram C. Order a pap smear D. Recommend a blood transfusion E. Recommend against further cancer directed screening

The correct answer is E. When using USPSTF guidelines for decisions regarding primary prevention, it is important to assess a patient's functional status and estimated life expectancy to ensure that screening benefits outweigh risks. With this patient who is wheelchair-bound, on dialysis, and has vascular dementia, primary prevention cancer screening risks outweigh benefits given her high mortality risk within the next few years. If she was more functional, given her last colonoscopy was normal and five years ago, another colonoscopy would not be due for five years. If she was more functional, routine mammograms can be spaced out to every 2 years until the age of 75 for functional older adults. Since she has never had a pap test, even though she is > 65 years old, a one-time pap test would be recommended if she was more functional. Given her functional status and comorbidities, the risks of a pap smear outweigh the benefits in her clinical case. She has ESRD and is on dialysis; therefore, her target hemoglobin is above 7 g/dL.