Week 4 Questions

Which one of the following interventions is associated with a reduced incidence of delirium after hip fracture surgery? (A) Strict avoidance of opiate analgesics (B) Geriatric consultation with structured protocols (C) Transfusion to hemoglobin level >10 mg/dL (D) Donepezil in the perioperative period

Geriatric consultation with structured protocols

Which one of the following classes of medication is the most common cause of delirium in hospitalized older adults? (A) Angiotensin-receptor blockers (B) H2-receptor antagonists (C) Selective serotonin-reuptake inhibitors (D) H1-receptor antagonists (E) HMG-CoA reductase inhibitors

H1-receptor antagonists

Which of the following groups has the highest rate of suicide in the elderly? a. Asian males b. Hispanic males c. Caucasian males d. African-American males

Caucasian males

An 83-year-old woman is hospitalized for treatment of pneumonia. History includes Alzheimer disease, depression, and urinary urgency. Baseline medications are sertraline 50 mg/d and extended-release oxybutynin 5 mg/d. During hospitalization, she has become more confused despite initiation of antibiotic and antipyretic agents. She awakens in the middle of the night demanding that staff bring her lunch, and she hallucinates and engages in conversation with children whom she believes are in the room. Which one of the following would be the most appropriate initial pharmacologic intervention? (A) Begin donepezil. (B) Begin quetiapine. (C) Begin ramelteon. (D) Discontinue sertraline. (E) Discontinue oxybutynin

Discontinue oxybutynin

The remission rate of elderly depressed patients to initial antidepressant treatment is: a. 30% b. 40% c. 70% d. 80%

30%

An 88-year-old woman has an unexplained fracture of the right zygomatic arch. She lives on a dementia unit in a nursing home. History includes moderately advanced Alzheimer disease. There is no history of witnessed or unwitnessed falls, nor any medical conditions that would lead to spontaneous or pathologic fractures. The facility conducts a thorough evaluation and determines that the injury is a result of physical abuse. Who is the most likely perpetrator? (A) Her assigned primary certified nursing assistant (B) The registered charge nurse assigned to the floor (C) Another resident (D) A family member visiting another resident (E) Maintenance staff

Another resident

The daughter of an 82-year-old woman calls because her mother has suddenly become more agitated, confused, and psychotic. Her mother has a 4-year history of Alzheimer disease. Psychotic symptoms and agitation have been well-controlled on quetiapine 50 mg at bedtime. Which one of the following is the most appropriate next step? (A) Increase quetiapine to 75 mg/d. (B) Discontinue quetiapine and initiate risperidone. (C) Stop all medications and reevaluate in 1 week. (D) Arrange urgent physical and laboratory evaluation

Arrange urgent physical and laboratory evaluation

A 78-year-old nursing home resident with Alzheimer's disease, chronic obstructive pulmonary disease, and seasonal allergies is transferred to your hospital with poor oral intake and confusion. Physical examination reveals a thin man with dry mucous membranes, tachypnea, tachycardia, and altered mental status. In order to reliably identify delirium in this patient in a time-efficient manner (<5 minutes), what will be your instrument of choice? a. Folstein Mini-Mental State Examination (MMSE) b. Confusion Assessment Method (CAM) c. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-V) d. Glasgow Coma Scale (GCS)

Confusion Assessment Method (CAM)

Strong evidence suggests that delirium is an important, independent predictor of all of the following EXCEPT: (A) Death (B) New institutionalization (C) Dementia (D) Functional decline (E) Delusional disorder

Delusional disorder

Which one of the following best describes the relationship between dementia and hip fracture? (A) Dementia does not increase risk of hip fracture but does worsen outcomes after a fracture. (B) Dementia does not affect the risk of hip fractures or outcomes after a fracture. (C) Dementia increases hip fracture risk and leads to poorer outcomes after a fracture. (D) Dementia increases hip fracture risk but does not change outcomes after a fracture

Dementia increases hip fracture risk and leads to poorer outcomes after a fracture

Which of the following is not a risk factor for late-life depression? a. Family history of depression b. Disability c. History of stroke d. History of a myocardial infarction e. Loss of a loved one

Family history of depression

Which one of the following is required for a diagnosis of delirium using the Confusion Assessment Method (CAM)? (A) Acute change or fluctuating course in physical status (B) Hallucinations (C) Lethargy (D) Inattention (E) Delusions

Inattention

The treatment for sleep-disordered breathing with the strongest empirical support is: a. Cognitive-behavioral therapy b. Positive airway pressure (PAP) c. Laser-assisted uvulopalatoplasty (LAUP) d. None of the above

Positive airway pressure (PAP)

Which one of the following is true regarding the risk of prescribing psychotropic medications to patients with dementia? (A) First- and second-generation antipsychotics increase both morbidity and all-cause mortality. (B) Second-generation antipsychotics do not increase morbidity and all-cause mortality. (C) First-generation antipsychotics do not increase morbidity and all-cause mortality. (D) First- and second-generation antipsychotics increase morbidity but not all-cause mortality

First- and second-generation antipsychotics increase both morbidity and all-cause mortality

Mr. F is an 81-year-old gentleman with a PMH of hyperlipidemia, HTN, BPH, and Diabetes. He is 4 days s/p total hip replacement and his family reports that he seems more confused than usual. Staff report he is increasingly paranoid and restless, and sleeps during the day and is up all night. His appetite is poor and he often falls asleep during his meals and physical therapy. What should you tell the family? a) This is to be expected in an older adult after hip surgery - it is nothing to worry about and it will resolve on its own b) He might have delirium, or acute confusion, which needs to be evaluated and treated immediately c) Put up his full bed rails to make sure he is safe while in bed d) This is most likely his dementia flaring up, so keep him safe while he recovers from his hip surgery

He might have delirium, or acute confusion, which needs to be evaluated and treated immediately

Hearing loss is an independent risk factor for which one of the following? (A) Institutionalization (B) Incident all-cause dementia (C) Mortality (D) Stroke

Incident all-cause dementia

Which of the following is not a side effect of SSRIs in the elderly? a. Extrapyramidal symptoms b. Gastrointestinal bleeding c. Gastrointestinal irritation d. Hyponatremia e. Increase in suicidal ideation

Increase in suicidal ideation

Bipolar disorder in older adults can mimic the clinical presentation of delirium, and it might be necessary to obtain the past psychiatric history of the patient to clarify the diagnosis. Which one of the following is true about use of lithium for bipolar illness in older adults? (A) It is not indicated in patients >75 years old. (B) Use of NSAIDs can cause lithium levels to decrease. (C) It cannot safely be used in patients with hypothyroidism. (D) It cannot safely be used in patient with diabetes. (E) It can be prescribed to patients who also take diuretics

It can be prescribed to patients who also take diuretics

A 78-year-old woman is brought to the office because her sleep is disrupted. Her son notes that over the past month, she has had difficulty falling asleep, and once she does sleep, she awakens after about 4 hours. Over-the-counter antihistamines helped her sleep, but she was groggy the following day. History includes Lewy body dementia. On examination, there are no findings that might contribute to insomnia. Which one of the following is the most appropriate initial treatment for this patient? (A) Mirtazapine (B) Ramelteon (C) Trazodone (D) Zolpidem (E) Melatonin

Melatonin

Which one of the following statements most accurately describes the relationship between apolipoprotein E4 (ApoE4) and Alzheimer disease? (A) Alzheimer disease develops in all carriers of the ApoE4 allele. (B) Most patients with Alzheimer disease are not carriers of the ApoE4 allele. (C) Risk for development of Alzheimer disease is the same in homozygous and heterozygous carriers of the ApoE4 allele. (D) In carriers of the ApoE4 allele, Alzheimer disease typically manifests at a later age. (E) Homozygous carriers of the ApoE4 allele are protected against late-onset Alzheimer disease

Most patients with Alzheimer disease are not carriers of the ApoE4 allele

A 70-year-old woman comes to the office for routine follow-up. History includes moderate Alzheimer disease, hypertension, and hypercholesterolemia. Medications include aspirin 81 mg, lisinopril 10 mg, simvastatin 40 mg, and donepezil 10 mg, each taken daily. She is accompanied by her daughter, who asks whether her mother would benefit from herbal or other supplement therapies for Alzheimer disease. Which one of the following supplements is most likely to help slow the progression of Alzheimer disease? (A) Ginkgo biloba (B) Caprylic acid (C) Coenzyme Q 10 (D) Omega-3 fatty acid (E) None

None

An 80-year-old woman comes to the office because she has had difficulty falling asleep for the past year. The difficulty now occurs nearly every day. She also describes discomfort in her legs and sometimes in her arms in the late afternoon and early evening; the discomfort makes it difficult for her to sit still or find a comfortable position to sleep. It takes her >1 hour to fall asleep, and sometimes she cannot get back to sleep because of the restlessness. Rubbing and moving her legs seem to temporarily relieve the discomfort. Laboratory findings for general chemistry, blood count, and thyrotropin are within normal range. Which one of the following is best supported by evidence as first-line treatment? (A) Gabapentin (B) Pramipexole (C) Iron supplementation (D) Vitamin D supplementation

Pramipexole

An 86-year-old man comes to the office accompanied by his daughter because he has episodes of increasing psychosis and aggression over the past 2 months. History includes moderate Alzheimer disease. His primary caregiver is his daughter, to whom he is often verbally abusive and threatening; he has punched her on 3 occasions. He believes that his food is being poisoned and that his son, who lives 1,000 miles away, has been coming into their home and stealing. Attempts at nonpharmacologic interventions have been unsuccessful, and his psychosis and aggression are increasing. Which one of the following is the most appropriate pharmacologic treatment for this patient? (A) Citalopram (B) Donepezil (C) Haloperidol (D) Risperidone (E) Valproic acid

Risperidone

Common age-related changes in sleep include all of the following except : a. Lower sleep efficiency b. A decrease in stage N3 sleep (i.e., slow-wave or deep sleep) c. Strengthening of endogenous circadian rhythms d. Increased daytime napping

Strengthening of endogenous circadian rhythms

An 84-year-old woman complains of nausea and vomiting for the past 3 days. She has a history of multiple abdominal surgeries, adhesions, and recurrent hospitalizations for partial small bowel obstruction. She has visual and hearing impairment and is currently taking oxybutynin for neurogenic bladder. You are worried about her developing delirium and would like to prevent it. Interventions that may prevent the onset of delirium among elderly hospitalized patients include all of the following except : a. Early mobilization b. Ensuring 6 hours of uninterrupted sleep per night c. Treating volume depletion d. Using lorazepam for anxiety e. Providing access to hearing and visual aids

Using lorazepam for anxiety

Mrs. P is a 75 year old female who has been hospitalized for the past 3 days for a COPD exacerbation. The nursing staff report that she has been more confused lately. What would be the best standardized assessment tool to use to determine if Mrs. P has delirium? a) Geriatric Depression Scale b) Mini-Mental Status Exam c) Confusion Assessment Method d) MoCA (Montreal Cognitive Assessment)

Confusion Assessment Method

Which one of the following shortens the duration of delirium and is associated with improved physical function, less functional decline, shorter hospital stay, and improved 1-year survival in critically ill older adults? (A) Reorientation (B) Early exercise and mobility (C) Use of 1:1 care (a caregiver for each patient) (D) Massage (E) Physical restraints

Early exercise and mobility

You are seeing an 84-year-old patient with dementia and her daughter, who cares for her at home. The patient hollers during the early hours of the day. Sometimes she yells "help me, help me." Her daughter is overwhelmed with this behavior. How would you initially approach this patient? a. Admit the patient into a nursing home. b. Identify triggers for behavior. c. Prescribe an antipsychotic medication. d. Provide caregiver skill in problem solving

Identify triggers for behavior

Which one of the following is true about untreated depressive illness in older adults? (A) It increases health care use and costs by 20%. (B) It increases health care use and costs by >40%. (C) It is associated with a 25% increase in mortality after myocardial infarction. (D) It is associated with a 40% increase in mortality after myocardial infarction. (E) It is associated with a 50% increase in risk of hospitalization within 1 year

It increases health care use and costs by >40%

Which one of the following is considered a psychosocial risk factor for development of depression in late life? (A) Perception of inadequate social support (B) Gender (C) Ethnicity (D) Family history of mental illness (E) Religious affiliation

Perception of inadequate social support

An 86-year-old woman is admitted to the hospital from a nursing home because over the past 2 days she has become increasingly lethargic, sleeping on and off throughout the day, and is slow to respond to questions. The staff accompanying her reports that she is normally alert and oriented, pleasant, and actively involved in her care. History includes hypertension, type 2 diabetes mellitus, paraplegia from a car accident 30 years ago, and recurrent pressure ulcers. On arrival in the emergency department, temperature is 39.3° C (102.8° F), blood pressure is 88/40 mmHg, and heart rate is 100 beats per minute. Behavior fluctuates between lethargy and mild agitation. She provides no useful history. Which one of the following is the most appropriate next step in her care? (A) Obtain CT of the head with contrast. (B) Administer a high-potency, low-dose antipsychotic agent. (C) Perform physical examination and order laboratory tests. (D) Transfer to ICU for observation. (E) Obtain psychiatric consultation

Perform physical examination and order laboratory tests

A 70-year-old man with colonic diverticulosis was admitted to the hospital with gastrointestinal bleeding and abdominal pain. He underwent colonoscopy under conscious sedation using fentanyl and midazolam. The following day, the patient was found to be delirious by the geriatric consultation services. Presence of delirium in this patient predisposes him to all but which one of the following? a. Higher risk of institutionalization b. Increased risk of dementia c. Recurrence of gastrointestinal bleeding d. Increased mortality

Recurrence of gastrointestinal bleeding

An 80-year-old woman comes to the office for follow-up related to laboratory findings. She is accompanied by her daughter. History includes recently diagnosed dementia, osteoarthritis, hypertension, hypothyroidism, and gout. Current medications are acetaminophen, lisinopril, levothyroxine, and allopurinol. Recent laboratory tests done as part of a dementia evaluation show macrocytic anemia, normal folate level, and decreased vitamin B12 level of 220 pg/mL. Which one of the following best describes the relationship between her low B12 level and cognitive disorder? (A) B12 deficiency is the likely cause of her dementia. (B) B12 deficiency is an incidental finding. (C) B12 deficiency increases her risk of Alzheimer disease. (D) B12 deficiency contributes to vascular brain pathology

B12 deficiency contributes to vascular brain pathology

Sleep disorders that increase in prevalence as people age include which of the following? a. Sleep disordered breathing (sleep apnea) b. REM sleep behavior disorder c. Narcolepsy d. a and b

a and b

A 72-year-old man is brought to the office for management of hallucinations that cause him severe distress. The hallucinations are of Civil War soldiers and monkeys, and he fears they will attack him. History includes early Lewy body dementia. In previous visits, no contributing medical or pharmacologic (eg, anticholinergic agents) causes of psychosis were identified. Behavioral interventions were unsuccessful. During a particularly stressful episode, his family took him to the emergency department, where he was prescribed risperidone 0.25 mg twice daily. He rapidly became more confused and markedly rigid. These symptoms resolved after risperidone was discontinued. Which one of the following is the most appropriate treatment recommendation for this patient? (A) Clozapine (B) Haloperidol (C) Lorazepam (D) Quetiapine (E) Rivastigmine

Rivastigmine

A 64-year-old female with a prior history of congestive heart failure and myocardial infarction is admitted to the hospital because of increasing confusion and lethargy over the last week. Physical examination reveals a confused woman with right lower lobe crackles and a pulse oximetry of 86% on room air. While you are interviewing the patient, she gets angry about one of your questions, and you notice waxing and waning in her alertness and cognitive status. Which one of the following features present in this patient best distinguishes delirium from depression or dementia? a. Presence of lethargy b. Symptom fluctuation c. Experience of hallucinations d. Aggressiveness

Symptom fluctuation

You are asked to evaluate Mrs. P who is a 65-year-old female who has been exhibiting increased confusion over the past 3 days, accompanied by disorganized thinking, visual hallucinations of little children playing in her room, physical aggression during ADLs, and an inability to focus her attention on exercise instructions when working with the physical therapist. The morning shift nurses state she "seems just fine", however night shift staff report she is more confused, restless and agitated at night. Which of the following accurately describes the CAM criteria she meets for a diagnosis of delirium? a) Acute onset of confusion with a fluctuating course, agitation, inattention and psychosis b) Acute onset of confusion with a fluctuating course, inattention and disorganized thinking c) Visual hallucinations, poor attention, confusion and agitation d) Acute onset of agitation, fluctuating course, psychosis and altered level of consciousness

Acute onset of confusion with a fluctuating course, inattention and disorganized thinking

A 76-year-old man comes to the office because for the past 3 months he has had frequent short arousals after sleep onset and increased daytime fatigue. History includes hypertension, controlled by medication for the last 10 years, and heart failure, diagnosed 1 year ago. Overnight polysomnography showed a moderate level of sleep-disordered breathing (apnea-hypoxia index of 28), consisting of both obstructive and central respiratory events. The central events were described as Cheyne-Stokes breathing pattern. The lowest O2 saturation recorded was 86%; saturation was <88% for under 5% of the night. Which one of the following is the most appropriate treatment for this patient's sleepdisordered breathing? (A) Nasal continuous positive-airway pressure (CPAP) (B) Mandibular advancement device (C) Oxygen supplementation overnight (D) Adaptive servo-ventilation

Adaptive servo-ventilation

Mrs. T is a frail 90-year-old widowed female nursing home resident with moderate to advanced dementia, osteoarthritis, hearing loss, failure to thrive. She has been admitted to the hospital for pneumonia. During the past 4 days of her hospital stay, she has experienced increased confusion and restlessness attributed to hypoxia from her pneumonia. The staff report she constantly tries to pull out her G-tube and IV; exhibits poor safety awareness manifested by attempts to get out of bed unassisted and tripping over her foley catheter bag; and experiences visual hallucinations of bugs crawling on the wall. What are some helpful non-pharmacological interventions for Mrs. T? a) Camouflage her G-tube with an abdominal binder and remove any unnecessary IV lines and/or foley catheter b) Make sure she is wearing her glasses and hearing aids and assess for pain as a possible cause for her behavior c) Move her closer to the nurses' station for closer supervision and institute 1:1 supervision as indicated d) All of the above

All of the above

A 92-year-old woman comes to the office for a routine visit. She seems more withdrawn than on previous visits, and the caregiver who accompanies her confirms that she seems depressed. She lives alone in a second-floor walk-up apartment and has difficulty getting down the stairs because of severe arthritis. The caregiver attends her 4 hours daily, 5 days each week, to assist with shopping, cooking, housekeeping, and transportation to medical appointments. The patient is independent in ADLs, and her cognition is intact. She no longer attends her book and bridge groups, because the caregiver is not available to drive her when they meet. Her children live across the country. They call regularly and visit twice each year. The patient acknowledges that she is very lonely. On examination, she has lost weight. Her score on the Geriatric Depression Scale is 8. Which one of the following would be the most appropriate recommendation for this patient? (A) Enroll in workshops for computer skills at the local library. (B) Ask her children to schedule regular videoconferences with her. (C) Advise the family to install a remote activity monitor in her home. (D) Order a robotic companion for the patient

Ask her children to schedule regular videoconferences with her

A 74-year-old woman comes to the office for routine follow-up. She had a stroke 7 months ago that caused unilateral sensory loss, with no residual effects and no known strokes since. Long-term outpatient cardiac monitoring after the stroke did not identify a proximate cause. MRI of the brain after the stroke revealed extensive white matter disease and evidence of a lacunar stroke in the thalamus. History includes diabetes, hyperlipidemia, and memory difficulty. Current medications are metformin, glipizide, and simvastatin. She ambulates with a walker and needs assistance with most of ADLs because of gait instability and memory impairment. On examination, there is evidence of slowed mentation, executive dysfunction, memory deficits marked by inconsistent acquisition rather than forgetfulness, and 4-word recall aided by cuing. Which one of the following treatments should be the first step in management? (A) Aspirin (B) Aspirin and clopidogrel (C) Donepezil (D) Rivastigmine (E) Souvenaid® (a medical food containing triglycerides)

Aspirin

You are evaluating Mrs. A, who is a 73-year-old woman who lives with her daughter in a single story home. Mrs. A is being seen in the ER after falling while walking down the hallway. She sustained a distal ulnar fracture, but no head injury or LOC. The daughter reports that her mother has been progressively confused over the past 4-6months with an increasingly unsteady gait and new onset urinary incontinence. Neuro exam reveals normal cranial nerve function, diffuse mild motor weakness, and positive Romberg. All of the following are an appropriate plan for Mrs. A except? a) Consult neurology to rule out normal pressure hydrocephalus (NPH) b) Refer to PT and OT for strength and endurance training and home safety evaluation upon discharge from the hospital c) Order CT scan and consult neurology d) Assess and treat the urinary incontinence and see again in one month

Assess and treat the urinary incontinence and see again in one month

A 67-year-old woman comes to the office because for the past 4 months she has had difficulty falling asleep on most nights. For many years, she has maintained a regular sleep and wake schedule (bedtime at 10 PM, wake time at 5:30 AM). It now takes her about 2 hours to fall asleep, and she often wakes up briefly 2-3 times during the night. The lack of sleep is affecting her work performance and energy level during the day. The sleep problem began around the time she started taking medication for high blood pressure. Which one of the following is most likely to be associated with her insomnia symptoms? (A) Atenolol (B) Hydrochlorothiazide (C) Olmesartan (D) Lisinopril

Atenolol

An 82-year-old patient comes to the office for follow-up on management of her depression. Because she did not respond to sertraline and venlafaxine, mirtazapine was initiated. She has had a partial response to mirtazapine, despite adequate dosage and duration of therapy. She continues to spend much time in bed, is deconditioned, and has fallen twice. Since beginning therapy, she has gained weight and is finding it difficult to control her diabetes. During this visit, she expresses a sense of hopelessness and states that she sometimes feels that she would be better off dead. She denies any intent or plan to kill herself. She reports frequent arguments with her unemployed son about finances. Referral for cognitive-behavioral therapy is impractical because there is no skilled provider in the area. Which one of the following treatment options should be considered next? (A) Hospitalization and electroconvulsive therapy (B) Referral for transcranial magnetic stimulation (C) Augmentation with bupropion (D) Switch from mirtazapine to duloxetine (E) Referral for family therapy

Augmentation with bupropion

An 85-year-old man is brought to the office by his son because his symptoms of Alzheimer disease have significantly worsened over the last 6 months. Probable late-onset Alzheimer disease was diagnosed 5 years ago, and until recently the disease had progressed slowly. History also includes hypertension and diabetes. Medication includes maximum dosages of donepezil and memantine. The son is the primary caregiver and health care proxy. The patient frequently wanders outside the house at night. He is convinced that people are breaking into his home at night, and his son recently found him in the kitchen holding a knife, yelling "intruder" at the window curtains. Reorientation tactics to address this behavior have not been successful. A thorough evaluation for reversible causes of acute psychosis is negative. The patient's son requests pharmacologic management of the psychosis, understanding the risks it entails in patients with dementia. Which one of the following regimens should be prescribed to help manage the patient's symptoms? (A) Begin haloperidol at a low dosage, increase the dosage until symptoms are controlled, then taper as soon as possible. (B) Begin quetiapine at a low dosage, increase the dosage until symptoms are controlled, then taper as soon as possible. (C) Begin duloxetine at a low dosage, increase the dosage until symptoms are controlled, then taper as soon as possible. (D) Prescribe lorazepam at a low dosage as needed

Begin quetiapine at a low dosage, increase the dosage until symptoms are controlled, then taper as soon as possible

A 71-year-old man comes to the office because for the past 5 months he has had difficulty staying asleep. He is sleepy from 7 PM-9 PM, but he tries to stay up until 10:30 PM to socialize with his wife and watch the news. He falls asleep easily but then is awake from 3 AM-4 AM. He goes to the bathroom and usually does not fall back asleep, or he dozes off and on until 5:00 AM. As a consequence, he has difficulty concentrating and is irritable and fatigued. History includes mild obstructive sleep apnea, for which he was told that he does not require treatment. He states that he does not have depressive symptoms. Which one of the following is the most appropriate initial treatment to improve his sleep? (A) Melatonin at bedtime (B) Eszopiclone at bedtime (C) Paroxetine at bedtime (D) Progressive muscle relaxation therapy (E) Bright-light exposure in the evening

Bright-light exposure in the evening

You have been asked to evaluate Mr. L who is a 75-year-old recently widowed gentleman who was admitted to the hospital 3 days ago with a heart failure exacerbation. Staff note that clinically his heart failure is improving, yet he seems withdrawn, periodically confused, sleeps intermittently throughout the day, is occasionally difficult to arouse and has a poor appetite. What is the first thing you should do in the case of Mr. L? a) Check oxygen sats, and rule out hypoactive delirium b) Start Remeron 7.5mg to improve his depression and appetite and normalize his sleep/wake cycle c) Do a MMSE d) Consult physical therapy as Mr. L is deconditioned and needs to increase his strength, stamina and endurance

Check oxygen sats, and rule out hypoactive delirium

Mr. G is an 86-year-old male with a PMH for Lewy Body Dementia, HTN, diabetes, and CAD s/p CABG 10 years ago. He recently suffered an AMI and is in the ICU. The nursing staff report he has been very confused, paranoid and hallucinating for the past few nights; gets physically aggressive during care; and frequently pulls at his tubes/IVs. The hospitalist ordered Haldol 5mg IV q4 hrs and Ativan 1mg q4hrs prn IV for agitation. He has also recently been placed in bilateral wrist restraints. The family is concerned that he is now drooling, somnolent and rigid. The nursing staff note the Ativan doesn't seem to help at all and possibly makes him more agitated. Which is the most appropriate initial plan for Mr. G? a) D/C Haldol and Ativan, d/c restraints, institute 1:1 supervision with family/staff b) Switch Haldol to Zyprexa since atypical antipsychotics are safer in older adults, d/c c) Ativan but keep the restraints to avoid interruption of needed medical therapies d) Increase the Haldol to 10mg IV q4hrs, d/c Ativan, and suggest a possible referral to the palliative/hospice care service e) Switch Haldol to Seroquel 75mg qhs, decrease Ativan to O.5 mg q 4hrs and make sure the family brings in his glasses to avoid misperceptions and hallucinations at night

D/C Haldol and Ativan, d/c restraints, institute 1:1 supervision with family/staff

Mr. K is a 72 year old gentleman with a PMH of HTN, GERD, OA and depression,who lives alone in a senior housing apartment. His family reports that he has been more confused and depressed over the past few months. Medication review reveals that he takes HCTZ 25mg daily, citalopram 10mg daily, Tagamet 300mg daily, and Tylenol PM prn insomnia/pain. What is the MOST appropriate initial plan for Mr. K? a) D/C Tagamet and Tylenol PM b) Increase his citalopram to 20mg daily c) Have a social worker visit him at home d) Tell his family he should move in with them to decrease his loneliness

D/C Tagamet and Tylenol PM

You are asked to see Mrs. J, an 85-year-old female nursing home resident, currently being evaluated in the ER for pneumonia. She has a past medical history (PMH) of HTN, osteoarthritis and Alzheimer's. Since arriving in the ER, she has been very restless, physically aggressive and experiencing visual hallucinations. Which diagnosis should you rule out first? a) Lewy Body Dementia b) Alzheimer's Disease c) Delirium Superimposed on Dementia d) Psychotic Depression

Delirium Superimposed on Dementia

Mr. W is a healthy 82-year-old gentleman with arthritis for which he occasionally takes Tylenol 325mg po daily. Otherwise he does not take any other prescribed or OTC medications or have any other medical problems. His family reports that over the past 18 months he has been getting lost in familiar places, requires frequent reminders to take a shower, asks repetitive questions, leaves the stove on after cooking and has been having more difficulties paying his bills. He also has become increasingly paranoid over the past few months - thinking someone has stolen his keys or wallet, when in fact he has simply misplaced them. Physical exam and lab tests are all normal. Which of the following diagnoses is most consistent with these signs and symptoms? a) Delirium b) Dementia c) Depression d) B and C

Dementia

A 76-year-old man comes to the office for his annual appointment. He is accompanied by his wife, who reports that the patient has been taking his antihypertensive medicine irregularly, is increasingly irritable, and no longer expresses interest in activities that they used to enjoy. She also notes that he has started to gamble impulsively and is losing a lot of money in poker games with friends. She says that he ignores her protests because he tends to be domineering and self-absorbed. The patient counters that he enjoys the games but loses money because his friends cheat. He insists that he takes his medication regularly and claims that he is only irritable around his wife and that she never raised concerns about his medication adherence with him. The patient seems unusually suspicious and mistrusting when asked for information about his daily routine, and he angrily leaves the office during a memory screen. Which one of the following is the most likely diagnosis? (A) Borderline personality disorder (B) Temporal lobe epilepsy (C) Dementia (major neurocognitive disorder) (D) Major depressive disorder (E) Paranoid personality disorder

Dementia (major neurocognitive disorder)

Mr. Brown is a 68-year-old retired teacher who lives with his wife and has remained active in volunteer programs in their community. However, according to Mrs. Brown, Mr. Brown has had several angry outbursts the past few months. He has lost interest in his hobby (building model cars) and has stopped participating in volunteer programs. Mr. Brown has also been having difficulty with sleep at night. What is the most likely diagnosis for this patient? a. Dementia b. Depression c. Insomnia d. Delirium

Depression

An 81-year-old man undergoes evaluation 2 days after cholecystectomy because his daughter is concerned about a change in cognition. When she entered his room today, he addressed her as his wife, who died 3 years ago. She believes he returned to baseline cognition 2 hours later. History includes mild dementia. His daughter states that at baseline he is oriented to person, place, time, and situation, and he is independent with all ADLs and most IADLs. On examination, vital signs are normal. He is alert and calm. He is oriented to self and place, but not to time or situation. Speech is tangential. Neurologic examination is otherwise unremarkable. Which one of the following would provide information on whether the patient meets Confusion Assessment Method criteria for delirium superimposed on dementia? (A) Drawing intersecting pentagons (B) Electroencephalography (EEG) (C) Digit span task (D) CT of the brain

Digit span task

The husband of an 82-year-old woman calls the clinic to report changes in her behavior over the last few days. She is confused, becomes agitated when he assists with ADLs, and will not eat because she thinks she is being poisoned. History includes hypertension, depression, osteoarthritis, probable Alzheimer disease (diagnosed 2 years ago), and urinary incontinence. Her score on the Mini-Mental State Examination was 22 of 30 at her last visit 2 months ago. Medications include acetaminophen 325 mg four times daily, donepezil 5 mg/d, extended-release memantine 14 mg/d, hydrochlorothiazide 25 mg/d, lisinopril 10 mg/d, tolterodine 2 mg twice daily, and citalopram 20 mg/d. The donepezil and memantine were begun 2 years ago, tolterodine was increased 1 week ago, and citalopram was increased (from 10 mg) 2 months ago. A visiting nurse obtains laboratory samples later that day. Laboratory findings: BUN 18 mg/dL Serum creatinine 1.1 mg/dL Sodium 138 mEq/L Glucose 81 mg/dL (consistent with prior measurements) Urinalysis shows 0-5 WBCs/high-power field and is negative for bacteria and leukocyte esterase. Which one of the following is most appropriate at this time? (A) Discontinue tolterodine. (B) Increase extended-release memantine to 28 mg/d. (C) Start lorazepam 0.5 mg twice daily. (D) Start risperidone 0.25 mg/d

Discontinue tolterodine

A 72-year-old woman has memory decline that has progressed gradually over 18 months. Symptoms include repeating statements and questions, frequently losing items, and forgetting things. According to her husband, she is not as patient as usual but has no problems with mood, sleep, appetite, interpersonal relationships, or activities of daily living and continues to work part-time as a substitute teacher. She is independent on scales of activities of daily living filled out by her husband. The patient is functioning quite well day-to-day and has not restricted any of her activities. What is the recommended action in this patient? a. No dementia screening is needed because these are normal aging changes. b. Discuss with the patient about the decision for dementia screening. c. Use the Mini-Cog, the MMSE, or SLUMS to screen for dementia. d. Refer to specialist for further dementia assessment

Discuss with the patient about the decision for dementia screening

A 68-year-old man comes to the office with his wife because she is concerned that he may be depressed. History includes moderate Alzheimer disease. She notes that over the past 2 months he has often appeared to be sad, with intermittent tearfulness. He has lost interest in his former hobbies. He often shadows her around the house or sits in his recliner, "doing nothing all day." These behavioral changes have been stressful for his wife. She does not think that she can continue to take care of him if he remains this way, but she is reluctant to move him to an assisted-living facility because that would upset him. Which one of the following is the most appropriate recommendation for this patient? (A) Begin sertraline. (B) Begin mirtazapine. (C) Encourage enrollment in a dementia-specific day activity program. (D) Encourage reconsideration of assisted-living placement

Encourage enrollment in a dementia-specific day activity program

Which of the following most accurately describes the sleep-related consequences of circadian rhythm changes commonly associated with older age? a. Feeling sleepy in the evening, and waking earlier than desired in the morning b. Feeling sleepy in the evening, and waking later than desired in the morning c. Inability to fall asleep at night and waking earlier than desired in the morning d. Inability to fall asleep at night and waking later than desired in the morning

Feeling sleepy in the evening, and waking earlier than desired in the morning

A 65-year-old man comes to the office with his wife because she is concerned about his memory. He is a retired engineer. His wife states that he has been making uncharacteristic mistakes in their finances. For example, he forgot to pay the mortgage several months ago and, in the grocery store, his credit card was denied for missed payments. The patient states that balancing his accounts feels more effortful and takes longer than it used to, and he feels overwhelmed when there are too many distractions. He is frequently unable to find his keys and other objects, and at times is unable to recall the names of acquaintances until minutes or hours later. Which one of the following is most likely to indicate pathologic neurologic decline? (A) Taking longer to complete routine tasks (B) Forgetting to pay mortgage and credit card bills (C) Having a complaint about memory (D) Experiencing difficulty retrieving names

Forgetting to pay mortgage and credit card bills

A 70-year-old man comes to the office because he has progressive difficulty speaking. The patient's family states that over the past 2 years he has gradually been speaking less. Another physician prescribed propranolol for anxiety related to his work as a museum docent, discussing art with tour groups. His difficulty continued, and in the last year, his responsibilities at work have been shifted. His family thinks he understands most of what is said to him, but he answers questions in 1- or 2-word phrases, typically just nouns and verbs. His memory seems to be relatively spared, and he performs many chores around the house, including cleaning and helping with cooking. The patient is partially independent in ADLs. However, because of his language difficulties, he cannot safely leave the house alone. More recently, he has acted inappropriately toward family members, and they are concerned about what he might do in public if he is alone. History includes hypertension, anxiety, and anemia. There is no history of drug or alcohol abuse. Physical examination is consistent with the history provided by the family. Laboratory findings include macrocytic anemia with a low level of vitamin B12. Levels of homocysteine, methylmalonic acid, and thyrotropin are normal. Renal function and hepatic synthetic function are intact. There is no evidence of prior stroke on MRI of the brain. Which one of the following is the most likely cause of the patient's cognitive impairment? (A) Lewy body dementia (B) Vascular dementia (C) Alzheimer disease (D) Frontotemporal dementia

Frontotemporal dementia

A 73-year-old man comes to the office because he has memory problems, which have become most evident to his wife this year. In addition, he has had repeated unexplained falls. History includes hypertension, hyperlipidemia, diabetes, urinary incontinence, and constipation. Seven years ago he began to have impaired smelling, altered taste, and fitful sleep with recurrent dream enactment; the dream enactments wake his wife at night. Symptoms progressed, and fluctuating cognitive dysfunction and bilateral arm tremors developed. For several years, he has had hallucinations of children in the room. The hallucinations do not frighten him, but they worsened during hospitalization for urinary tract infection last year. Neuroleptic agents were administered, but his condition deteriorated and he required restraints for several hours. Behavioral interventions for the patient's neuropsychiatric symptoms have been unsuccessful. MRI of the brain shows mild white matter changes. Which one of the following medications should NOT be considered for this patient? (A) Clonazepam (B) Donepezil (C) Fludrocortisone (D) Haloperidol (E) Rivastigmine

Haloperidol

An 80-year-old man with multi-infarct dementia, chronic kidney disease, congestive heart failure, and uncontrolled hypertension was hospitalized with a heart failure exacerbation. He was initially treated with diuretics and salt restriction and his condition stabilized. On day 2 of his hospital stay, he developed confusion, inattention, and agitation. Application of nonpharmacologic measures to treat delirium was unsuccessful. Which of the pharmacologic agents mentioned below would be the best choice for treating the agitation associated with his delirium? a. Melatonin b. Haloperidol c. Diazepam d. Gabapentin

Haloperidol

A 75-year-old woman comes to the office for routine follow-up. Medications include aspirin 81 mg, glipizide 5 mg, lisinopril 5 mg, and pravastatin 20 mg, each taken daily. She states that she feels well overall, except that in the last several months she has had difficulty sleeping, such that her energy level is affected. She sleeps intermittently about 4 hours each night. There have been no changes in her sleep routine, and she does not drink caffeine after 10 am. She is not depressed or anxious. She asks whether she should try melatonin to help her sleep. Which one of the following is important to know? (A) Melatonin will interact with glipizide. (B) Long-acting melatonin is more effective than the short-acting form. (C) There is insufficient evidence that melatonin improves insomnia compared with placebo. (D) Melatonin will interact with pravastatin

Long-acting melatonin is more effective than the short-acting form

An 82-year-old man comes to the office because his wife is concerned about abnormal behaviors during sleep. History includes Parkinson disease, hypertension, and arthritis. For the past year, he has been mumbling or yelling in his sleep. During the past 3 months, at least 3 times each week, he has also been sitting up and moving his hands and arms, as if he were pushing someone away. Last week, he injured his hand when he knocked over the night lamp. When questioned, he sometimes recalls dreams in which he is playing football or basketball. Polysomnography shows increased motor activity in rapid eye movement (REM) sleep and mild obstructive sleep apnea. Which one of the following is the best initial treatment for this patient? (A) Clonazepam (B) Gabapentin (C) Sertraline (D) Melatonin

Melatonin

A 72-year-old woman is brought to the emergency department because of declining mental status. History includes mild vascular dementia. She lives in a nursing home, and the staff reports that she has been more somnolent and agitated over the past week. She has had no fever, chills, or change in frequency of urination, and she reports no dysuria or suprapubic tenderness. Nursing home staff notes that the patient's urine has a foul odor. She does not have an indwelling Foley catheter. On physical examination, vital signs are normal. She is oriented to person but somewhat difficult to arouse. There is no evidence of suprapubic or costovertebral angle tenderness. Microscopy shows 20 WBCs/high-power field (HPF), 2-4 epithelial cells/HPF, and numerous bacteria. A urine culture is obtained. Pending results of other diagnostic studies, which one of the following should be administered? (A) Oral nitrofurantoin (B) Oral ciprofloxacin (C) Intravenous ceftriaxone (D) Intravenous piperacillin-tazobactam (E) No antibiotic therapy

No antibiotic therapy

An 82-year-old man comes to the office because he wakes up to urinate up to 4 times each night. His wife states that he snores loudly, and she frequently nudges him during sleep so that he will turn over on his side. He reports daytime napping because he does not feel rested. History includes heart failure secondary to diastolic dysfunction, type 2 diabetes, chronic kidney disease (baseline creatinine of 1.3 mg/dL), hypertension, and hyperlipidemia. He had transurethral resection of the prostate 5 years ago for benign prostatic hypertrophy. Current medications are carvedilol, lisinopril, furosemide, atorvastatin, aspirin, glargine insulin at bedtime, and tamsulosin. The furosemide dosage is 40 mg/d, which he takes at 9 AM. On examination, BMI is 32 kg/m2 and blood pressure is 145/80 mmHg. Heart sounds are regular in rate and rhythm, with a loud P2 heard best during inspiration over the left parasternal region, intercostal space 2. There is bilateral 2+ pitting edema at the calves. Rectal examination reveals a nontender prostate estimated to weigh 30 g (minimally enlarged). Ultrasonography of the bladder shows 50 mL of residual urine after normal voiding. Urinalysis reveals 0-5 WBCs/high-power field and is otherwise unremarkable. Which one of the following is the most appropriate next step in evaluation of the nocturia? (A) Overnight sleep study or polysomnography (B) Transrectal ultrasonography to estimate prostate volume (C) Urodynamic evaluation to exclude bladder outlet obstruction (D) Measurement of brain natriuretic peptide level

Overnight sleep study or polysomnography

Which one of the following is most likely to result from use of an interprofessional inpatient geriatric consultation team to care for patients admitted for hip fracture? (A) Reduced number of delirium episodes (B) Reduced severity of incident delirium (C) Reduced duration of incident delirium (D) Increased cognitive decline during hospitalization

Reduced number of delirium episodes

A 71-year-old man is referred to the office for follow-up after a thyrotropin level of 0.5 mIU/L is found during evaluation for a concern for memory loss. He feels well and has no tremor, palpitations, or heat intolerance. On further questioning, his wife, who has accompanied him, states that she is worried about his memory and his ability to drive. She reports that he has had trouble remembering plans they make with friends and, most recently, he got lost driving to a local restaurant that they have been going to for years. On examination, blood pressure is 125/80 mmHg, heart rate is 72 beats per minute, and BMI is 23 kg/m2. Thyroid gland is of normal size, with no palpable nodules. Electrocardiography is normal. Laboratory findings: Thyrotropin (repeat) 0.4 mIU/L Free thyroxine 2 ng/dL Total triiodothyronine 165 ng/dL Which one of the following is the most appropriate next step?(A) Start treatment with propranolol. (B) Start treatment with propylthiouracil. (C) Refer for cognitive testing. (D) Order Holter monitoring. (E) Order echocardiography

Refer for cognitive testing

An 82-year-old woman comes to the office for follow-up related to treatment of depressive disorder. At an appointment 4 months ago, she was tearful and sad and described loss of appetite, poor sleep, and loss of interest in usual activities. She had no psychotic symptoms or suicidal ideation. She attributed her symptoms to a change in her living situation: her son had recently moved in with her after he lost his job and got divorced. In addition to depression, history includes diabetes mellitus, hypertension, coronary artery disease, and osteoarthritis. There is no history of suicide attempt or psychiatric hospitalization. Current medications are metformin, levothyroxine, hydrochlorothiazide, metoprolol, and docusate, as well as ibuprofen as needed. Trials of sertraline and venlafaxine were attempted beginning 4 months ago, but she did not tolerate either drug. Mirtazapine was started, with the dosage titrated up to 45 mg nightly. She has now taken mirtazapine for 3 months. She reports better mood and improved sleep and appetite, and she cries less. However, she spends most of her time in bed and remains uninterested in usual activities, and she is troubled by adverse effects of constipation and weight gain. Laboratory findings include hemoglobin A1c of 8% and glomerular filtration rate of 35 mL/min. Thyrotropin level is normal. Which one of the following treatment options should be considered next? (A) Discontinue mirtazapine and initiate tricyclic antidepressant. (B) Refer for cognitive-behavioral therapy. (C) Add aripiprazole. (D) Add lithium. (E) Refer for electroconvulsive therapy

Refer for cognitive-behavioral therapy

A 71-year-old woman comes to the office for a 1-year follow-up appointment. During review of systems, she describes noticing problems with memory for the past 8 months. She forgets where she places objects and has trouble remembering the names of people right away. She has never gotten lost. She lives alone at home and performs all ADLs. She has fallen twice in the past year and is developing a fear of falling. She drives without incident, mostly to local, familiar places. Recently, she has asked her daughter to join her in grocery shopping because she forgets items. She cleans and cooks simple meals, but her daughter goes to her house weekly to help. She still enjoys gardening and going to the senior center most days of the week. She reports no symptoms of depression or hallucinations and has had no recent illness. History includes hypertension and osteopenia. Current medications are lisinopril 10 mg/d and calcium with vitamin D. There is no history of smoking. Her mother had Alzheimer disease in her 80s, and she is concerned that she will, too. On examination, blood pressure is 156/92 mmHg, heart rate is 68 beats per minute, and O2 saturation is 100%. Her score on the Mini-Mental State Examination (MMSE) is 24 of 30. She rises from the chair on the second try and displays path deviation when she walks down the hall. In addition to repeating the MMSE in 6 months, which one of the following is the most appropriate intervention? (A) Increase lisinopril dosage to achieve target blood pressure <140/90 mmHg. (B) Refer for physical therapy assessment. (C) Refer for cognitive rehabilitation. (D) Prescribe daily Ginkgo biloba. (E) Prescribe daily vitamin E

Refer for physical therapy assessment

A 48-year-old woman who accompanies her father to the office expresses concern about her memory. Her father has Alzheimer disease; his symptoms manifested when he was 77 years old. The daughter describes her own lapses related to forgetting names and losing her keys, and asks to undergo genetic testing. Which one of the following is the most appropriate next step for this patient? (A) Test for apolipoprotein E4 (ApoE4); if positive, refer for genetic counseling. (B) Test for presenilin-1 and -2 gene mutations; if positive, refer for genetic counseling. (C) Test patient's father for presenilin-1 and -2 mutations; if positive, refer for genetic counseling. (D) Refer for pretest genetic counseling

Refer for pretest genetic counseling

An 82-year-old woman comes to the office accompanied by her daughter. History includes diabetes, hypertension, and hyperlipidemia. Medications include lisinopril 20 mg/d, metformin sustained-release 1,000 mg/d, atorvastatin 40 mg/d, and aspirin 81 mg/d. The patient lives alone. The daughter sees her mother most days and notes that she has been less active recently. She seems less interested in the grandchildren and in reading, and she frequently skips her daily walk. The patient explains that she has been walking less frequently because of poor weather. She has no pain with walking and has had no recent falls; she states that her balance has been good and her vision has been stable. Retinal screening 18 months ago showed no retinopathy, and hemoglobin A1c 3 months ago was 7.5%. On examination, blood pressure is 145/85 mmHg. She has lost 1.8 kg (4 lb) since her last visit 6 months ago. Which one of the following is the most appropriate next step? (A) Increase lisinopril to 40 mg. (B) Refer for retinal screening. (C) Check hemoglobin A1c level. (D) Screen for depression and cognitive impairment

Screen for depression and cognitive impairment

Which one of the following statements about therapy for patients with agitated dementia is true? (A) Second-generation antipsychotic agents are associated with a 5- to 6-fold increased risk of death compared with first-generation antipsychotics. (B) Second-generation antipsychotic agents are associated with a 1.5-fold increased risk of death compared with placebo. (C) First-generation antipsychotic agents are associated with a lower risk of death than second-generation antipsychotic agents and are therefore the treatment of choice for psychosis with agitation in older patients. (D) Sedating antidepressants have a lower risk of death than either first or secondgeneration antipsychotic agents and are therefore the treatment of choice for psychosis with agitation in older patients.

Second-generation antipsychotic agents are associated with a 1.5-fold increased risk of death compared with placebo

A 78-year-old man was hospitalized 3 weeks ago because of a left hemisphere stroke that caused right hemiplegia (strength ⅗ in both upper and lower extremities), mild expressive aphasia, and mild dysphagia. After 3 days he was transferred to an inpatient rehabilitation facility for postacute care. He showed progress at first, but in the last 2 weeks he has been sleeping poorly and has lost his appetite. He seems to have trouble concentrating during therapy and has expressed concern that he might not be able to return home after discharge. He states that he does not feel depressed. Which one of the following would be the best next step in his management? (A) Increase time in physical therapy. (B) Start zolpidem 5 mg at bedtime. (C) Start dronabinol 2.5 mg twice a day. (D) Start citalopram 20 mg/d. (E) Start cognitive-behavioral therapy

Start citalopram 20 mg/d

A 73-year-old woman comes to the office a few days after the death of her husband from endstage renal disease and metastatic cancer. She was his sole caregiver for the last 3 years and took care of all medical and practical decisions in his last days. She now is distressed and barely able to speak. She is sleeping poorly, has lost weight, and feels isolated and unable to function. She has no children or other family, and she neglected friendships because of the demands of caregiving. She declines medication to help her sleep and agrees to return in a few days for follow-up. One week later, she is calmer, but she still cries easily, cannot sleep, and is unable to concentrate. She realizes that she neglected her health during her husband's illness and wants to start taking care of herself, but she has a feeling of futility at the idea of engaging in any activity. She states that she has no active or passive suicidal ideation. History includes hypertension, osteoarthritis, and hypercholesterolemia. Which one of the following is the most appropriate course of action? (A) No treatment is necessary for normal grief reaction. (B) Start treatment with an antidepressant if she shows no improvement in 2 weeks. (C) Consider psychiatric diagnosis unrelated to grief. (D) Encourage her to start seeing friends

Start treatment with an antidepressant if she shows no improvement in 2 weeks

You want to start pharmacologic treatment for depression in an older patient who is taking numerous medications. You are concerned about drug-drug interactions. Which of the following antidepressants is the least likely to cause such an interaction? a. Citalopram b. Fluoxetine c. Paroxetine d. Venlafaxine e. Bupropion

Citalopram

An 80-year-old woman has symptoms of decline in cognitive functioning. According to her son, the patient has had difficulty with word-finding as well as problems with short-term memory that have worsened over the last year and a half. She forgot to pay her bills last month, and now her son has taken over managing her finances. Additionally, the patient has spontaneously stopped driving. There have been no acute episodes of decline. When asked about her memory she denied having any difficulties. What is the most likely diagnosis for the patient? a. Vascular dementia b. Depression c. Alzheimer's dementia d. Cannot determine at this time because of lack of information

Cannot determine at this time because of lack of information

A 76-year-old man undergoes evaluation to determine whether he needs an assistive device for daily mobility. He recently received a diagnosis of moderate Alzheimer disease and now lives in the dementia care unit at an assisted-living facility. On examination, the patient has memory deficits for recent events and some elements of his personal history, he is disoriented to day and place, and he is unable to count backward from 20 by 2s. He is mildly dysphoric and displays decreased awareness of his surroundings. He is able to walk within parallel bars with supervision. Which one of the following ambulatory devices would be most appropriate for his daily mobility? (A) Single-tip cane (B) Small quad cane (C) Rolling walker (rollator) (D) Merry Walker® (E) Wheelchair

Merry Walker

All of the following are true about sleep of older adults, except : a. Older adults with health problems and psychiatric disorders are more likely to have sleep problems than their healthy counterparts. b. Older people are more likely to use medications for sleep than younger adults. c. Older people commonly have a delayed sleep phase, characterized by late onset of sleep and awakening later than desired in the morning. d. Sleep problems are associated with impaired cognitive and physical functioning in older people

Older people commonly have a delayed sleep phase, characterized by late onset of sleep and awakening later than desired in the morning

A 70-year-old man comes to the office because he has knee pain. He has been walking more since he started a part-time job at a hardware store 2 months ago. He mentions that his mood has been down since his wife died 6 months ago. He has no history of psychiatric illness, and he does not smoke, drink, or use drugs. His children live out of state. Score on the Geriatric Depression Scale is 9. He states that he does not like to take medications but would consider taking "something natural" for his mood. Each of the following therapies may help with depression EXCEPT: (A) Curcumin (B) St. John's wort (C) S-adenosyl methionine (SAMe) (D) Valerian

Valerian