Geriatrics - Book Questions

Definition of fraile

"State of increased vulnerability to adverse outcomes", also reduced functional capacity, defined often by weight loss, decreased in strength, etc.

A week in the hospital can age a person by...

10+ years

MiniCog

3-minute instrument that can detect cognitive impairment in the older adult

What is the recommended age for colon cancer screening?

50-75 yearly fecal occult blood Sigmoid every 5 years Colonoscopy every 10 years Dont screen over 85

What is the recommended age for prostate screening?

55-69yrs case by case

Hyperthyroidism is diagnosed with which of the following: a. A decreased serum level of thyroid-stimulating hormone (TSH) and an elevated serum level of unbound thyroxine (free T4). b. A normal serum level of TSH and an elevated serum level of unbound thyroxine (free T4). c. A elevated serum level of TSH and a decreased serum level of unbound thyroxine (free T4). d. A normal serum level of TSH and a decreased serum level of unbound thyroxine (free T4).

A decreased serum level of thyroid-stimulating hormone (TSH) and an elevated serum level of unbound thyroxine (free T4).

What are the activities of daily living?

Bathing, Dressing, Feeding, Transferring, Toileting, and Continence

What is the rule of fourths?

Changes in the elderly are due to each of these factors 1/4 of time: -Disease -Disuse - being sedentary -Misuse - misusing joint earlier in life (e.g., football player) -Physiologic aging

CAM test is used for

Delirium

Whats the difference between delirium and dementia?

Delirium Most common complication of acute hospitalization in elderly patients. Dementia: Chronic, progressive, irreversible

When should elderly be given the pneumococcal (PCV13) vaccine?

Every pt 65 and older one time dose unless high risk

Describe stage III of a wound

Full thickness tissue loss. Subcutaneous fat may be visible but nothing else.

ADL/IADL assessments evaluate

Functional status as a measurement of the client's ability to perform activities of daily living independently

What is the 2nd leading cause of legal blindness in the US?

Glaucoma

What is the leading cause of vision loss in African Americans?

Glaucoma

Fever is never minor in elderly, what does it mean?

Have a low index for this, fever will always mean something in this population

What is recommended for mild/moderate pain in elderly?

Lortab with close monitoring

______________ ____________is the leading cause of severe vision loss and the most common cause of new visual impairment in patients over 65. More adults will become blind from ARMD than from glaucoma and diabetic retinopathy combined.

Macular Degeneration

Medicare vs medicaid, whats the difference?

Medicare is an entitlement program established to cover the acute care needs of people who have reached the age of 65 (or have end-stage renal disease or are on Social Security Disability Insurance). Medicaid was established to provide coverage for people who have insufficient income to pay for services Medicaid is paid for by federal, state and local taxes

The pneumovax 23 is a one time dose and should be given after?

One year after PCV13 unless certain medical conditions

Describe stage II of a wound

Partial Thickness loss of the dermis. Shallow open ulcer with a red/pink woundbed, without slough. Can also have a blister filled with clear (not bloody) fluid.

Describe stage I of a wound

Stage I - intact skin, nonblanchable redness of a localized area.

Joyce Mitchell is a 73-year-old frail female with a history of frequent falls, who presents with rapid onset of nausea, vomiting, sweating, and horizontal nystagmus. She also reports hearing loss in the right ear. After testing and further questioning, you diagnose the patient with vestibular neuritis. What is the best initial course of treatment? a. Vestibular rehabilitation b. Supportive care with antinausea and antivertigo medication c. Fluids d. Epley maneuver

Supportive care with antinausea and antivertigo medication

What is the recommendation for cervical cancer screening in women over 65 if they had adequate screening prior and are not otherwise at high risk for cervical cancer?

They dont need it

Which of the following is a true statement? a. "Homebound" patients are those for whom leaving the home requires considerable and taxing effort. b. Skilled home care is covered by Medicare only in the 90 days after admission to a hospital for 3 midnights. c. "Homebound" patients may not leave the home more than twice during a home care certification period without completing an advance beneficiary notice from Medicare. d. Essential home modifications such as ramp and stairlift installation are covered by Medicare.

a. "Homebound" patients are those for whom leaving the home requires considerable and taxing effort.

Healthcare providers should recommend that older adults engage in which one of the following? a. 150 minutes of moderate intensity physical activity weekly b. 20 minutes of moderate intensity physical activity 3 days per week c. 10 minutes of vigorous physical activity most days of the week d. 30 minutes of vigorous physical activity 3 days per week

a. 150 minutes of moderate intensity physical activity weekly

The remission rate of depressed patients who are 65 years and older to initial antidepressant treatment is: a. 30% b. 40% c. 70% d. 80%

a. 30%

A 70-year-old man has bothersome lower urinary tract syndrome (LUTS) associated with benign prostatic hyperplasia (BPH). His symptoms are no longer well managed with lifestyle modifications. He is interested in medication to reduce his urinary symptoms but is concerned about possible side effects. He notes that he is recently married and sexual activity is very important to him. Which of the following medications would be most appropriate for this patient? a. Alfusozin b. Ditropan c. Dutasteride d. Tamsulosin e. Tadalafil

a. Alfusozin

Ms. J, who is 82 years old, complains of urine leakage while playing golf. This has gotten worse over the past year, and she rarely makes it through nine holes without feeling like she needs to "run into the bushes and go." Leakage is usually small volume, but causes her extreme embarrassment because she is afraid she will smell of urine. She has tried limiting caffeine in the morning before she golfs and avoiding drinking water while playing, to no effect. She also tried "those Kegler" exercises in the past without success. Which of the following is the most appropriate recommendation for Ms. J? a. Bladder training b. Referral for biofeedback training in pelvic muscle exercise c. Trial of solifenacin d. Trial of topical estrogen

a. Bladder training

`An older woman with a history of mild Alzheimer disease was recently started on oxybutynin 10 mg orally twice daily for urinary incontinence. Her family reports that she has been increasingly disoriented over the past month and she notes some constipation on the review of systems during her office visit. What management is best regarding her urinary incontinence? a. Change oxybutynin to mirabegron 25 mg orally daily. b. Change oxybutynin to tolterodine 2 mg orally twice daily. c. Continue oxybutynin and add donepezil 5 mg orally daily. d. Discontinue oxybutynin and recommend adult briefs.

a. Change oxybutynin to mirabegron 25 mg orally daily.

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

a. Citalopram

An old woman who is cared for by attentive, cautious, concerned family is particularly likely to suffer from which one of the following complications after an episode of gastroenteritis? a. Immobility related to overconcern b. Continued vomiting caused by too-rapid feeding c. Diarrhea resulting from administration of milk products d. Constipation related to overtreatment of diarrhea

a. Immobility related to overconcern

Key neurotransmitter-based therapeutic strategies for PD include all the following except: a. Increase glutamatergic stimulation b. Decrease cholinergic stimulation c. Increase dopaminergic stimulation

a. Increase glutamatergic stimulation

Guidelines for the primary prevention of stroke recommend that aspirin be used in which one of the following? a. Individuals whose risk is high enough for the benefits to outweigh the risks b. Individuals regardless of risk level c. Males regardless of risk level d. Females who are also taking antihypertensives

a. Individuals whose risk is high enough for the benefits to outweigh the risks

Benefits of oral disease screening of older adults with chronic systemic diseases within the medical office include all except: a. Intensive management of diabetes and its complications in older adults is not likely to provide benefit. b. Provides initial screening to older adults at high risk of oral diseases and lack of dental insurance/financial resources. c. Assessment for referral and oral disease prevention options.

a. Intensive management of diabetes and its complications in older adults is not likely to provide benefit.

Which of the following management strategies would have the lowest risk of hypoglycemia in an older adult with type 2 diabetes mellitus? a. Metformin b. Sulfonylurea c. Exenatide d. Lantus insulin

a. Metformin

A positive response to carotid sinus massage indicates a high likelihood of which one of the following types of syncope? a. Neurally mediated b. Cardiac c. Neurologic d. Orthostatic e. Psychiatric

a. Neurally mediated

A 90-year-old Black man visits your office and complains of pain in both knees. He has had the problem for several years; he has morning stiffness for less than 1 hour a day and pain mostly in the hands and knees. On physical examination, he has hard nodes on the distal interphalangeal joints and no effusion in the knees, although they look bigger than normal. Laboratory work revealed a low titer-positive rheumatoid factor, and the erythrocyte sedimentation rate and C-reactive protein were within normal limits. The rest of the physical examination was unremarkable. The most likely diagnosis is: a. Osteoarthritis b. Rheumatoid arthritis c. Psoriatic arthritis d. Polymyalgia rheumatica e. Myositis

a. Osteoarthritis

Mr. O. is a 66-year-old man coming in for his regular checkup on his hypertension, coronary artery disease, osteoarthritis, and diabetes. He reports no falls in the past year, no chest pain, and elevated blood sugars up to 200. His medications include metoprolol, celexicob, metformin, and glipizide. He is alert and cooperative, his blood pressure is 130/75 mmHg, he has a grade 2 systolic murmur, and on range of motion he is unable to turn his head to the right. He takes 22 seconds to walk 10 feet, turn, and sit down again. The best option for primary prevention of driving impairment is: a. Physical therapy referral b. Cardiology referral c. Ophthalmology referral d. Endocrinology referral

a. Physical therapy referral

Over-the-counter Milk of Magnesia and polyethylene glycol improve constipation by:' a. Promoting secretion of water into the intestinal lumen b. Inducing mild inflammation c. Improving coordination of the bowel wall d. Improving rectal capacity to hold stool 5. True or False

a. Promoting secretion of water into the intestinal lumen

Which one of the following is most true about aging changes? a. Stage 3 and 4 sleep decreases. b. Renal perfusion is not reduced, but renal function is reduced. c. Hearing acuity declines beginning in middle age. d. Prostatic enlargement occurs only in a minority of men.

a. Stage 3 and 4 sleep decreases.

A 90-year-old Black woman is found to have a uric acid of 13 mg/dL with a creatinine of 0.6 mg/dL. She does have a history of osteoarthritis and heart failure and is taking furosemide 80 mg orally daily. She develops acute onset first metatarsal phalangeal joint pain. The best approach for this patient will be: a. Start colchicine b. Start allopurinol c. Start probenecid d. Reduce the furosemide dose

a. Start colchicine

A 79-year-old woman was admitted to the hospital a month ago with an acute left middle cerebral artery ischemic stroke. On examination, she had right hemiparesis, mild motor aphasia, and dysphagia. After discharge, she was transferred to a skilled nursing facility where she has been working with physical, occupational, and speech therapy. Despite initial progress, in the last 2 weeks, she has lost her appetite, and complains of insomnia and difficulty concentrating. Which would be the next best step in management? a. Start escitalopram 5 mg orally daily. b. Start eszopiclone 1 mg orally at bedtime. c. Start a high calorie supplement twice a day. d. Change the time at which she gets physical therapy.

a. Start escitalopram 5 mg orally daily.

An 80-year-old Black woman has a blood pressure (BP) of 168/102 mmHg and is started on amlodipine 5 mg daily. The JNC 8 panel recommends treating this patient to a goal blood pressure of less than a. 160 mmHg systolic and 90 mmHg diastolic b. 150 mmHg systolic and 90 mmHg diastolic c. 140 mmHg systolic and 90 mmHg diastolic d. 135 mmHg systolic and 85 mmHg diastolic e. 130 mmHg systolic and 80 mmHg diastolic

b. 150 mmHg systolic and 90 mmHg diastolic

An 82-year-old woman with a past medical history of essential hypertension and type 2 diabetes mellitus, and who currently smokes, was brought to the hospital after collapsing at home. The onset of her symptoms was 1 hour before arrival to the emergency room. On examination, she is awake, alert, and oriented to person, place, and time. She has moderate dysarthria, right gaze preference, left hemineglect, and left face, arm, and leg weakness. Her blood pressure is 190/90 mmHg and her glucose is 110 mg/dL. What diagnostic test should be done first? a. Complete blood count and basic metabolic panel b. A STAT noncontrast head computed tomography (CT) c. A two-dimensional echocardiogram d. Urinalysis

b. A STAT noncontrast head computed tomography (CT)

The most common presenting feature of hyperthyroidism in older adults is: a. Exophthalmus. b. Atrial fibrillation. c. Tremor. d. Heat intolerance.

b. Atrial fibrillation.

A clinical prodrome of nonspecific symptoms of Parkinson disease (PD) include all the following except: a. Hyposmia b. Bradykinesia c. Constipation d. Fatigue

b. Bradykinesia

Which one of the following is most true of the capacity to make medical decisions? a. It should be addressed within the legal system. b. It includes the ability to express a choice and to weigh options. c. It is an all-or-none determination (i.e., not decision specific). d. It is beyond the capability of most nursing home residents.

b. It includes the ability to express a choice and to weigh options.

Mrs. Green is an 88-year-old female discharging home from the hospital after sustaining a right hip fracture from a fall. She required surgery to fix the fracture and is now ambulating using a walker. Her Mini-Nutritional Assessment in the hospital was positive for malnutrition risk. She lives alone and only has one family member who lives nearby. What nutrition interventions is least helpful once she discharges home? a. Consult social work to connect her to community resources like Meals on Wheels b. Recommend she move into a retirement community c. Start high-calorie nutrition supplements at home twice daily d. Consult dietician to assist with nutritional interventions in the home

b. Recommend she move into a retirement community

On admission to the hospital, an 85-year-old woman was found to have a fungating mass on her right breast. The mass is 9 cm in diameter, partially ulcerated, and associated with edema of the arm and obvious pain. The patient has no children and had lived alone until recently, when a neighbor became concerned for what appeared to be a progressive loss of memory and neglect of the house. A nephew living in another city eventually came to take care of the situation and arranged for the admission. The patient appears confused and withdrawn; her appearance is disheveled, but she seems to be independent in her ADLs. The medical history is negative for any serious illnesses. She was able to drive her own car until shortly before this admission. The nephew does not wish to authorize hospice "right now." A positron-emission tomography scan was negative for metastatic disease. In addition to determining the cause of her delirium, which of the following is the best way to address the breast mass? a. Tamoxifen should be initiated immediately. If no response is seen in 3 months, the patient should receive chemotherapy. b. The mass should be biopsied to study hormone receptor and HER2/neu antigen status. c. The patient should undergo surgery as initial treatment. d. The initial treatment should be radiation therapy. e. No treatment is indicated because the patient's average life expectancy is less than 1 year, and during this period of time the tumor is unlikely to cause local complications.

b. The mass should be biopsied to study hormone receptor and HER2/neu antigen status.

When a Medicare beneficiary with only traditional Part A and Part B coverage is admitted to the hospital, what will he or she will have to pay out of pocket? a. Nothing b. $500 deductible c. 20% of the hospital and physician fees

c. 20% of the hospital and physician fees

In which of the following patients is chemical or surgical castration likely to prolong survival? a. A 78-year-old man with advanced dementia and prostate cancer metastatic to the bone. b. A 78-year-old man who had a radical prostatectomy 10 years earlier and now has a PSA level of 5.7 ng/mL. A year ago it was 0.1 ng/mL. A bone scan is negative and an abdomen-pelvis computed tomography (CT) is negative. c. A 78-year-old man who had a radical prostatectomy and external beam radiation therapy 10 years earlier now has a PSA level of 24.5 ng/mL. A CT scan of the pelvis shows an enlarged pelvic lymph node, and a bone scan is positive in the pelvis. d. A 78-year-old man with prostate cancer limited to the prostate with a Gleason score of 6. e. None of the above.

c. A 78-year-old man who had a radical prostatectomy and external beam radiation therapy 10 years earlier now has a PSA level of 24.5 ng/mL. A CT scan of the pelvis shows an enlarged pelvic lymph node, and a bone scan is positive in the pelvis.

Which class of medications is least likely to contribute to fall risk? a. Benzodiazepines b. Tricyclic antidepressants c. Antiplatelet agents d. Loop diuretics

c. Antiplatelet agents

. Your patient, a 68-year-old male, presented to the hospital with gastrointestinal bleeding from a duodenal ulcer that was treated endoscopically. His hemoglobin at discharge was stable at 10 g/dL, and he has had no recurrent signs of bleeding. He is now in your office 1 week after hospital discharge for a follow-up visit, being treated for iron deficiency anemia with iron sulfate 325 mg three times daily and is complaining of dyspepsia with iron supplementation. Your next step in management should be: a. Continue his current therapy of iron sulfate 325 mg TID until he is no longer anemic. b. Repeat complete blood count (CBC) to confirm he is still anemic, and then decide on the treatment plan. c. Decrease his iron sulfate to 325 mg once daily. d. Check for concomitant B 12 and folate deficiency.

c. Decrease his iron sulfate to 325 mg once daily.

Which of the following is a potential consequence of persistent pain? a. Mental status changes b. Increased blood pressure c. Depression d. Altered self-concept

c. Depression

A 66-year-old man complains of nocturia (three to four times a night), hesitancy, and incomplete emptying of the bladder. Physical examination reveals an enlarged, nontender prostate, about 40 g in size without discrete nodules. Urinalysis reveals hematuria without leukocyte esterase. Upon further evaluation, the hematuria is attributed to his BPH. The patient declines surgical options at this time. Which of the following medications would be most appropriate? a. Oxybutynin b. Doxazosin c. Finasteride d. Silodosin e. Tadalafil

c. Finasteride

The pathophysiology that underlies the formation of atherosclerotic plaque in coronary arteries is primarily associated with which of the following mechanisms? a. Arterial infection b. Coronary dissection and repair c. Inflammation d. Folate deficiency

c. Inflammation

A 65-year-old man develops back pain and paraplegia because of a pathologic T12 vertebral burst fracture that requires surgical decompression and fixation. The patient desires intensive therapy to improve his mobility and self-care skills, requires training for his neurogenic bowel and bladder dysfunction, and needs evaluation for a wheelchair. Which environment is most appropriate for his rehabilitation following hospitalization? a. Home with home healthcare b. Skilled nursing facility c. Inpatient rehabilitation facility d. Long-term acute care hospital

c. Inpatient rehabilitation facility

Which of the following is true about cultural humility? a. It is typically accomplished through professional development courses. b. It can only be achieved by underrepresented minority groups. c. It places emphasis on power imbalances and promotes interpersonal sensitivity through partnerships with and learning from patients. d. It rarely considers the biologic, socioeconomic, and racial impacts of upstream structural factors on health disparities.

c. It places emphasis on power imbalances and promotes interpersonal sensitivity through partnerships with and learning from patients.

Mr. Hunter, a 69-year-old man, complains of urinary frequency and urgency that have increased over the past several months. There is no dysuria, hematuria, or sensation of incomplete voiding. He drinks 2 cups of coffee daily and diet cola multiple times a day. His International Prostate Symptom Score (IPSS) is 6, with a bother score of 1 indicating mild voiding symptoms with low impact on his quality of life. His medical history includes hypertension, coronary artery disease, and benign prostatic hyperplasia. Current medications are aspirin, metoprolol, and hydrochlorothiazide. Physical examination reveals normal sized prostate. Which of the following is the best next step? a. Urinalysis b. Cystoscopy c. Lifestyle modifications d. Tamsulosin e. Finasteride

c. Lifestyle modifications

If untreated, subclinical hyperthyroidism: a. May benefit those who are obese because weight loss can be expected. b. Can cause osteoporosis that is not prevented by estrogen-replacement therapy. c. May cause cardiac failure. d. Lowers the risk of abnormal cardiac rhythms.

c. May cause cardiac failure.

Pedro Lopez is an 89-year-old male who presents to you with the complaint that he continuously experiences the feeling that a fall is imminent. He appears comfortable when seated, but is notably unsteady and imbalanced when erect, walking with a broad-based gait. Which of the following is not a standard treatment modality for this condition? a. Assistive device, such as a cane b. Physical therapy focusing on balance training c. Meclizine d. Hearing and vision amplification

c. Meclizine

Which sentence completion is false? The Veterans Health Administration: a. Is an integrated network of service providers across the United States b. Serves a population with an average age of nearly 65 years c. Provides care management only for individuals with disabilities that are service related d. Can provide older adults home-based primary care, geriatric assessment, and long-term care

c. Provides care management only for individuals with disabilities that are service related

Patient GG is an 82-year-old woman with complaints of dysuria and polyuria. A urinalysis is positive for a urinary tract infection. She is 55 kg, her serum creatinine is 1.5 mg/dL, and she has no known drug allergies. Which of the following is the most appropriate antibiotic regimen? a. Ciprofloxacin 500 mg BID for 3 days b. Nitrofurantoin 100 mg BID for 7 days c. Sulfamethoxazole/trimethoprim 400/80 mg BID for 3 days d. Sulfamethoxazole/trimethoprim 800/160 mg BID for 3 days

c. Sulfamethoxazole/trimethoprim 400/80 mg BID for 3 days

You are on your porch when you hear your older neighbor who is out gardening yell for help. She says that she splashed fertilizer spray into her eyes. What do you do? a. Call 911. b. Go get a bottle of sterile saline from the house to rinse her eye. c. Use the garden hose and run water into her eyes. d. Call your friend who is an ophthalmologist and ask for advice.

c. Use the garden hose and run water into her eyes.

A 72-year-old woman with a history of chronic heartburn comes in to discuss gastroesophageal reflux disease management. She asks whether she should remain on her proton-pump inhibitor (PPI); she has been on lansoprazole 15 mg daily for the past 12 years. With the medication, diet, and lifestyle changes, she has been asymptomatic for almost all of that time. An upper endoscopy performed 4 years ago revealed a small hiatal hernia and mild erosive esophagitis. She is concerned about long-term risks of PPIs. Which of the following is the most appropriate recommendation at this time? a. Advise her to taper off the PPI and transition to on-demand histamine 2 receptor antagonist (H2RA) b. Advise her to continue the PPI to prevent worsening esophagitis and the development of Barrett esophagus c. Advise her to continue her PPI, but increase the dose to heal the mild esophagitis noted on her last endoscopy d. Advise her to undergo a repeat upper endoscopy to help determine if it is safe to stop her PPI

d. Advise her to undergo a repeat upper endoscopy to help determine if it is safe to stop her PPI

Relative contraindications for performance of carotid stenting include which one of the following? a. History of neck radiation. b. Contralateral recurrent laryngeal nerve injury. c. Recurrent carotid stenosis within 1 year of previous carotid endarterectomy. d. Age >80 years.

d. Age >80 years.

Which of the following code sets are used for reporting the procedures performed by professionals? a. ICD b. CPT c. HCPCS II d. Both b and c e. Answers a, b, and c

d. Both b and c

Which is the most reasonable first step in the treatment of older men with erectile dysfunction? a. Sex therapy b. Testosterone c. Yohimbine d. Sildenafil

d. Sildenafil

Which of the following statements is false regarding the role of the medical social worker in the healthcare team? a. Social workers frequently are the translators between patients/family and the rest of the team. b. Social workers are trained to conduct cognitive and psychological assessments of patients. c. Social workers provide care management assistance to patients/families (e.g., community service referrals). d. Social workers make diagnostic decisions about the patient's clinical symptoms.

d. Social workers make diagnostic decisions about the patient's clinical symptoms.

A 70-year-old man undergoes an upper endoscopy for the evaluation of dyspepsia. He has a large nonbleeding ulcer and biopsies reveal the present of Helicobacter pylori infection. He is given a 10-day course of clarithromycin, tetracycline, and omeprazole twice daily. His symptoms resolve. A urea breath test performed 2 weeks later is positive for H. pylori . Which of the following is the best next step in management of this patient? a. No further treatment since his symptoms have improved b. Repeat treatment with clarithromycin, tetracycline, and omeprazole, but for 14 days c. Treatment with amoxicillin, clarithromycin, and omeprazole for 14 days d. Treatment with bismuth, metronidazole, tetracycline, and omeprazole for 14 days e. Repeat upper endoscopy to confirm positive breath test results

d. Treatment with bismuth, metronidazole, tetracycline, and omeprazole for 14 days

MMSE (Mini Mental State Examination) evaluates

differentiate organic from functional disorders and to measure change in cognitive impairment. It is not used for diagnostics. It measures orientation, registration, attention and calculation, short-term recall, language, and visuospatial function..

Agoraphobia

fear or avoidance of situations, such as crowds or wide open places, where one has felt loss of control and panic

Who does the VA serve?

if you served in the active military, naval, or air service and didn't receive a dishonorable discharge

Anhedonia means what

inability to experience pleasure

Imaging plays a limited role in diagnoses of PD but is central in making diagnosis of: a. Multiple system atrophy (MSA) b. Progressive supranuclear palsy c. Dementia of Lewy body type d. Normal pressure hydrocephalus

d. Normal pressure hydrocephalus

Which test/examination is typically most helpful as part of a fall workup? a. Echocardiogram b. Holter monitor c. Noncontrast head computer tomography scan d. Orthostatic vitals

d. Orthostatic vitals

CAGE test evaluates

Alcohol abuse screening

Jerry Carmichael is a 66-year-old man who lives with his sister. He worked several years as a cement finisher and bricklayer. Past medical history includes diabetes, hypertension, and a history of stroke. He has history of alcohol and heroin use (past 20 years). He is now in a methadone treatment program and is committed to long-term recovery. True or False: Patients like Mr. Carmichael are uncommon because older adults with a history of illicit drug use rarely have medical co-morbidity because they die before reaching old age.

False

What are the instrumental activities of daily living (IADLs)?

Ability to use telephone Food prep Laundry Responsible formeds Shopping Housekeeping Mode of transportation Ability to handle fiances

What is recommended for mild pain in elderly?

Tylenol

For women aged 30-65 years what is the recommended screening if a women has cervical cytology alone?

Every 3 years with cervical cytology alone Every 5 years with hrHPV testing in combo with cytology

Jerry Carmichael is a 66-year-old man who lives with his sister. He worked several years as a cement finisher and bricklayer. Past medical history includes diabetes, hypertension, and a history of stroke. He has history of alcohol and heroin use (past 20 years). He is now in a methadone treatment program and is committed to long-term recovery. True or False: Methadone treatment centers that tailor services to older adults are common, especially in medium or large cities.

False

Which of the following is a true statement? a. For a Medicare-certified home health agency to receive Medicare payment for services provided to a patient, either the patient's physician or an associated nonphysician provider in the same practice must certify that the patient is homebound and has a skilled need. b. For a Medicare-certified home health agency to receive payment for home care services, a face-to-face visit for home care order certification purposes must occur in the 90 days before or 30 days after the date on which the home care agency begins to provide home care. c. A nonphysician provider may perform the required face-to-face visit for recertification of home care services. d. A nonphysician provider may bill for care plan oversight if he or she spends more than 30 minutes reviewing and certifying the initial home care certification.

For a Medicare-certified home health agency to receive payment for home care services, a face-to-face visit for home care order certification purposes must occur in the 90 days before or 30 days after the date on which the home care agency begins to provide home care.

Describe stage IV of a wound

Full thickness tissue loss with exposed bone, tendon, or muscle.

Lung cancer screening for geriatrics

The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years

A 75-year-old man with lung cancer metastatic to the bones is receiving hospice care in his home. His predominant symptom is nociceptive and neuropathic right chest wall pain caused by a fourth rib metastasis. In recent days he has experienced a dramatic increase in his pain, and hospice staff have titrated his pain regimen to gabapentin 900 mg three times daily, extended release morphine 100 mg three times daily, and immediate release morphine 30 mg every 2 hours as needed. The hospice nurse calls you to ask about next steps, and reports that he is still in severe pain but is now nonverbal, and his family is struggling to administer his medication orally because of his somnolence. The patient's family is exhausted. What is the best next step to assure the patient's comfort? a. Admit to an inpatient facility under the General Inpatient Hospice benefit. b. Discharge from hospice, admit to the hospital. c. Call 911. d. Instruct the family to give the immediate release morphine every 30 minutes instead of every 2 hours.

a. Admit to an inpatient facility under the General Inpatient Hospice benefit.

All of the statements about Medicare are true except: a. All of the funding for Medicare comes from federal taxes. b. Durable medical equipment has no out-of-pocket cost to the patient. c. Part B covers outpatient services and all physician professional fees whether inpatient or outpatient. d. Patients are generally responsible for 20% of Part B bills.

a. All of the funding for Medicare comes from federal taxes.

Which one of the following Medicare patients qualifies for skilled home care? a. An 86-year-old man who was ambulatory before he spent 4 days in bed during a recent episode of pneumonia and is now unable to walk from his bed to the bathroom without assistance. b. A 78-year-old bedbound woman with dementia and urinary incontinence who requires daily assistance with bathing and frequent turning to prevent skin breakdown. c. A 97-year-old woman with uncontrolled hypertension and ongoing medication adjustment who goes to her granddaughter's house 5 days a week to babysit her great-grandson. d. A 66-year-old man with severe osteoarthritis and stage V chronic kidney disease who requires monthly monitoring of renal function and electrolytes but cannot descend the six steps to leave his home.

a. An 86-year-old man who was ambulatory before he spent 4 days in bed during a recent episode of pneumonia and is now unable to walk from his bed to the bathroom without assistance.

A 54-year-old Hispanic woman has home BP of 155/95 mmHg, confirmed by multiple similar readings and office BP of 154/94 mmHg. She exercises, follows a low-salt diet, and rarely drinks alcohol. Which one of the following medications would be most appropriate for this patient? a. Chlorthalidone b. Clonidine (Catapres) c. Doxazosin (Cardura) d. Metoprolol succinate (Toprol-XL) e. Spironolactone (Aldactone)

a. Chlorthalidone

Ms. Anderson has chronic spinal stenosis rating her pain today as 3/10 with household activities. She is presently taking gabapentin 200 mg by mouth twice per day and sertraline 50 mg by mouth daily. She reports her mood as good and is sleeping well. She is concerned about her ongoing mild pain and fearful about resuming her usual social and volunteer activities. Which of the following is most likely to result in the patient returning to her prior level of function? a. Cognitive-behavioral therapy b. Transcutaneous nerve stimulation c. Chiropractic care d. Acupuncture

a. Cognitive-behavioral therapy

Which of the following is not a trait of effective interprofessional healthcare teams? a. Effective teams include leaders who take full responsibility for decision making. b. Members of effective teams have mutual support for other team members: They respect the role that other members play, offer to help other team members, and ask for help when they need it themselves. c. Effective teams can use a variety of evidence-based techniques to facilitate effective communication. d. Healthcare professionals who work in effective interprofessional teams can experience greater job satisfaction and reduced burnout compared with providers who do not provide team-based care.

a. Effective teams include leaders who take full responsibility for decision making.

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

a. Family history of depression

An 80-year-old woman that you follow in a nursing home has an acute decline in her mental status. She has a fever >100° F, but no other focal complaints or findings on physical examination except for a chronic indwelling urinary catheter. What statement is true ? a. Fever in an older adult with an indwelling urinary catheter is an appropriate indication to start empiric antibiotic therapy. b. Older adults with an indwelling urinary catheter are less likely to have bloodstream infection than older adults without a catheter. c. It is not necessary to obtain a urine culture; empiric antibiotic treatment is sufficient. d. She only needs antibiotic treatment for 3 days.

a. Fever in an older adult with an indwelling urinary catheter is an appropriate indication to start empiric antibiotic therapy.

. An 86-year-old male who lives in an assisted living facility is at the clinic. He has a history of hypertension and manages his own medications. He admits he takes them sometimes. After speaking to him, you find it unclear if he understands the questions and discussions. Which of the following evidences that the patient has adequate health literacy? a. He knows the names and doses of his medications and can explain why he takes them. b. He knows how to call 911. c. He has spoken over the phone with a dietician who has recommended a low-salt diet. d. He uses terms such as hypertensive , nephropathy , and retinopathy .

a. He knows the names and doses of his medications and can explain why he takes them.

A 65-year-old female is evaluated for dyspnea, chronic cough, and mucoid sputum for the past 4 months. She has noticed that she has to walk slower than she used to and has to stop to catch her breath after walking 5 to 6 city blocks. The patient has a 40 pack-year history of cigarette smoking but quit smoking 1 year ago. She is otherwise healthy. On physical examination, vital signs are normal. Breath sounds are decreased, but there is no edema or jugular venous distention. What is the next best test you would order to make a diagnosis? a. Obtain spirometry. b. Check a chest radiograph. c. Obtain a fractional exhaled nitric oxide measurement. d. Check an electrocardiogram.

a. Obtain spirometry.

With regard to endovascular versus open aortic aneurysm repair, which of the following is false? a. Open repair results in a threefold increase in operative mortality. b. Endovascular repair requires lifelong surveillance after graft placement. c. Endovascular repair commonly requires additional procedures after graft placement.

a. Open repair results in a threefold increase in operative mortality.

Randall Johnson, an 80-year-old man with a history of high blood pressure and hypothyroidism, presents to your office with ongoing dizziness. He feels it has worsened since the summer months began. He states it is worst when he gets up from his chair on his front porch to stand or when he is working in his garden. If he stands still for a few minutes, the dizziness typically resolves on its own. If he tries to move too quickly, he has felt like he may pass out, but has not yet done so. He denies changes in vision or hearing. He has had no recent changes in his medication. On examination today, he is a frail-appearing older man in no acute distress. Vitals show a blood pressure of 118/71 mmHg with a pulse of 55 beats per minute. Heart and lung exams are benign. What is the most likely cause of his dizziness? a. Orthostatic hypotension b. Benign positional paroxysmal vertigo c. Overcontrol of thyroid d. Ménière disease

a. Orthostatic hypotension

The intervention most likely to maximize nutrition for hospitalized older adults is: a. Providing assistance with all meals b. Ensuring that all hospitalized older adults are provided a diet of increased-consistency liquids with limitations of salt and saturated fat c. Liberal use of megestrol acetate or dronabinol to stimulate the appetite d. Nothing-by-mouth status for all older adults until a barium swallowing evaluation and a consultation by a speech-and-language pathologist have been completed

a. Providing assistance with all meals

Mr. S. is a 84-year-old man establishing care with you who presents with his wife because of poor sleep. He has no trouble with sleep onset on his current medications, gets up one to two times per night to urinate, and rises for the day 9 hours after going to bed. However, he is still tired on awakening and takes at least one nap per day, frequently falling asleep while watching TV. His medical history includes obesity, sinus headaches, and mild hypertension. Current medications include hydrochlorothiazide in the morning, acetaminophen with diphenhydramine twice a day, zolpidem, and trazodone at night. His wife reports that he has occasionally needed to swerve to avoid going off the side of the road and insists on driving when they go out together. You should: a. Refer him to pulmonology b. Discontinue hydrochlorothiazide c. Switch to triazolam instead of zolpidem d. Check his hemoglobin A 1C level

a. Refer him to pulmonology

What are proven methods to identify if older adults have a problem with alcohol? a. Screening with The Michigan Alcoholism Screening Test has two geriatric versions (MAST-G and SMAST-G). b. Performing random blood tests for alcohol and liver function tests c. Watching older adults walk to and from the exam room

a. Screening with The Michigan Alcoholism Screening Test has two geriatric versions (MAST-G and SMAST-G).

During the physical assessment, you notice Mr. Lee has temporal wasting, loss of subcutaneous fat, and decreased handgrip strength. He also complains of dry mouth. His C-reactive protein is within normal limits. What additional lab test(s) are most useful for evaluating his nutritional status? a. Serum albumin b. Lipid panel c. Serum iron d. Vitamin D

a. Serum albumin

Even though older adults are less likely to get counseled for smoking cessation, they have which one of the following? a. The same quit rates as younger individuals b. Approximately 50% better quit rates than younger individuals c. Approximately 25% better quit rates than younger individuals d. Much lower quit rates than younger individuals

a. The same quit rates as younger individuals

Barriers to detecting elder mistreatment include all except: a. The tendency for many older adults to falsely claim they are being abused b. The fear that one might be institutionalized if one admits to being abused c. The shame that older adults feel if they have been a victim of abuse d. The difficulty that healthcare providers have making a determination regarding abuse if the victim has a dementia

a. The tendency for many older adults to falsely claim they are being abused

A 69-year-old female presents to your office for routine primary care. Her elder sister was recently diagnosed with Alzheimer disease, and she wonders what steps she can take to reduce her own risk of developing dementia. Which of the following statements about the prevention of dementia is true? a. There is moderate quality evidence to support daily use of vitamin B 12 and fish oil to prevent risk of cognitive decline. b. Risk of dementia is modulated by nonmodifiable risk factors, such as genetics, family history, and educational attainment, and there are no behavioral interventions that can be taken to reduce risk of developing dementia. c. There is moderate quality evidence to suggest control of cardiovascular and metabolic risk factors, such as blood pressure, weight, and blood sugar, may reduce risk of dementia. d. There is moderate to low quality evidence supporting cannabinoids may reduce rates of progression from mild cognitive impairment to dementia.

a. There is moderate quality evidence to support daily use of vitamin B 12 and fish oil to prevent risk of cognitive decline.

A 78-year-old male was recently diagnosed with Alzheimer disease. He scored 23/30 on his Montreal Cognitive Assessment (MoCA) and his clinical presentation is consistent with mild disease. He returns to clinic with his family to discuss possible initiation of pharmacotherapy. You consider beginning donepezil 5 mg daily for 4 weeks, with a plan to increase to 10 mg daily if he tolerates the lower dose. Which of the following is not a common side effect of donepezil? a. Thrombocytopenia b. Bradycardia c. Vivid dreams d. Gastrointestinal distress

a. Thrombocytopenia

In patients with heart failure, the most useful initial imaging modality is: a. Transthoracic echocardiogram b. Transesophageal echocardiogram c. Chest x-ray d. Cardiac magnetic resonance scan e. Cardiac catheterization with coronary angiography

a. Transthoracic echocardiogram

A 67-year-old male with severe bilateral hearing loss comes to the clinic to establish primary care. A nurse practitioner observes that he does not understand what is said to him during his assessment. He has no hearing aids. Which of the following should be attempted to enhance communication? a. Use a personal amplification device, such as a Pocket Talker b. Shout into his better ear c. Exaggerate lip movements to facilitate lip reading d. Call emergency contact for collateral history

a. Use a personal amplification device, such as a Pocket Talker

Mr. Lee is an 80-year-old man who lives alone who comes to the office for a routine visit. He lost 10 lb in the last 3 months and complains of fatigue, poor appetite, and trouble sleeping. Which of the following is least useful during his initial assessment? a. Vaccination history b. Mini-Nutritional Assessment c. Medication review d. Depression screening

a. Vaccination history

George Hall is a 91-year-old man visiting his physician to receive the results of a recent computed tomography scan of his abdomen. He is cognitively intact and still works 2 days a week. He is accompanied by his daughter Eleanor. She takes the doctor aside before the appointment and says, "Please do not tell my father any bad news. It would just kill him." If the physician were to agree, which ethical principles might this violate? a. Paternalism b. Autonomy c. Authenticity d. None of the above e. Answers a, b, and c

b. Autonomy

A 65-year-old otherwise healthy woman presents to the office with dysphagia that has been ongoing for nearly a year. She states that sticky foods, such as rice and tougher foods, such as beef or chicken, can transiently get stuck in her esophagus. On one occasion, she has had to vomit food out because it would not pass with time or by drinking water. She has had no weight loss and her symptoms have not been particularly progressive in nature. She has never had an endoscopy, but is up-to-date with her health care maintenance, including colon cancer screening. She reports no significant family history of gastrointestinal (GI) diseases or malignancies. Her examination is notable only for conjunctival pallor. Laboratories are significant for a microcytic anemia. A barium esophagram is performed, which reveals a thin, smooth, transverse filling defect in the midesophagus. Which of the following complications is this patient most at risk for? a. Eosinophilic esophagitis b. Achalasia c. Esophageal adenocarcinoma d. Esophageal squamous cell carcinoma e. Zenker diverticulum

b. Achalasia

A 65-year-old male is evaluated in a follow-up examination for worsening dyspnea and chronic cough productive of mucoid sputum for the past 6 months. He is otherwise healthy but was diagnosed with chronic obstructive pulmonary disease (COPD) 3 years ago, and uses inhaled albuterol as needed. The patient has a 40 pack-year history of cigarette smoking but quit smoking 8 months ago. On physical examination, vital signs are normal and the patient is not in any respiratory distress. Breath sounds are decreased, but there is no edema or jugular venous distention. Spirometry shows a forced expiratory volume in the first second (FEV1) of 58% of predicted with no reversibility and an FEV1/forced vital capacity (FVC) ratio of 65%. His COPD symptoms seem poorly controlled and he has had one exacerbation in the past year. A chest radiograph is obtained and shows mild hyperinflation. Which of the following is the most appropriate therapy for this patient? a. Add inhaled corticosteroid to his current treatment plan. b. Add a long-acting inhaled bronchodilator. c. Continue with inhaled albuterol every 4 hours. d. Add theophylline and montelukast. e. Treat the patient with an antibiotic.

b. Add a long-acting inhaled bronchodilator

Dr. Smith is obtaining informed consent from Mr. Jones to perform a colonoscopy, because the patient had blood in his stool and Dr. Smith is concerned that this might indicate the presence of carcinoma of the colon. Mr. Jones is able to recite back to Dr. Smith what a colonoscopy is, how it is done, and that a colonoscopy is performed to look for cancer. He then tells Dr. Smith that he is refusing the procedure; he knows he does not have cancer because he has not experienced any bleeding. Of the following required elements for Mr. Jones's decision-making capacity, which is impaired? a. Understanding b. Appreciation c. Ability to express a choice

b. Appreciation

A 78-year-old male who resides at a nursing home has Lewy Body dementia, frequent falls, visual hallucinations, and sleep disturbances. He is transferred to your hospital with poor oral intake and confusion of 3 days duration. Physical examination reveals a thin man with dry mucous membranes, tachypnea, tachycardia, and confusion. 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, Fifth Edition (DSM-V) d. Glasgow Coma Scale (GCS) e. Delirium Rating Scale - Revised 1998 (DSR-R98)

b. Confusion Assessment Method (CAM)

Mrs. Miller is a 78-year-old female admitted to the hospital with pneumonia. She is on oxygen and is fatigued. The nurses notice her coughing when she drinks regular liquids. She states this happens at home as well. Her appetite has been poor in the hospital and she is only eating 50% of her meals. What is your first nutrition intervention? a. Insert a nasogastric tube and start enteral feedings b. Consult speech therapy for a swallowing evaluation c. Continue current diet, her cough is likely just from the pneumonia d. Start high-calorie supplements three times a day

b. Consult speech therapy for a swallowing evaluation

Which of the following statements regarding programs to increase daytime engagement in persons with dementia is true? a. Daytime exercise programs are contraindicated in this population because of high risk of fall and fracture. b. Daytime programs are designed to maintain client wakefulness, and as such can cover a broad range of topics, including music, art, exercise, dance, and cognitive tasks (puzzles, etc.), and should be designed with patient cognitive and physical status, cultural beliefs, social support, and available staffing in mind. c. Daytime programs that lack a physical exertion component do not contribute to physiologic need for sleep, and are thus less effective than programs that require client physical exertion. d. Daytime programs must include moderate to rigorous intensity physical exercise (3-6 mets) to generate an appropriate sleep deficit in nursing home residents.

b. Daytime programs are designed to maintain client wakefulness, and as such can cover a broad range of topics, including music, art, exercise, dance, and cognitive tasks (puzzles, etc.), and should be designed with patient cognitive and physical status, cultural beliefs, social support, and available staffing in mind.

An 80-year-old woman is evaluated in your clinic for muscle aches. Her daughter, who is a nurse, states that her symptoms worsened after recently starting atorvastatin 80 mg daily. This medication and dose was selected based on the patient wanting to reduce her chance of a heart attack or stroke. She has a known history of stable coronary artery disease (CAD), without prior coronary revascularization. She takes low dose aspirin and her blood pressure is well controlled on lisinopril 20 mg once daily. You recognize that myalgias and myopathic symptoms are dose related and more common in older adults prescribed statins. Which of the following recommendations would be appropriate at this time? a. Discontinue atorvastatin and begin omega 3 fatty acids b. Discontinue atorvastatin until the myopathy has resolved, then consider restarting atorvastatin at a low dose, such as 10 mg once daily or an alternative statin c. Discontinue atorvastatin and begin niacin d. Discontinue atorvastatin and begin fenofibrate

b. Discontinue atorvastatin until the myopathy has resolved, then consider restarting atorvastatin at a low dose, such as 10 mg once daily or an alternative statin

A 78-year-old man with multiinfarct 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 3 of his hospital stay, he developed confusion, restlessness, and combativeness. Utilization of sitter, redirection, calming music, and reassurance are unsuccessful. When safety of the patient and staff are in jeopardy and nonpharmacologic approaches have failed, which of the pharmacologic agents would be the best choice for treating the agitation associated with his delirium? a. Melatonin b. Haloperidol c. Diazepam d. Gabapentin e. Diphenhydramine

b. Haloperidol

A 75-year-old man with stable ischemic heart disease (SIHD) and moderate angina returns for follow-up. Prior stress testing has documented myocardial ischemia. A coronary angiogram performed 6 months ago showed that he has few options for revascularization and should be managed medically, although high-risk percutaneous coronary intervention (PCI) can be performed for lifestyle limiting symptoms. Reviewing his medications, it appears that he has been taking amlodipine 10 mg daily, in addition to statin, aspirin, and as needed sublingual nitroglycerin. What would be the most appropriate next step in his management? a. Given that he has few options for PCI, he should be referred for coronary artery bypass grafting (CABG). b. His antianginal regimen should be improved to include the addition of a beta blocker and/or a long acting nitrate. c. Cilostazol can be considered for its antiplatelet effect given that symptoms may be related to a primary platelet problem. d. His calcium channel blocker should be changed to short-acting nifedipine.

b. His antianginal regimen should be improved to include the addition of a beta blocker and/or a long acting nitrate.

Which of the following is correct about thyroid disease in older adults? a. Hyperthyroidism is more common than hypothyroidism. b. Hypothyroidism is associated with weight loss in older adults. c. Elevated TSH levels are indicative of hypothyroidism and require treatment even in the oldest old. d. Production of thyroxin (T4) increases with age.

b. Hypothyroidism is associated with weight loss in older adults.

A 67-year-old female with a history of congestive heart failure and myocardial infarction is admitted to the hospital because of increasing altered mental status and decreased arousal 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 is irritable, paranoid, and inattentive, which her family tells you is out of character. You notice waxing and waning in her alertness and impaired short-term memory during your examination. Which one of the following features present in this patient best distinguishes delirium from depression or dementia? a. Irritability b. Inattentiveness c. Paranoia d. Aggressiveness

b. Inattentiveness

Which of the following is true about coding? a. Thanks to HIPAA every payer must follow exactly the same rules. b. Each payer can create any type of code he or she likes. c. It is a system that is generally uniform, but some variation exists. d. It is complicated and best left to billing personnel who know the rules. e. It does not matter that much how you code if you are on a salary.

c. It is a system that is generally uniform, but some variation exists.

Ms. Greta Thornberg is an 88-year-old woman admitted to the hospital with a diagnosis of squamous cell carcinoma of the lung with metastases to liver. She has signed a POLST indicating that she would like no limitation on life-sustaining measures, including resuscitation, artificial feeding, antibiotics, and hydration. On the second day of her stay, she sustains a stroke, resulting in global aphasia and hemiparesis. As her clinician, in addition to instituting appropriate medical management, you contact her healthcare agent and: a. Inform her healthcare agent of the POLST and notify her that it cannot be changed. b. Inform her healthcare agent of the POLST and notify her that the change of condition requires that the POLST be reviewed. c. Ask her healthcare agent to locate her Last Will and Testament. d. Since she has a signed POLST, there is no reason to contact the healthcare agent.

b. Inform her healthcare agent of the POLST and notify her that the change of condition requires that the POLST be reviewed.

Patient SL is a 68-year-old man you are seeing for follow-up of uncontrolled hypertension. He is currently prescribed amlodipine 10 mg daily, azilsartan 40 mg daily, metoprolol tartrate 50 mg BID (twice daily), and hydrochlorothiazide (HCTZ) 25 mg daily, and his blood pressure is consistently above target. Secondary causes of hypertension have been ruled out. You ask him about missing doses and he tells you that it is difficult to take so many tablets and the brand-name medication is very expensive. Select the best way to improve this patient's adherence. You decide to discontinue brand name azilsartan and: a. Increase HCTZ to 50 mg daily. b. Initiate losartan/HCTZ 50/25 mg once daily; HCTZ is stopped. c. Initiate captopril 12.5 mg TID as replacement for azilsartan. d. Initiate clonidine 0.1 mg/24-hour patch once weekly; metoprolol is stopped.

b. Initiate losartan/HCTZ 50/25 mg once daily; HCTZ is stopped.

A 78-year-old woman with atherosclerotic cardiovascular disease (ASCVD), peripheral vascular disease, and a history of transient ischemic attacks s/p carotid endarterectomy is seen as part of an annual wellness visit. She is advised to create an advance directive but declines, saying "I don't know who to pick" for a healthcare agent. Which one of the following is a necessary characteristic of a healthcare agent? a. Geographic proximity to the patient's home b. Knows how the patient defines quality of life c. Is a member of the patient's immediate family d. Has medical training or experience

b. Knows how the patient defines quality of life

As the medical director at the local nursing home, you are seeing an 84-year-old female nursing home resident for the first time. She has a past medical history (PMH) of vascular dementia and hypertension. The patient needs assistance with her activities of daily living (ADLs) and instrumental ADLs, but is able to communicate her needs. She enjoys spending time in the commons area. The nurse asks you to reorder her antibiotic eye drops that her previous provider used to treat her recurrent episodes of conjunctivitis because the patient's eyes seem to be getting red again. When you see the patient, the patient denies any pain or blurriness of her vision. Her visual acuity is 20/20 and she has bilateral injection of her sclera without any ciliary flush noted. Her bilateral lower eyelids are everted outward (ectropion), and she has bilateral tearing. Her pupils are equal round and reactive to light and accommodation, her extraocular muscles are intact. What should you recommend? a. Antihistamine eye drops b. Lubricating eye drops c. Nonsteroidal eye drops d. Tobramycin eye drops

b. Lubricating eye drops

Which of these clinical vignettes are not part of the Fried frailty paradigms? a. Mrs. P has a caregiver comb her hair now because of inability to hold her arm up long enough to brush it herself. b. Mr. J has just been diagnosed with congestive heart failure after a recent admission to the hospital for a myocardial infarction. c. Mr. K has been losing weight for the last year despite family support of bringing food and negative workup for more insidious cause. d. Mrs. T tells you she spends the majority of her time in her chair and only walks to the bathroom now because she gets too fatigued for minor home care tasks.

b. Mr. J has just been diagnosed with congestive heart failure after a recent admission to the hospital for a myocardial infarction.`

A 78-year-old man has an emergency partial colectomy for lower gastrointestinal bleeding. A localized colonic adenocarcinoma is completely resected. The surgeon did not dissect lymph nodes for metastatic sampling. The patient wants to know if he should have chemotherapy. Should he? a. Yes because without knowing his complete staging it would be safer. b. No because he can be followed with serial carcinoembryonic antigens and CT scans. c. Yes because the severe bleeding indicates advanced disease. d. No because he is too old and will not likely have any problems during his lifetime. e. No because the chemotherapy is too toxic

b. No because he can be followed with serial carcinoembryonic antigens and CT scans.

Which of the following statements about thyroid cancer are true? a. Radiation is a risk factor throughout the life span. b. Papillary thyroid cancer is more common in older adults. c. The prevalence of thyroid nodules decreases with age. d. Thyroid cancer represents 5% of all cancers in women.

b. Papillary thyroid cancer is more common in older adults.

A 75-year-old man visits your clinic complaining of hearing loss. On examination you note impacted cerumen, which you are able to extract under direct visualization with a lighted curette. Which of the following is an appropriate next step? a. Perform Weber and Rinne tests b. Perform whisper test c. Advise watchful waiting d. Arrange for otolaryngology consultation

b. Perform whisper test

Since passage of the ACA in 2010, the following are true about payments changes except: a. Beneficiaries no longer have cost sharing for preventive services b. Providers in Medicare Advantage will be paid higher fees c. The coverage gap known as the donut hole in Part D will be reduced over time d. Hospitals have incentives to prevent readmission and coordinate care more effectively

b. Providers in Medicare Advantage will be paid higher fees

The first step in developing a treatment strategy for a physically active patient with constipation symptoms that are not caused by other potential causes is to: a. Suggest a short course of laxative b. Recommend higher fiber and water intake c. Order a colonic transit study d. Determine which symptoms are the most bothersome

b. Recommend higher fiber and water intake

Effective 2021, Office and Other Outpatient visits code levels will be selected based upon: a. Face-to-face time on the date of the encounter. b. History and examination. c. Medical decision making or total time on the date of the encounter. d. Total time on the date of the encounter, if counseling and coordination of care dominate. e. Total time 7 days before and 7 days after the visit.

c. Medical decision making or total time on the date of the encounter.

Arnold Sheffield is an 88-year-old man who is brought to the office by his daughter after sustaining a ground level fall at home. He reports he tripped over his grandson's toy and landed on a carpeted floor without striking his head. He denies any loss of consciousness but complains of left-sided chest wall pain, worse with deep breathing. Vital signs are notable for a blood pressure of 124/86 mmHg, a heart rate of 84 beats per minute, a respiratory rate of 20 breaths per minute, with an oxygen saturation of 99% on room air. His physical examination is notable for a well-developed male, appearing his stated age in mild discomfort taking shallow breaths. His pulmonary examination demonstrates diminished breath sounds at the bases bilaterally without focal findings. Bruising with associated tenderness is appreciated along the left, midaxillary chest wall. You obtain a chest x-ray, which demonstrates nondisplaced seventh through ninth left-sided rib fractures. The next best step in management of this man is: a. Antibiotic administration to prevent the development of pneumonia. b. Referral to the emergency department for full trauma evaluation and hospitalization. c. Multimodal pain management and referral to pulmonology. d. Incentive spirometry teaching and home physical therapy evaluation.

b. Referral to the emergency department for full trauma evaluation and hospitalization.

An 82-year-old man, Mr. A, complains of worsening nocturia, occurring four times per night. His other lower urinary tract symptoms are slow stream, occasional urgency, and urgency-related leakage once weekly. Medical problems include poorly controlled hypertension, diastolic heart failure, hyperlipidemia, osteoarthritis, and prediabetes. His medications include lisinopril 20 mg daily, metoprolol succinate 75 mg daily, atorvastatin 10 mg daily, metformin 500 mg twice daily, hydrocodone-acetaminophen as needed, and aspirin 81 mg daily. Amlodipine 5 mg daily was recently added by his cardiologist. On review of systems, Mr. A complains that nocturia is causing daytime fatigue, and he is more constipated. Physical examination is notable for blood pressure 162/83 mmHg, heart rate 60 beats per minute, clear lungs, soft abdomen, enlarged prostate, and 21 pretibial edema. Your next step in management should be: a. Stop hydrocodone-acetaminophen and add naproxen. b. Stop amlodipine and increase lisinopril. c. Add afternoon furosemide. d. Add tamsulosin.

b. Stop amlodipine and increase lisinopril.

. A 72-year-old woman reports vaginal dryness that interferes with coitus. Her medical history includes type 2 diabetes, hypertension, and osteoarthritis. Medications are glyburide, chlorthalidone, and acetaminophen. What would be your first step in therapy? a. Stop glyburide b. Stop chlorthalidone c. Stop acetaminophen d. Start topical vaginal lubricant

b. Stop chlorthalidone

Which type of exercise has been proven to reduce the number of falls by patients? a. High-intensity cardiovascular exercise b. Tai Chi c. Group chair aerobics d. Regular stretching

b. Tai Chi

. Two years later Mr. Hunter reports progression of his urinary symptoms and desires "a pill to make this better." His current IPSS is 17, with a bother score of 3 indicating moderate voiding symptoms with moderate impact on his quality of life. On review of systems he notes that his vision has worsened, especially in his left eye. His ophthalmologist has recommended cataract surgery. For which of the following medications would initiation of therapy be delayed until after cataract surgery? a. Finasteride b. Tamsulosin c. Tadalafil d. Oxybutynin

b. Tamsulosin

Dementia is a relatively common condition in the geriatric population. It becomes more common as people age. Which is the most appropriate description of "personhood" as it relates to people with dementia? a. Personhood is a universal concept that is defined the same way in all cultures. b. The ability to relate to others as people, rather than preserving cognitive independence, is an important aspect of "personhood." c. The ability to recognize family members by name is an important aspect of "personhood." d. A deterioration

b. The ability to relate to others as people, rather than preserving cognitive independence, is an important aspect of "personhood."

You are performing a geriatric assessment on an 82-year-old female. At the end of the visit, which of the following would require top priority over the others? a. A sodium level of 133 b. The death of the patient's caregiver c. Vague bilateral knee pain d. A 5-lb weight gain over the past 2 months

b. The death of the patient's caregiver

. A 65-year-old female patient who is new to your practice presents after one episode of syncope that was sudden and without prodromal symptoms. She has hypertension, hypothyroidism, and depression, all controlled on medication per her report. Her physical examination reveals an obese woman with 2+ pretibial edema and a normal cardiovascular and neurologic examination. Her electrocardiogram (ECG) shows left ventricular hypertrophy. Which of the following would be reasonable as the next step in determining the etiology of her syncope? a. Carotid Dopplers b. Transthoracic echocardiogram c. Computed tomography scan of head d. Tilt table testing

b. Transthoracic echocardiogram

An 85-year-old man with chronic obstructive pulmonary disease presents to your office with his daughter with the complaint of new onset chest pain, shortness of breath, and cough. He is clearly tachypneic and has tactile fremitus and egophany and crackles heard at the right lung base. His daughter just wants you to give him an antibiotic pill so that she can take him home. You are concerned that he might need to be hospitalized and require IV antibiotics. What statement is true? a. All older adults with pneumonia must be treated for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas infection. b. Treatment decisions for pneumonia are based on its severity, the presence of comorbid illnesses, and a prior history of MRSA or Pseudomonas respiratory infection. c. All older adults with pneumonia must be treated in hospital. d. Pulse oximetry, respiratory rate, and chest radiography would not be helpful for the diagnosis and management of pneumonia in older adults.

b. Treatment decisions for pneumonia are based on its severity, the presence of comorbid illnesses, and a prior history of MRSA or Pseudomonas respiratory infection.

Which one of the following is correct about subclinical hypothyroidism? a. A diagnosis can be made with a TSH less than 0.01 in the presence of a normal serum level of unbound thyroxine (free T4). b. Treatment is controversial. c. It is commonly associated with a multinodular goiter. d. If untreated, there is no increase in morbidity unless clinical hypothyroidism supervenes.

b. Treatment is controversial.

An 83-year-old female presents to your clinic for a routine physical examination. On basic laboratory tests you note a hemoglobin level of 11.2 g/dL (1 year ago was 11.8 g/dL), a hematocrit of 33.6%, a white blood count of 8.1×10 3 µL (normal differential), a mean corpuscular volume 96.2 fL, a mean corpuscular hemoglobin concentration of 37 g/dL, and a platelet count 287,000×10 3 µL. Her creatinine clearance is 66 mL/min/1.73m 2 . On subsequent laboratory testing, she is found to have a ferritin level of 72 ng/mL, a normal transferrin saturation, B 12 , C-reactive protein, and thyrotropin levels. The most likely diagnosis at this time is: a. Anemia of chronic disease b. Unexplained anemia c. Anemia of chronic kidney disease d. Lab tests are concerning for myelodysplasia or malignancy and she should be referred to a hematologist

b. Unexplained anemia

Which of the following statements concerning advance directives is true? a. The Supreme Court has established a standard advance directive form. b. The living will is used to appoint a healthcare agent to make medical decisions if an individual loses decision-making capacity. c. A DNR order is not equivalent to a do-not-treat order. d. Periods of acute illness are the most appropriate times to begin discussions with patients about advance directives.

c. A DNR order is not equivalent to a do-not-treat order.

The following are components of the open disclosure of medical error, except : a. An apology to the injured patient. b. An explanation of the error in lay language. c. A best guess as to why the error occurred. d. An assurance that a full investigation will take place.

c. A best guess as to why the error occurred.

An 86-year-old female comes to your office for a wellness visit. Her blood pressure is 125/70 mmHg, pulse 69 beats per min, and respiratory rate 18 breaths per min. She is well appearing and reports she is up to date on her routine vaccinations. She introduces her partner of 35 years whom she would like to make medical decisions for her in case she becomes unable to make decisions for herself. She reports that she and her partner are not married. She asks if she needs any further documentation to ensure her goals of care are followed. Which one of the following would be the most appropriate recommendation for this patient and her partner? a. Advise them to complete a POLST. b. Advise them that they have adequate documentation to be recognized legally. c. Advise them to file an advanced directive. d. Respond that although they lack documentation, her partner will be recognized de facto.

c. Advise them to file an advanced directive.

Which one of the following Medicare patients has a skilled need? a. A 67-year-old man with a 3-year history of atrial fibrillation who requires monthly monitoring of his international normalized ratio. b. A 74-year-old woman with a feeding tube since her stroke 3 years ago who requires frequent tube changes. c. An 80-year-old man with benign prostatic hyperplasia and urinary retention for 2 years who requires a urinary catheter. d. A 78-year-old man with dementia and chronic obstructive pulmonary disease who requires assistance with bathing and dressing.

c. An 80-year-old man with benign prostatic hyperplasia and urinary retention for 2 years who requires a urinary catheter.

Compared with angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blocker are less likely to be associated with: a. Hypotension b. Renal insufficiency c. Angioedema d. Hyperkalemia e. Bradycardia

c. Angioedema

What is the most common cause of erectile dysfunction in older men? a. Psychological stress b. Adverse drug reaction c. Atherosclerosis d. Autonomic neuropathy

c. Atherosclerosis

An 85-year-old woman falls and is hospitalized for a pelvic fracture that is treated nonoperatively. Which of the following factors increases her chances of being discharged directly to home for rehabilitation? a. Difficulty bearing weight on her legs b. The presence of a flight of stairs to be able to access her house c. Availability of a caregiver who can provide assistance in the home 24 hours/day, 7 days/week. d. Difficulty using a rolling walker for mobility before the fall e. Worsening cognitive deficits because of pain medication

c. Availability of a caregiver who can provide assistance in the home 24 hours/day, 7 days/week.

You are seeing an 80-year-old woman who recently moved to the area to live closer to her daughter. She reports a 10-year history of diabetes mellitus, which she has managed with metformin and glimeperide. She feels well but admits to having been very busy in the recent past. In fact, she has not seen a doctor in nearly a year. Which of the following health assessment measures would be appropriate in this patient? a. Oral glucose tolerance test and exercise treadmill test b. Fasting lipid profile and carotid ultrasound c. Brief cognitive testing and examination of gait and balance d. Pelvic examination and Pap smear

c. Brief cognitive testing and examination of gait and balance

Which one of the following is most true about the staffing of a typical nursing home? a. Most of the nurses are RNs. b. LPNs or LVNs develop the patient care plan. c. CNAs provide most of the direct patient care. d. Staff turnover is not a major issue.

c. CNAs provide most of the direct patient care.

A 71-year-old woman with hypertension, diabetes, and ischemic cardiomyopathy visits your office after a witnessed episode of syncope at a church gathering. She does not remember the event, but her daughter describes her suddenly appearing pale while sitting and then slumping over and hitting her head on the side of a table. After about 30 seconds she came to on her own. She has a normal physical examination except for an abrasion on her forehead and her only electrocardiogram (ECG) abnormalities are the changes from her previous myocardial infarction. What type of syncope is most likely in your differential diagnosis? a. Neurologic b. Neurally mediated c. Cardiac d. Orthostatic e. Psychiatric

c. Cardiac

You are seeing an 85-year-old gentleman with a 15-year history of diabetes mellitus, coronary artery disease and coronary artery bypass grafting 7 years ago, and mild chronic obstructive pulmonary disease. He lives in a senior living community in an independent apartment and gets help from family with shopping and medication management. He feels generally well, but complains of occasional episodes of weakness and nausea in the morning and before lunch. What is the most appropriate advice for this gentleman with respect to treatment goals for his diabetes? a. Check blood glucose three times daily and adjust medications to get hemoglobin (Hb)A 1C <7%. b. Check blood glucose each morning before breakfast and adjust medications to keep HbA 1C <7.5%. c. Check blood glucose each morning before breakfast and adjust medications to keep HbA 1C <8%. d. Stop checking blood glucose or HbA 1C .

c. Check blood glucose each morning before breakfast and adjust medications to keep HbA 1C <8%.

Which of these statements about frailty are false? a. Neither prominent frailty model currently uses age as a component for defining frailty b. Individuals who are prefrail have a higher likelihood of becoming robust than those with frailty. c. Clinical diagnosis of anxiety or depression do not have any effect on frailty rates. d. Frailty diagnosis has proved valuable in preoperative assessment of patients likely to do well with surgical interventions.

c. Clinical diagnosis of anxiety or depression do not have any effect on frailty rates.

All of the following evaluation methods are part of the routine workup for a first episode of syncope except: a. Electrocardiogram b. Complete history and physical examination c. Computed tomography (CT) scan of the brain d. Review of medication use

c. Computed tomography (CT) scan of the brain

While discussing Mr. Lee's diet, he states that his wife did all the cooking and since she passed away 5 months ago, he eats mostly soups and sandwiches. He does not drive, and he does not like to ask his son to take him to the store because he does not want to be a burden. What nutrition intervention would you recommend? a. Move to a retirement home b. Learn to cook meals c. Consult dietician to determine nutritional needs d. Use a taxi to get to the grocery store

c. Consult dietician to determine nutritional needs

Mrs. C. is a 72-year-old woman with hypertension who was recently involved in a driving incident, which she states was caused by glare from oncoming traffic causing her to miss seeing a stop sign at night. The most likely cause of her vision impairment is: a. Irreversible b. Treated with eyedrops c. Correctable surgically d. Rare in older adults

c. Correctable surgically

An 81-year-old transgender female with history of depression and hyperlipidemia presents to your clinic for routine care. She endorses a history of smoking, currently smoking 1 pack per day, and occasionally drinks a glass of wine, although she denies illicit drug use. She reports she takes atorvastatin 20 mg and subcutaneous estrogen therapy. Which of the following is the most important next step in this patient's primary care? a. Counseling on starting aspirin b. Counseling on alcohol cessation c. Counseling on smoking cessation d. Counseling on mammogram

c. Counseling on smoking cessation

The daughter of a 79-year-old woman notes that her mother, who has dementia and lives with her, is wetting herself when she attends her new day program. Program staff have requested that "something be done" as she is requiring a clothes change nearly every time she is there. She cannot describe the circumstances of leakage, saying "it just comes." Leakage is uncommon at home. Her medications include donepezil and acetaminophen. Physical examination is normal. Initial treatment approach will require intervention by which of the following? a. Mrs. A's physician b. Mrs. A's daughter c. Day program staff

c. Day program staff

Mr. Davis, a 73-year-old patient, presents to the office with leg pain. He has a 10-year history of diabetes that is managed with glipizide 10 mg by mouth twice per day. He describes his pain as a burning sensation in his feet and ankles that is moderate in intensity and worse at night. His latest glycosylated hemoglobin was 8%. In addition to improving his diabetes control, which of the following would be the most appropriate treatment for his pain? a. Oxycodone 5 to 10 mg by mouth every 3 to 4 hours as needed for pain. b. Oxycontin 20 mg by mouth bid. c. Gabapentin 100 mg twice daily by mouth. d. Celecoxib 100 mg twice daily by mouth.

c. Gabapentin 100 mg twice daily by mouth.

. Ms. M's family has noticed memory loss for the past 6 months. She continues to drive but recently had a fender bender and was caught speeding on a 35-mph road. She insists that she is safe and needs to drive to church and for shopping. What is the best next step? a. Take away her license. b. Sell her car. c. Get a driving evaluation. d. Get her a GPS. e. Continue letting her drive.

c. Get a driving evaluation.

MM is a 72-year-old female presenting with a sensation of dryness of the mouth. Past medical history includes hypertension, diabetes mellitus, and osteoarthritis. Current medications include metformin, canagliflozin, lisinopril-hydrochlorothiazide, and acetaminophen. Hemoglobin A 1 C is 6.8. Physical examination reveals a normal eye examination, dry oral mucosa, and normal sized salivary glands. Which of the following is the most likely cause of her xerostomia? a. Sjögren syndrome b. Reduced salivary flow because of aging c. Her medications d. Uncontrolled diabetes

c. Her medications

A 70-year-old woman reports sexual pain with deep penetration only. What is the most likely cause of her problem? a. Vaginal atrophy b. Provoked vulvar vestibulodynia c. High-tone pelvic floor dysfunction d. Endometriosis

c. High-tone pelvic floor dysfunction

Alice Danforth is a 72-year-old retired college professor. She lives with her husband of 42 years in a retirement community where there are other people of similar age and social experiences. She has high cholesterol and hypertension, as well as mild cognitive impairment (MCI). She reports noticing that she has trouble retrieving names, which frustrates her and worries her husband. When you are meeting with her, you probe more deeply into her substance use history and she reports two to three glasses of red wine most evenings and sometimes more at social gatherings in the community (which are fairly frequent). She also reports marijuana use two to three times per month. In reflection, her problems with memory do seem most apparent in the evenings. •What are considered the upper limits of recommended alcohol intake for older adults?' a. Three drinks per week b. No more than six mixed drinks on any given c. No more than 7 drinks in a week or 3 drinks on a given day d. Same amount as the person has consumed throughout life

c. No more than 7 drinks in a week or 3 drinks on a given day

An 88-year-old woman was admitted to the hospital 1 week ago. The physiologic risk factors that contribute to the geriatric syndrome of frailty for this woman include all of the following except: a. Weight loss of 15% over the past 6 months b. Decreased self-perceived ability to walk one city block because of fatigue c. Ongoing vitamin D supplementation during this hospital stay d. Exclusive bed rest for the past 4 days e. Eating <25% of provided meals for the past 3 days

c. Ongoing vitamin D supplementation during this hospital stay

Which of the following is true about the primary functions and duties of the skilled nursing facility medical director? a. Is responsible for the direct patient care of all patients in the facility b. Is solely responsible for drafting policies and procedures c. Participates in monitoring and improving the facility's medical care d. Refers patients in need of skilled care to the facility

c. Participates in monitoring and improving the facility's medical care

A 72-year-old female with progressive fatigue is found to have a hemoglobin of 9.1 g/dL, mean corpuscular volume of 108 fL, and a platelet count of 67×10 9 /L on a routine laboratory evaluation. She has a normal B 12 and folate level. She has never had a history of anemia and does not have signs or symptoms of bleeding or hemolysis. She does not use alcohol, and she has no liver disease. Your next step in management should be: a. Refer the patient to gastroenterology for evaluation of bleeding of occult gastrointestinal bleeding. b. Treat the patient empirically for iron deficiency anemia. c. Refer to hematology for bone marrow examination. d. Monitor the patient and repeat the CBC in 3 months since the patient is asymptomatic.

c. Refer to hematology for bone marrow examination.

A 75-year-old Hispanic woman is admitted to the hospital with atrial fibrillation and started on anticoagulation plus rate control medications. Her past medical history was significant for rheumatoid arthritis (RA), and she was taking weekly methotrexate and daily folic acid. On the third day in the hospital, the patient developed significant right knee pain. Her last methotrexate dose was taken 6 days ago. Physical examination detected a red, swollen right knee. What would your next approach be? a. Restart methotrexate b. Start prednisone c. Request an arthrocentesis d. Order magnetic resonance imaging e. Start colchicine

c. Request an arthrocentesis

John Rivera is a 77-year-old man who reported to his primary care provider that he had 3 days of left-sided, sharp, pleuritic chest pain without associated shortness of breath. Other than with taking deep breaths, he denies any other exacerbating factors. He has been able to complete his daily tasks despite this discomfort. He denies any trauma, infectious complaints, or lower extremity swelling. The pain is not associated with eating. He denies any skin changes. His vital signs and physical examination are within normal limits. His electrocardiogram is suggestive of left ventricular hypertrophy only, a finding noted on his past ECGs. You decide to send a D-dimer as you consider pulmonary embolism (PE) as a possible cause. Which of the following is true regarding the D-dimer test? a. An elevated D-dimer has similar sensitivity to Westermark sign and Hampton hump on chest x-ray. b. In patients with high pretest probability of PE, a D-dimer should be obtained before advanced imaging, such as a computed tomography angiogram of the chest. c. Results of a D-dimer should be age adjusted to improve the specificity in older adults. d. A D-dimer to evaluate for PE is not indicated in a patient with normal oxygen saturation.

c. Results of a D-dimer should be age adjusted to improve the specificity in older adults.

The National Institute of Neurologic Disorders and Stroke (NINDS) criteria require a confirmatory autopsy for PD to be described as "definitive" but would rate as "probable" if three of the four primary clinical features were present for at least 3 years. Which of the following lists three primary clinical features of PD? (Choose one) a. Fatigue, postural instability, gait dysfunction b. Rigidity, resting tremor, urinary urgency c. Rigidity, bradykinesia, resting tremor d. Freezing, sleep disturbance, arthralgias

c. Rigidity, bradykinesia, resting tremor

What are best practices with regard to opioid prescribing in chronic pain? a. Never initiate opioids for the management of chronic pain in older adults. b. Use short acting opioid only; avoid long-acting forms. c. Share your general concerns about the risk of long-term dependence on opioids when initially prescribed for chronic pain.

c. Share your general concerns about the risk of long-term dependence on opioids when initially prescribed for chronic pain.

. A 72-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 positive on the Confusion Assessment Method performed by the geriatric consultation services. Presence of delirium in this patient predisposes him to all of the following except: a. Higher risk of institutionalization b. Increased risk of dementia c. Shorter length of stay in the hospital d. Increased mortality

c. Shorter length of stay in the hospital

Mr. B is an 82-year-old enrolled in your primary care clinic panel. His medical history includes moderate dementia and probable Alzheimer disease. He requires cues to bathe and dress but is otherwise independent in his activities of daily living. He cannot manage his medications and does not drive. His wife is his primary caregiver and has been providing 24-hour care supervision since he was found wandering outside by their neighbors. During your visit today, she admits that she is "feeling stressed" and at times "overwhelmed" with her caregiving responsibilities. She wants to know what options are available to help support her taking care of him. All of the following would be appropriate for Mr. B except: a. Adult day program b. Assisted living c. Skilled nursing facility d. In-home paid care provider

c. Skilled nursing facility

An 85-year-old man with newly diagnosed nonvalvular atrial fibrillation comes to the office for a follow-up. He has a history of essential hypertension, type 2 diabetes mellitus, hyperlipidemia, and stage 3B chronic kidney disease. He takes lisinopril, atorvastatin, metformin, and aspirin. He lives in an assisted living facility and uses a walker for ambulation. He has fallen twice in the past year. On physical examination, his heart rate is normal but his rhythm is irregularly irregular. His blood pressure is 135/70 mmHg. Which medication change would be most appropriate for reducing his stroke risk? a. Current medications are appropriate. b. Continue aspirin and start warfarin with international normalized ratio goal 2-3. c. Stop aspirin and begin apixaban 5 mg twice a day. d. Continue aspirin and start apixaban 5 mg twice a day.

c. Stop aspirin and begin apixaban 5 mg twice a day.

John P. is an 81-year-old male with extensive cardiac history, including three vessel coronary artery bypass graft when he was in his 60s, hypertension, diabetes mellitus, osteoarthritis, sciatica, and progressive macular degeneration. His vitals today are blood pressure 146/86 mmHg, heart rate 67 beats per minute, respiratory rate 21 breaths/min, and temperature 98.7° F. He is here with his only son and has been living in an assisted living since his wife died 3 years ago. His Montreal cognitive assessment (MoCA) 1 month ago was 23/30. He has no advance directive in the chart. He tells you he's "been slowing down" a lot lately. He does not go down to the dining room because it is too taxing, he has been slowly losing weight because food does not taste good, he has fallen four times in the last year. He has no specific concerns to discuss today. What is the most important thing that can be addressed at today's visit? a. His elevated blood pressure noted on today's vitals. b. Repeating his MoCA testing to assess for cognitive change. c. Suggest completion of an advance directive at visit with his goals of care in mind for moving forward in his care. d. Review his last colonoscopy report and discuss further screening procedures.

c. Suggest completion of an advance directive at visit with his goals of care in mind for moving forward in his care.

Mrs. Gloth is an 84-year-old woman whom you are admitting to the nursing home. Her son takes you aside and tells you that she has metastatic ovarian cancer but has not been told the diagnosis. He asks that you not tell her, because she would "lose all hope and die." Which of the following is an appropriate response? a. Tell the son that you are going to immediately inform the patient of her diagnosis. b. Tell the son that he can count on you to respect his wishes. c. Suggest that you discuss this further after getting to know the patient and family a little better. d. Find out from the son what the family has been telling her about her health, so you will maintain a consistent story.

c. Suggest that you discuss this further after getting to know the patient and family a little better.

What is an appropriate step in the initial management of the seven patients receiving atypical antipsychotics? a. No action is necessary, because one potential indication for atypical antipsychotic use is refractory behavioral disturbance in persons with significant dementia. b. Taper to discontinue the atypical antipsychotic; after a 2-week washout, begin therapy with zolpidem. c. Taper to discontinue the atypical antipsychotic, and create day programs that allow patients to develop a sleep deficit/need through the morning/afternoon/early evening.

c. Taper to discontinue the atypical antipsychotic, and create day programs that allow patients to

Which one of the following statements is false regarding the role of the primary care provider (PCP) in the healthcare team? a. The PCP is responsible for assessing and managing the patient's medical problems. b. The PCP has the responsibility to inform other team members of the patient's medical condition. c. The PCP is always the leader of an interprofessional team. d. The PCP plays an important role in the discussion of advance care planning with the patient and family.

c. The PCP is always the leader of an interprofessional team.

Which of the following is true with regard to lower extremity peripheral arterial disease? a. The disease commonly leads to amputation. b. The most common location of the disease is at the level of the tibial arteries. c. The ankle brachial index is an easy-to-perform office-based procedure that is rapid and reliable for diagnosing peripheral arterial disease. d. Diabetes mellitus and renal failure have improved outcomes regarding revascularization compared with control patients.

c. The ankle brachial index is an easy-to-perform office-based procedure that is rapid and reliable for diagnosing peripheral arterial disease.

All of the statements about Medicaid are true, except: a. Medicaid is jointly funded by federal and state governments. b. Medicaid provides coverage for low-income people of all ages. c. The coverage provided under Medicaid is the same in every state. d. Long-term care for elderly and disabled people accounts for the largest proportion of Medicaid spending.

c. The coverage provided under Medicaid is the same in every state.

A 72-year-old woman with moderately advanced Parkinson disease is having difficulty being understood because of her worsening hypophonia. Speech therapy should encourage which of the following? a. Speak slowly and clearly. b. Think loud and think shout. c. Think loud and think low. d. Speak fast and high.

c. Think loud and think low.

To receive payment from Medicare for a home visit, a nurse practitioner must: a. Indicate that a collaborating physician was available in the home during the time of the visit. b. Be the certifying clinician on the initial or recertification home care orders. c. Describe the patient's homebound status in accordance with Medicare requirements for skilled home care. d. Document the medical necessity of seeing the patient at home instead of in the office.

d. Document the medical necessity of seeing the patient at home instead of in the office.

An 84-year-old woman has been readmitted to a long-term care facility after a fall and C6 fracture. Initially, she developed neurogenic shock, resulting in hypotension, bradycardia, and flaccid paralysis. She was in the intensive care unit for 1 week and a long-term acute care hospital for 6 weeks. She has been slow to recover. Her tracheostomy was removed about a week ago. She has a percutaneous endoscopic gastrostomy tube for nutrition. She spends most of her time in bed, requiring full assistance with turning and repositioning. She is easily fatigued when out of bed to chair. She has a Foley catheter for urinary retention. One week after readmission she develops copious diarrhea of unclear etiology. Clostridium difficile and other stool studies have been negative. In the past, a rectal tube caused severe gastrointestinal bleeding requiring a blood transfusion; this device was not reconsidered for stool management. Turning her for hygiene care has been a challenge because she will often yell out in pain or become combative. She has developed a wound on her right buttock area. The discharge paperwork from the long-term care facility indicates that this started as a purplish discoloration 5 days ago. What is the diagnosis? a. Deep tissue injury b. Moisture-associated skin damage/incontinence-associated dermatitis c. Unstageable pressure injury d. Ulcer resulting from low-flow arterial state

c. Unstageable pressure injury

An 85-year-old woman with congestive heart failure, end-stage chronic obstructive pulmonary disease, chronic kidney disease stage 4, and frailty is brought to your office for a routine appointment. She has preserved cognition and her last Mini-Mental State Examination was 26. Affect is normal, and she has no history of depression. She has a loving and supportive family with whom she lives. During the visit, she shares that her quality of life is no longer acceptable, and asks about options to hasten the end of her life. Which of the following means of hastening death is legal throughout the United States? a. Euthanasia b. Palliative sedation c. Voluntary stopping of eating and drinking d. Physician-assisted death

c. Voluntary stopping of eating and drinking

You provide chronic disease management for a 94-year-old male with advanced Alzheimer dementia. He lives with his daughter. She and his other children rotate shifts to provide round-the-clock care. He also goes to an adult day center 5 days per week. The daughter wants to talk to you about pressure injury prevention. You had recently ordered a lift to help him transfer from bed to wheelchair, where he spends most of his day. The wheelchair was assessed by physical therapy and he has a pressure-redistributing cushion. When in bed, he tends to sleep on his back all night unless repositioned by family. He is incontinent of bowel and bladder. At the last visit 3 months ago, the daughter noticed that he had started to pocket his food intermittently. Speech consultation provided education to the family on how to cue the patient for safe swallowing. He has maintained his current weight. Presently he has no pressure injuries. Which care plan will minimize this patient's chances of developing a pressure injury? v a. While in bed, reposition every 2 to 4 hours, order a powered mattress that turns the patient at night, place a Foley catheter to manage incontinence, and place a temporary nasogastric feeding tube. b. While in bed, reposition every 2 to 4 hours, order specialized foam overlay, apply barrier cream every shift to protect skin from moisture-associated skin damage, and continue one-to-one feeding. c. While in bed, reposition every 2 to 4 hours, order a powered mattress that turns the patient, place a Foley catheter to manage incontinence, and continue one-to-one feeding. d. While in bed, reposition every 2 to 4 hours, order specialized foam overlay on hospital mattress, place a Foley catheter to manage incontinence, and place a temporary nasogastric feeding tube.

c. While in bed, reposition every 2 to 4 hours, order a powered mattress that turns the patient, place a Foley catheter to manage incontinence, and continue one-to-one feeding.

Which of the following groups has the highest rate of suicide in older adults? a. Asian males b. Hispanic males c. White males d. Black males

c. White males

What is recommended for severe pain in elderly?

chronic illness / dying - Morphine is most common but many meds are used

Ways in which a hospital physical design fails to meet the needs of older adults include all of the following except: a. Noisy units with excess background commotion b. Lack of supportive, functional seating for patients and family c. A lack of accessible emergency staff-call systems d. Easily graspable handrails on both sides of all hallways

d. Easily graspable handrails on both sides of all hallways

Which one of the following is most true about psychological aging? a. Disengagement tends to promote better psychological health than continued engagement. b. Most older adults do not worry about memory loss. c. Happiness declines starting in middle age. d. Ageism can lead to isolation and depression.

d. Ageism can lead to isolation and depression.

What are the concerning aspects of continuing to prescribe oxycodone for chronic pain? a. There might diversion of medication to family members who visit infrequently b. Severe constipation that leads to non-specific abdominal pain and the perception of more lower back pain c. Increased social isolation d. All of the above

d. All of the above

The US Advisory Committee on Immunization Practices and the Centers for Disease Control currently recommend which one of the following? a. All older adults be immunized against influenza annually and that they receive at least one pneumococcal vaccination. b. All high-risk older adults should receive an additional pneumococcal vaccination 5 years or more after their first immunization. c. Older adults should receive a one-time revaccination for pneumonia if they were initially vaccinated more than 5 years previously and were less than 65 years of age at the time of the initial vaccination. d. All of these are recommended.

d. All of these are recommended.

How might you engage in a therapeutic plan with someone like Ms. Alice Danforth (Case #1)? a. Inform the patient that his/her adult child has asked you to intervene b. Avoid Alcoholics Anonymous as these are not helpful in older adults c. Suggest disulfuram ( Antabuse ) as an essential component of management d. Apply motivated interviewing techniques to encourage her to commit to a plan to reduce her daily alcohol intake

d. Apply motivated interviewing techniques to encourage her to commit to a plan to reduce her daily alcohol intake

Lenore White is an 80-year-old woman who smokes two packs of cigarettes per day. She is hospitalized for pneumonia because she has presenting symptoms of cough and fever. On her second day of hospitalization, she asks the nurse to please wheel her outside so she can smoke a cigarette. The nurse feels uncomfortable agreeing to this and speaks to her clinical nurse manager. What two ethical principles are in conflict? a. Beneficence and community b. Nonmaleficence and justice c. Autonomy and justice d. Autonomy and nonmaleficence

d. Autonomy and nonmaleficence

All of the following about the Medicare Part D prescription medication benefit plan are true except: a. Medicare Advantage plans include Part D coverage. b. There are multiple companies that offer prescription plans from which the beneficiary must choose. c. In 2019 the monthly premium for Part D coverage is approximately $30. d. Beneficiaries have no out-of-pocket expense for each prescription filled.

d. Beneficiaries have no out-of-pocket expense for each prescription filled.

A 75-year-old man develops severe right arm upper extremity spasticity after a left hemispheric stroke. Which medication is least likely to cause sedation and falls? a. Oral baclofen b. Oral tizanidine c. Oral diazepam d. Botulinum toxin injections into affected spastic muscles

d. Botulinum toxin injections into affected spastic muscles

Treatment for early PD in an otherwise healthy older patient without significant functional impairment should begin with: a. Catechol-o-methyl transferase (COMT) inhibitors b. Dopamine agonist c. Levodopa d. Careful observation

d. Careful observation

An 88-year-old female patient with Parkinson disease presents to clinic for hospital follow-up for atrial fibrillation (AF) with rapid ventricular response (RVR). Home heart rate monitoring shows good rate control of her AF ventricular rates. She has a history of falls and labile international normalized ratio (INR) with irregular adherence with blood draws. Her current medications include carbidopa-levodopa, metoprolol, and warfarin and she has a robust drug plan that allows for a variety of medication choices. What changes would you recommend to her medication regimen? a. Stop warfarin and start full-dose aspirin b. Decrease her goal target INR to 2.0 c. Add digoxin d. Convert warfarin to a direct oral anticoagulant

d. Convert warfarin to a direct oral anticoagulant

Which of these is true regarding the relationship of frailty with cognition? a. Cognitive frailty is synonymous with dementia. b. Patients with Alzheimer disease do not have higher rates of frailty. c. Neither the frailty index or Fried frailty criteria include cognition assessment. d. Currently, to be considered cognitively frailty it requires a MMSE score over 26.

d. Currently, to be considered cognitively frailty it requires a MMSE score over 26.

Which class of drug has not been shown to provide a mortality benefit in heart failure patients with reduced ejection fraction? a. Beta blockers b. ACE inhibitors c. Neprilysin inhibitor combined with an angiotensin receptor blocker d. Diuretics e. Mineralocorticoid antagonists

d. Diuretics

An 82-year-old woman receives oral amoxicillin-clavulate for a skin abscess on her leg. She develops new onset of frequent watery stool that persists for several days after the antibiotic is stopped. You obtain a stool for Clostridium difficile antigen, toxin, and polymerase chain reaction (PCR). The antigen and PCR are both positive. She has never had C. difficile infection before. What one statement is the best answer regarding her management? a. Metronidazole is the treatment of choice for C. difficile infection. b. Older adults with their first episode of C. difficile require a longer duration of treatment with vancomycin. c. Fecal transplantation is the treatment of choice for C. difficile infection. d. Either vancomycin or fidaxomicin are recommended for the first episode of C. difficile infection.

d. Either vancomycin or fidaxomicin are recommended for the first episode of C. difficile infection.

Which of the following medications would have the greatest efficacy in treating persistent neuropathic pain? a. Celecoxib b. Acetaminophen c. Codeine d. Gabapentin

d. Gabapentin

You are the hospice provider for an 87-year-old male assisted living resident, Mr. Jones, who is on hospice for hypertensive heart disease with heart failure. He also has a history of insulin-dependent diabetes mellitus type 2 and mixed Alzheimer/vascular dementia. Your hospice nurse calls you because Mr. Jones has a reddened right eye over the last 2 days. The patient denies pain, but has difficulty communicating because of his dementia. He has been dabbing his eye with a tissue, and this does not seem to bother him to do so. You ask the nurse to provide you more detail about what his eye looks like and she mentions that he seems to have a cloud over his pupil. The family is present and says that there is no history of eye disease and wonders if he needs to go to the emergency room. What is your next step? a. Order antibiotic eye drops. b. Monitor for any change in symptoms. c. Send Mr. Jones to the emergency room. d. Get Mr. Jones into an ophthalmology clinic by the end of the day.

d. Get Mr. Jones into an ophthalmology clinic by the end of the day.

A 79-year-old woman with a 1.5-cm breast cancer underwent lumpectomy. Pathology revealed ductal carcinoma that is hormone receptor negative (estrogen receptor 0%, progesterone receptor 1%) and HER2/neu negative. Surgical margins were adequate and uninvolved with cancer. Sentinel lymph node sampling was negative for lymph node involvement. She has good performance status and no activities of daily living (ADL) or instrumental (IADL) dependencies. What treatment would you recommend? a. Adjuvant chemotherapy b. Adjuvant chemotherapy with irradiation c. Adjuvant irradiation only d. Hormonal therapy only e. None of the above

d. Hormonal therapy only

Of the following conditions, which one is most common and most often preventable? a. Falls b. Frailty c. Cognitive impairment d. Iatrogenic disease e. Depression

d. Iatrogenic disease

Which of the following is true about "incident to" billing? a. It is used when faculty have residents do consults in the hospital. b. It requires that the physician be present with the patient for the key components of the service. c. Advanced Practice Nurses use it for new patients. d. It allows services by RNPs, CNSs, and PAs to be reported by the physician when certain criteria are met. e. It is the rule that pays nonphysicians 85% of what physicians get.

d. It allows services by RNPs, CNSs, and PAs to be reported by the physician when certain criteria are met.

Which of the following is true about tolterodine? a. It should be avoided in men with prostatic hypertrophy. b. It increases the risk of constipation compared with oral oxybutynin. c. It acts by ablating detrusor spasms. d. It has greater risk of adverse effects with its twice-daily formulation.

d. It has greater risk of adverse effects with its twice-daily formulation.

Jon Rankowski is retired electrician who is 77 years old. He has been widowed for the past 4 years. He is fairly healthy with the exception of bilateral knee arthritis and chronic lower back pain. He does not like to see specialists and would not consider surgery even if recommended. He does not really have a primary care provider, but does occasionally see the geriatrician his wife was seeing before she died (she had a stroke 2 years earlier). He has noticed more problems with his back pain in the last year and he received a prescription for oxycodone in the past 6 months, which he has refilled regularly. The geriatrician is sympathetic to his situation but concerned that he now has a secondary problem related to the oxycodone use. Although never very "social," he reports not leaving the house except to go shopping with his daughter every 2 weeks. She is concerned about his growing apathy. • How common is prescription opioid use in the older adult population? a. Since the Beers' criteria were developed, it has become very rare among older adults. b. Much less common that benzodiazepine use. c. More common than alcohol misuse. d. It is common, including an increase in ER prescription.

d. It is common, including an increase in ER prescription.

Ways to prevent delirium in a hospitalized older adult include all of the following except: a. Ensuring optimal pain control with narcotic medications b. Engaging family members and staff to frequently reorient patients and provide a familiar environment c. Providing vision, hearing, and other sensory adaptive measures to all appropriate patients d. Limiting time out of bed to prevent overstimulation e. Preserving clear day/night differences by keeping shades open during the day and promoting a quiet environment at night with limited interruptions

d. Limiting time out of bed to prevent overstimulation

A 72-year-old man with a history of hypertension recently had acute coronary syndrome for which he was hospitalized and treated with a stent to one of his coronary arteries. In addition to antiplatelet therapy, what antihypertensives are recommended to treat his BP and improve outcomes regarding his ischemic heart disease? a. Chlorthalidone and atenolol b. Chlorthalidone and lisinopril c. Lisinopril and losartan d. Lisinopril and metoprolol e. Metoprolol and amlodipine

d. Lisinopril and metoprolol

What aspects of sleep hygiene may make your facility more conducive for nighttime sleep? a. Bright lights to illuminate pathways to bathrooms. b. Judicious restraint use to ensure patients remain in bed overnight. c. Allow patients with greater degree of dementia an opportunity for an afternoon nap to improve their cognitive status. d. Neutralizing antiseptic smells, minimize movement of equipment through halls, maintain quiet hours where staff can speak in areas away from residents, avoid using overhead announcement systems.

d. Neutralizing antiseptic smells, minimize movement of equipment through halls, maintain quiet hours where staff can speak in areas away from residents, avoid using overhead announcement systems.

Several years later, Mr. Hunter, who is now 75 years old, seeks additional intervention for his urinary symptoms that have progressed further. He now experiences slow urinary stream, hesitancy, straining, and a feeling of incomplete emptying in addition to the previous urinary urgency and frequency. At times, he has noted blood in his urine. He has had five urinary tract infections (UTIs) in the past 2 years. His current IPSS is 24, with a bother score of 5 indicating severe voiding symptoms with high impact on his quality of life. Mr. Hunter's updated medical history includes hypertension, coronary artery disease, benign prostatic hyperplasia, cataract surgery 4 years ago, and two falls within the past year while rushing to the bathroom during the night. Current medications are aspirin, metoprolol, finasteride, and tamsulosin. Physical examination reveals an enlarged, nontender prostate, about 50 g in size without discrete nodules. Upon further evaluation, the intermittent hematuria is attributed to BPH. Postvoid residual volume is 110 mL. Uroflowmetry reveals urinary flow rate of 12 mL/s. Which of the following is the best next step in management? a. Start tadalafil. b. Switch from tamsulosin to silodosin. c. Switch from finasteride to dutasteride. d. Perform surgical resection of prostate.

d. Perform surgical resection of prostate.

Margaret Wilson is a 66-year-old woman who is evaluated as an urgent visit in your clinic. She complains of new onset chest pain since this morning after waking up. She describes her pain as a pressure with radiation to both the left and right shoulders. She vomited once after the pain started. Her history is remarkable for chronic obstructive pulmonary disease (COPD) for which she is on home oxygen, 2 L a minute, as well as hypertension and diabetes. Vital signs are notable for a blood pressure of 92/56 mmHg, a heart rate of 110 beats per minute, a respiratory rate of 20 breaths per minute, with an oxygen saturation of 99% on her home oxygen. On examination, she appears moderately uncomfortable, her examination is most notable for trace crackles in the lower lung fields bilaterally. In addition to immediate referral to the emergency department (ED), what is the next most important step in caring for this patient assuming equipment availability in your office? a. Obtaining basic laboratory values to help expedite her ED visit once she arrives b. Obtaining an electrocardiogram c. Assisting the patient in administering some of her prescribed nitroglycerin d. Placing an intravenous line and starting fluids

d. Placing an intravenous line and starting fluids

JD is a 76-year-old male who presents to the clinic for recommendations for an upcoming dental extraction. He has a history of diabetes mellitus, hypertension, and coronary artery disease. He had a heart attack 4 months ago and had a right coronary artery stent placed. He is currently on clopidogrel and a baby aspirin. What would be the most appropriate recommendation to his oral surgeon? a. He is not a candidate for extraction because of his heart attack. b. Wait for 6 months after his heart attack before doing the extraction. c. Proceed with extraction but hold the clopidogrel and aspirin a week before. d. Proceed with extraction without discontinuing his antiplatelet therapy.

d. Proceed with extraction without discontinuing his antiplatelet therapy.

A 67-year-old man with no significant medical problems passes out at a cookout soon after standing up to go to the bathroom. He had recently finished his barbecue dinner and admits to having consumed three beers. He denies any previous syncopal episodes. His complete physical examination reveals a very healthy-appearing man with no abnormal findings. His electrocardiogram (ECG) is normal. What should you do?' a. Admit him to the hospital for telemetry monitoring. b. Refer him to a cardiologist for intracardiac electrophysiologic studies. c. Schedule an exercise treadmill cardiac stress test. d. Reassure him and follow up with him in clinic again later in the week.

d. Reassure him and follow up with him in clinic again later in the week.

An 80-year-old White female patient comes to your office worried about a repeated positive test of antinuclear antibodies (ANA) 1:80 with a speckled pattern. She was previously diagnosed with systemic lupus erythematosus. The patient is otherwise asymptomatic and functional, and her physical examination is normal. Which one of the following would be the best approach for this patient? a. Reassure the patient that lupus is treatable, and cure is the goal. b. Tell the patient that she is going to develop symptomatic lupus in the next year or less. c. Repeat the ANA to see whether it has increased in titer in the last 2 weeks. d. Reassure the patient that her ANA do not have clinical significance. e. Instruct the patient to stay away from the sunlight as much as possible.

d. Reassure the patient that her ANA do not have clinical significance.

Ms. M. is a 79-year-old woman whose daughter brings her in for concerns about her memory. She lives alone, appears to be in good health, and reports that she is independent in self-care activities of daily living. Her daughter states that she began to handle her mother's major bills and to do the major housework about 6 months ago when her mother forgot to pay the utilities and take out the trash. Ms. M states that everything is fine and reports that she drives to church and the grocery alone. She denies becoming lost or having any fender-benders. She does not like to drive to her daughter's home since her daughter moved to another area and thinks her daughter is making a big deal about nothing. You should: a. Recommend immediate complete driving cessation b. Refer to the local Aging Disability Resource Center alternative transportation options c. Recommend that she move in with her daughter for closer observation d. Refer to a driving rehabilitation specialist for on-road evaluation and counseling

d. Refer to a driving rehabilitation specialist for on-road evaluation and counseling

An 86-year-old man with no ADL deficits who has stopped driving because of macular degeneration is evaluated for a urinary tract infection associated with urinary retention. The consulting urologist places a Foley catheter and sends a prostate-specific antigen (PSA) level that comes back 12 ng/mL. Three months later after the Foley has been removed and he has had a good response to tamsulosin, his PSA is still 10 ng/mL. What is the appropriate next step in managing this man's prostate problem? a. Transrectal ultrasound and biopsy b. Empiric finasteride c. Bone scan d. Repeat PSA in 6 months e. Observation

d. Repeat PSA in 6 months

Mr. Roberts, a 72-year-old patient who has sought medical care on an intermittent basis in the past, complains of aching discomfort in his perineal area, urinary urgency, and frequency for the past few years. He also complains of insomnia and intermittent anxiety that he attributes to loneliness after his wife's death about a year ago. Digital rectal examination (DRE) reveals a slightly enlarged, nontender prostate with no palpable nodules. Perineal examination is normal. Bladder scan is unremarkable and postvoid residual urine volume is 50 mL. Urinalysis shows no WBCs or RBCs. Urine culture is negative. Previous treatment has included dietary modification and alpha-blocker medication. What is the most appropriate next step? a. Start an 8-week course of ciprofloxacin. b. Start a 5-alpha-reductase inhibitor. c. Perform urodynamic testing. d. Screen for depression.

d. Screen for depression.

For the patient in question 3, in addition to floating the heels and other pressure reduction techniques, which is the preferred local wound care management plan? a. Wet to dry dressings four times per day b. Bacitracin once daily and as-needed cleansing c. Silver-impregnated hydrogel three times per week and as-needed cleansing d. Silver-impregnated hydrofiber three times per week and as-needed cleansing

d. Silver-impregnated hydrofiber three times per week and as-needed cleansing

Mr. Quince is a 68-year-old patient who describes several months of urinary frequency and a sensation of incomplete emptying with no associated dysuria, hematuria, or fever. Physical examination reveals a slightly enlarged but nontender prostate, a postvoid residual urine volume of 20 mL, and a urinalysis with 15 white blood cells (WBCs) and 5 red blood cells (RBCs). Urine culture reveals 30,000 colony-forming units of Escherichia coli . You see a report from last year that shows urinalysis with 10 WBCs and 4 RBCs that was obtained as part of a routine evaluation. What is the most appropriate next step in the management of Mr. Quince's symptoms? a. Start an alpha-blocker. b. Start a 5-alpha-reductase inhibitor. c. Start combination therapy with an alpha-blocker and a 5-alpha-reductase inhibitor. d. Start a 4-week course of ciprofloxacin

d. Start a 4-week course of ciprofloxacin

A 77-year-old female with asthma is evaluated for a very slow increase in the frequency of episodes of wheezing and dyspnea not relieved by short-acting beta-agonist therapy. She states that she uses her controller medications regularly with good inhaler technique, which include an inhaled long-acting beta-agonist and an inhaled low-dose corticosteroid. Despite this, she has daily daytime and frequent nocturnal symptoms of chest tightness and wheezing. She does not feel acutely ill. On physical examination, the patient is not in any respiratory distress. Her temperature is 37.0° C (98.6° F), blood pressure is 140/85 mmHg, pulse rate is 90 per minute, and respiration rate is 18/min. She has bilateral wheezing. In-office spirometry shows an FEV1 of 65% of predicted. After the supervised use of a bronchodilator in the office, there was some relief of her symptoms, and repeat spirometry 15 minutes later showed that the FEV1 increased to 85% of predicted. Which of the following is the appropriate next step in this patient's management? a. Start high-dose oral prednisone. b. Add omalizumab injections. c. Send her to the emergency department for further urgent evaluation. d. Step up to medium-dose inhaled corticosteroid and have her return in 4 to 6 weeks for evaluation.

d. Step up to medium-dose inhaled corticosteroid and have her return in 4 to 6 weeks for evaluation.

A 75-year-old man presents with the chief concern, "I may have a bladder infection." Further questioning reveals for several months he has been needing to void every couple of hours (can't sit through a whole ball game), feels he must go as soon as he feels the urge (he tried putting it off and had urinary leakage), and is getting up two to three times at night to void. He denies delay in voiding or straining to initiate voiding, slow stream, feeling of incomplete emptying, or dribbling after completion of urination. He also denies dysuria and abdominal pain. Which of the following best describes the category or type of his lower urinary tract symptoms? a. Prostatism b. Overactive bladder c. Postmicturition d. Storage (irritative) e. Voiding (obstructive)

d. Storage (irritative)

Which of the following statement about community-based services is true? a. Senior centers may be used only by low-income older adults. b. Funding for Meals on Wheels is solely from local sources. c. Area Agencies on Aging usually do not provide services directly to older adults. d. The majority of the Administration on Aging budget goes to nutrition programs and community-based supportive services.

d. The majority of the Administration on Aging budget goes to nutrition programs and community-based supportive services.

A physician or other medical provider may receive Medicare reimbursement for medical house calls if which of the following conditions is met? a. The patient is homebound according to Medicare skilled home care criteria. b. The patient cannot obtain reliable transportation to the provider's office. c. The provider accurately documents the round-trip mileage for the house call. d. The provider documents the medical necessity of the home visit in lieu of an office visit.

d. The provider documents the medical necessity of the home visit in lieu of an office visit.

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 recognize she is high risk for development of delirium. Interventions that may prevent the onset of delirium among older adult 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. Treating anxiety with lorazepam e. Ensuring access to hearing and visual aids

d. Treating anxiety with lorazepam

An 82-year-old female presents for evaluation of hearing loss. Which of the following features would prompt referral to otolaryngology? a. Bilateral tinnitus b. Copious nonobstructing cerumen c. Hearing loss that is most bothersome in large-group settings d. Unilateral hearing loss

d. Unilateral hearing loss

You have recently assumed directorship of a nursing home that has a 30-bed dementia unit. The nursing home does not have an onsite pharmacist. You go to the dementia unit for patient observation and chart review. Immediately, you notice that although it is 9:00 AM, and most of the patients have been taken out of their rooms and placed in the dayroom, they are dozing in their wheelchairs. The window blinds block about half of the sunlight, and without the overhead fluorescent lighting, the room would be considered dimly lit. The nurses have just finished administering the morning medications. You begin focused chart review, concentrating on patient medications, cognitive/functional status, and comorbidities. When you are finished, you note that of the 28 patients currently living in this facility, seven of them are receiving a low-moderate dose of an atypical antipsychotic (quetiapine, olanzapine, risperidone, etc.) before bedtime, but only one of these patients has any history of recurrent visual hallucinations and delusions. All of these individuals have either moderate-to-severe dementia from Alzheimer disease or vascular/Alzheimer overlay listed among their problems. You ask the charge nurse why these patients are receiving these medications, and he replies that his counterpart on the night shift stated that many of these patients did not sleep through the night, cried out from their rooms, woke other patients, and seriously disrupted the limited staff's ability to manage the facility. The night nurse thus asked the previous attending to prescribe medications that would help these individuals sleep through the night. 1. What further diagnostic steps are required in the seven patients receiving atypical antipsychotics? a. All patients should receive 1 week of actigraphy monitoring both on and off their current antipsychotic. b. All patients should be immediately referred for cognitive behavioral therapy for insomnia (CBTI). c. All patients should receive referral to both psychiatry and neurology, neuroimaging, and screening polysomnography to identify underlying sleep disorder. d. Unless there is an underlying suspicion of obstructive sleep apnea (OSA) or other sleep disorder, these patients already meet criteria for irregular sleep-wake phase disorder, and no further diagnostic steps are required

d. Unless there is an underlying suspicion of obstructive sleep apnea (OSA) or other sleep disorder, these patients already meet criteria for irregular sleep-wake phase disorder, and no further diagnostic steps are required

An 84-year-old male with history of stroke without residual deficit, systolic heart failure, and type 2 diabetes presents to clinic for follow-up. He is independently living in a retirement community and still works part time on a golf course. He currently takes aspirin 81 mg, metoprolol tartrate 25 mg BID (twice a day), furosemide 20 mg BID, and lisinopril 10 mg daily. He reports his last colonoscopy was 8 years ago, with no abnormality. He reports he is sexually active with men and women, engaging in receptive oral, receptive anal, and penetrative sex. He states he has had over three sexual partners in the last year with intermittent condom use. What sexually transmitted infection testing should be offered? a. Urine testing b. Urine testing, blood testing c. Urine testing, blood testing, anal swab d. Urine testing, blood testing, anal swab, and oropharyngeal swab

d. Urine testing, blood testing, anal swab, and oropharyngeal swab

Which one of the following is most true about the rule of fourths? a. One-fourth of geriatric problems are iatrogenic. b. Little can be done to prevent three-fourths of the problems of aging. c. For every medical complaint a patient presents with, a careful assessment can identify three other diagnoses. d. What used to be called normal aging can be largely explained by processes that are not normal. e. A good way to conduct a geriatric assessment is to use four categories: mental, physical, psychosocial, and environmental.

d. What used to be called normal aging can be largely explained by processes that are not normal.

A 65-year-old male with Parkinson disease comes to your clinic after a 6-week hospitalization for aspiration pneumonia. He has had worsening mobility in the past year and now predominantly uses a wheelchair. During this hospitalization, he developed a stage 3 heel pressure injury. Vascular surgery was consulted and determined that he had adequate arterial flow for wound healing. They recommended wet to dry dressings three times per day. With the assistance of a visiting nurse, the wife has been providing his rehabilitative care at home. She notes that the wet to dry dressings are painful to the patient. She gives him oxycodone before dressing changes with good relief. The wound has moderate foul-smelling drainage, wet necrotic slough that does not obscure the wound base, and mild erythema. The wife notes that her husband has increasing pain over the past few days and bleeds easily with dressing changes. He has had no fever, chills, or other systemic symptoms. Which of the following signs or symptoms would suggest that a wound is infected? a. Increasing pain b. Foul-smelling drainage c. Necrotic tissue d. Erythema e. All of the above

e. All of the above

Which of the following would be consistent with the new onset of heart failure in an older patient? a. Dyspnea b. Worsening ability to self-care c. Anorexia d. Confusion e. All of the above

e. All of the above

ealthcare professional(s) responsible to alert the patient about the association of oral disease and diabetes mellitus, as well as management options include: a. Nurse b. Dentist/dental hygienist c. Physician d. Physical/occupational therapist e. All of the above

e. All of the above

Risk factors associated with constipation in older women are: a. High number of medications b. Multiple comorbidities c. Female sex d. Black American race/ethnicity e. All of these

e. All of these

Subtypes of elder mistreatment include: a. Psychological mistreatment b. Physical mistreatment c. Sexual mistreatment d. Financial exploitation e. All of these

e. All of these

Evaluation and management code level is based on which of the following (as of 2020)? a. Medical decision making only; it determines the history and exam. b. The number of diagnoses on a problem list. c. History, examination, and medical decision making. d. Time, when counseling and coordination of care dominate the service. e. Both c and d

e. Both c and d

A 65-year-old man is hospitalized with sudden onset chest pain but has a negative cardiac workup. You notice pink eroded papules along the left sternum and left flank that abruptly stop at the midline, where he thinks electrical leads were placed. He thinks these painful and somewhat itchy bumps are increasing in number. He is afebrile, otherwise stable, and has no other complaints. Which of the following is the most appropriate next step? a. Triamcinolone 0.1% ointment twice a day. b. Saline wet-to-dry dressings on the affected area. c. Readmission to the hospital with urgent dermatology consult. d. Refer to allergy or dermatology for skin patch testing. e. Empiric valacyclovir.

e. Empiric valacyclovir.

Risk factors for elder mistreatment include all except: a. Physical disability of patient b. Dementia of patient c. Caregiver burden d. Substance abuse of caregiver e. Financial independence of the caregiver

e. Financial independence of the caregiver

Which of the following is not a side effect of selective serotonin reuptake inhibitors in older adults? a. Extrapyramidal symptoms b. Gastrointestinal bleeding c. Gastrointestinal irritation d. Hyponatremia e. Increase in suicidal ideation

e. Increase in suicidal ideation

An 80-year-old woman has no weight loss, no pain, and no distention but over 2 years increasingly complains of constipation despite adequate medical treatment. A colonoscopy is negative. An abdominal CT is performed. It reveals well-circumscribed pelvic masses, the largest adherent to the ovarian ligament. The best first step is: a. Referral to a gynecological oncologist. b. Transcutaneous CT guided biopsy. c. Because it is unrelated to her symptoms advise observation. d. Refer to hospice because massive ovarian cancer is unlikely to be curable. e. Invite her to return with a family member and have a long talk about the diagnostic and therapeutic options.

e. Invite her to return with a family member and have a long talk about the diagnostic and therapeutic options.

Constipation in older adults may result from many factors. Which of the following is not considered a common contributing factor to constipation in older adults? a. Poor dietary intake of fiber b. Medications c. Immobility d. Dehydration e. Obesity

e. Obesity

An 80-year-old non-Hispanic White man was taking cyclooxygenase (COX)-2 inhibitors and heard on the news that it was bad for the heart. He was tolerating the medication, and his knee pain from osteoarthritis was well controlled. When he started having the pain 5 years ago, his primary care provider put him on the COX-2 inhibitor as a first option, and he has been taking the same medication since that time. He has a history of peptic ulcer disease and renal insufficiency. Which is the best option for this patient to try? a. Acetaminophen b. Traditional nonsteroidal antiinflammatory drugs (NSAIDs) with food c. Traditional NSAIDs plus 200 mcg of misoprostol d. COX-2 plus aspirin e. Topical NSAID and acetaminophen

e. Topical NSAID and acetaminophen