Health Promotion

At what age should hearing screening take place in older adults according to Assessing Care in Vulnerable Elders (ACOVE-2)?

60 years 65 years 70 years 75 years Assessing Care in Vulnerable Elders (ACOVE-2) authors recommend annual hearing screen for adults age 75 years and older as part of initial evaluation. If he fails hearing screening, he then should be offered formal audiologic evaluation within 3 months. In studies, screening annually resulted in greater adherence with using hearing assistive devices when hearing problems were identified.

Which finding below is considered "within normal limits"?

A diastolic murmur in an 18-year-old An INR of 2.0 in a patient taking warfarin Cholesterol level of 205 mg/dL in a 15-year-old Blood pressure of 160/70 mmHg in a 75-year-old An INR (International Normalized Ratio) is considered the best measure of clotting status in outpatients. Depending on the reason for anticoagulation, a common target is 2.0 - 3.0. Diastolic murmurs are always considered abnormal regardless of age. Cholesterol levels in adolescents should be less than 170 mg/dL (according to National Heart, Lung and Blood institute, NHLBI). Blood pressure of 160/75 mmHg constitutes isolated systolic hypertension, so this is abnormal.

Which pharmacokinetic factor is influenced by a decrease in liver mass in an older adult?

Absorption Distribution Metabolism Elimination As the liver decreases in mass and potentially has a decrease in blood flow, drug metabolism is decreased. Consequently, lower doses of medications in older adults may be as efficacious as higher doses in their younger counterparts. Production of enzymes in the cytochrome P450 system may be decreased, which further impacts metabolism.

In older adult females, which screening test has demonstrated greatest reduction in mortality from cancer?

Breast Cancer screening Cervical Cancer screening Ovarian cancer screening Lung cancer screeing There are no recommendations for screening for ovarian or lung cancer in older women. Cervical cancer is primarily a disease found in younger women. When it is identified in older adults, there is usually a higher mortality rate than in younger women. However, the incidence of cervical cancer is much lower in older adults. Screening for breast cancer has demonstrated the highest reduction in mortality. Mammography should be performed every 1-2 years, according to the American Geriatrics Society.

A patient is 86 years old and functions independently. He has hypertension, hyperlipidemia, BPH, and flare-ups of gout. His last colonoscopy was at age 76 years. What should he be advised about having a colonoscopy?

Colonoscopy is the preferred method for screening in older adults Colonoscopy is ill advised in older adults It is not advised in this patient at this time Screening is not necessary after age 80 years Prior to any screening test such as colonoscopy, consideration must be given to the patient's overall health status, colorectal cancer risk, and desire to pursue treatment if cancer or disease is diagnosed. The United States Preventive Services Task Force, American College of Physicians, and American College of Gastroenterology do not recommend screening an 86-year-old for colorectal cancer. As a general rule, patients with a life expectancy of less than 5-10 years should forego colorectal cancer screening via colonoscopy. Colonoscopy enables the examiner to visualize the entire colon and is a superior screening tool for colorectal cancer, but there are significant risks of bleeding and perforation in older adults. Additionally, the colon prep can produce massive shifts in electrolytes that can increase the likelihood of arrhythmias, heart failure, weakness, and falls.

A patient who has been treated for hypothyroidism presents for her annual exam. Her TSH is 4.1 (normal = 0.4- 3.8). She feels well. How should she be managed?

Continue her current dosage of thyroid replacement. Increase her replacement. Decrease her replacement. Repeat the TSH in 2-3 weeks. When an abnormal TSH is received, especially when a patient is not symptomatic, it should be repeated. Sometimes there are periods of transient hypothyroidism, lab error, and missed doses that can cause changes in TSH levels.

What should the nurse practitioner recommend to any elder taking medications?

Have someone check your medications prior to taking them Never take your medicine on an empty stomach Keep a list of all of your medications with you. Have a pharmacist review your list once a year A list of current medications should be kept with each patient and carried with him, especially when healthcare visits are scheduled. Many older adults can take medications without supervision. Many medications should be taken without food (thyroid supplementation for example). A pharmacist can evaluate the list of medications for drug-drug interactions, but the pharmacist will not know the diagnoses and other reasons for choosing the medications.

A patient who wrote a living will has changed his mind about the initiation of life-sustaining measures. Which statement is true about this?

He cannot change his mind regarding the content of the living will. He can only change the content if he is of sound mind. A healthcare provider is exempt from liability if they provide care outside the living will. An attorney must be consulted if the living will is changed at any time. A living will is intended to allow a patient to provide instructions for his family and healthcare providers about how he would like his care directed if he is unable to make these decisions. He can change the content at any time. If, however, he is determined not to be of sound mind, any changes that he attempts to make should not be followed. A healthcare provider is bound to carry out the living will, provided it does not violate any laws or the ethics of the provider. In this case, the provider would be exempt from liability for not carrying these out. In the case of an ethical dilemma, the healthcare provider should identify another healthcare provider who is willing to carry them out. An attorney is not required to be consulted to change the content of a living will.

What is true regarding the shingles vaccine given to adults at or after age 50?

It is a weakened form of the chickenpox virus. It is the same as the chickenpox virus. It contains significantly more virus than the chickenpox vaccine. It is not related to the chickenpox immunization at all. The shingles (Herpes zoster) vaccine contains 14 times the number of plaque-forming units of virus than the varicella vaccine. The immunization has reduced the incidence of shingles and postherpetic neuralgia in adults who received it. The vaccine is recommended by CDC for all immunocompetent adults who are 60 years or older. It is given once. The FDA has approved use of this vaccine at age 50 years. The vaccine is only used to prevent shingles. It is not used to treat shingles or postherpetic neuralgia.

Which recommendation below reflects CDC's recommendation for administration of the zoster vaccine?

It should be given to immunocompetent adults age 60 and older. It should be given to immunocompetent adults age 65 and older. It can be given regardless of immune status at age 50. It can be given regardless of immune status at age 60. CDC's recommendation for the zoster vaccine is for administration in immunocompetent adults aged 60 years and older. The zoster vaccine is currently FDA approved for use in immunocompetent adults age 50 or older. It should never be used to treat shingles.

What temperature should be set on a water heater in the home of an older adult to prevent burn injury?

Less than 110 degrees Less than 120 degrees Less than 130 degrees Less than 140 degrees Hot water heaters are common sources of burns in homes of older adults and very young patients. Many safety organizations in the United States believe that burns can be prevented if hot water heaters are set to less than 120° F.

The incidence of osteoporosis in older adults is high. Which characteristics below would increase the risk of osteoporosis in an older adult male patient?

Low body weight, age 60 years Smoker, age 65 years Chronic glucocorticoid therapy, age 70 years Family history of hypothyroidism, age 65 years Women should be screened for osteoporosis starting at age 65 years, and sooner if risk factors are present. Males older than 65 years should be screened with DEXA scanning if they exhibit risk factors. Risk factors with the greatest impact on bone density include primary hyperparathyroidism, chronic glucocorticoid therapy and hypogonadism.

A 76-year-old patient who is very active has elevated cholesterol and LDLs. He had been treated for hypertension for > 10 years with near normal blood pressures. What is the current recommendation for managing his lipids?

No treatment should take place since his age exceeds 75 years. He should be treated with an aspirin only. He should be treated with a statin. The benefits of treating this patient do not exceed the risk of using a statin or aspirin. Numerous studies (PROSPER, 2006) and learned authorities (including the USPSTF) have found that lipid-lowering drug therapy decreases the incidence of coronary heart disease and vascular events in middle-aged and older adults. The current recommendation is to screen and treat lipid abnormalities in patients who are at risk for a cardiac event. It is unclear whether treatment of middle-aged and older adults at low risk for cardiac events is beneficial.

A 58-year-old patient has an annual exam. A fecal occult blood test was used to screen for colon cancer. Three were ordered on separate days. The first test was positive; the last two were negative. How should the nurse practitioner proceed?

Rescreen in one year. Perform a fourth exam. Examine him for hemorrhoids. Refer him for a colonoscopy. A fecal occult blood test is performed multiple times on different days because tumors don't consistently excrete blood. The reason multiple tests are performed is to increase the likelihood of identifying blood. The patient needs to have a colonoscopy performed for examination of the colon. The standard of practice is to refer all positive colon cancer screens for colonoscopy.

A 75-year-old adult asks for the pneumonia vaccine. His immunization record indicates that he had one at age 65 and another a year later. What is the recommendation of the CDC about how the NP should handle his request?

Revaccination is recommended now Revaccination is recommended every 5 years after age 65 years Do not revaccinate this patient at this time He should have received one at age 70 years The recommendation of CDC is NOT to revaccinate this patient. After initial vaccination with PCV13 at age 65 years and subsequent vaccination with PPSV23 1 year later, no revaccination is recommended in this patient.

What choice below would be beneficial to a 76-year-old who takes daily oral steroids for COPD and now takes a daily aspirin for primary prevention of myocardial infarction?

Screen for infection with H. pylori Daily proton pump inhibitor (PPI) Antacids PRN heartburn Daily use of low dose famotidine Aspirin does increase the risk of gastrointestinal bleeding, especially if it is given in combination with oral steroids. Most learned authorities and ACOVE (Assessing Care of Vulnerable Elders) agree that when two or more risk factors for GI bleed are present, aspirin should not be added without some form of protection for the GI tract (misoprostol or a daily PPI). In considering all the risks for GI bleed, the most significant ones are age > 75 years, history of GI bleeding, warfarin use, daily NSAID use, and chronic steroid use.

A 67-year-old patient presents an immunization record that reflects having received the PCV13 immunization when she was 65 years old. She received the PPSV23 immunization one year later. Which statement below reflects the current standard of practice recommended by ACIP and CDC for this patient?

She should be revaccinated today. She should receive the immunization every 5 years. She can elect to receive it today if she has COPD. She does not need the immunization. The recommendation by ACIP and CDC is as this patient has received it, the PCV13 at age 65 and PPSV23 1 year later. Routine revaccination is not recommended for this patient because she has met the standard by ACIP and CDC. It should not be routinely given every 5 years.

A 74-year-old who retired as a store clerk last year would like to start an exercise program. She tells the nurse practitioner that she would like to start walking 15-20 minutes daily. Which statement is correct regarding the patient?

She should have a stress test prior to initiating a walking program. She should have an EKG performed in the clinic today. She does not need any testing because she is asymptomatic. She should have labs and EKG performed prior to starting. The obvious risk of starting a new exercise program is the risk of cardiac events. Evidence does not support routine EKG or cardiac testing in patients who are asymptomatic. She should be told about symptoms to watch for and to stop immediately if chest pain or shortness of breath develops. A 74-year-old who retired last year will benefit from any type of exercise. She will develop improved conditioning, reduce her risk of many chronic diseases including cardiovascular disease, reduce the risk of falls, and decrease functional limitations. Exercises for older adults fall into four categories: aerobic, muscle strengthening, flexibility, and balance

A 20-year-old student has an MMR titer that demonstrates an unprotective titer for rubella. She is HIV positive. Her CD4 cell count is unknown. Which statement is true?

She should not receive the MMR immunization because she is at low risk for the disease. MMR is safe to give but she does not need this. She is at risk for MMR but should not be immunized. She should receive this. The immunization is not alive. This patient is at risk for rubella because she does not have a sufficient titer. The MMR immunization is an attenuated virus. Though an attenuated immunization is weakened, it is still considered live and so is contraindicated in anyone who may be immunocompromised. Since her CD4 cell count is unknown, she should not receive this immunization yet. She may be able to receive this immunization if her CD4 count is normal.

An older adult has osteopenia. Her healthcare provider has recommended calcium 500 mg three times daily. What is the most common side effect of calcium supplementation?

Stomach upset Diarrhea Constipation Mild nausea initially Constipation is the most common side effect of calcium supplementation. To improve tolerance, the nurse practitioner can suggest 500 mg daily for a week, then 500 mg twice daily for a week, then three times daily. The patient should be encouraged to increase the intake of fruits, vegetables, fluid, and fiber. Weightbearing exercise and vitamin D intake should be encouraged to improve bone density.

What is the recommendation for daily multivitamin supplementation in older adults?

Supplementation reduces morbidity. Supplementation reduces mortality. It decreases the relative risk of dementia. It has no proven benefit. No studies have demonstrated specific benefits to daily consumption of multivitamins in older adults. However, a daily multivitamin supplement ensures adequate intake of essential vitamins and so should be considered for older adults.

A patient who is 62 years old asks if she can get the shingles vaccine. She has never had shingles but states that she wants to make sure she doesn't get it. What should the nurse practitioner advise?

The immunization will protect you from acquiring shingles. You are not old enough to receive the immunization. The immunization is offered only to those who have had shingles. You are eligible to receive it but you still may get shingles. Patients must be at least 50 years old to receive the shingles immunization. It is generally well tolerated but provides protection from shingles in 50-64% of patients. The incidence of postherpetic neuralgia is decreased up to 65% after immunization. The patient still may develop shingles after receiving the immunization. The vaccine may be offered regardless of whether the patient has history of shingles. However, since it is a live vaccine, it may be contraindicated because of steroid use or immune status.

What is the most common nutrition syndrome in older adults?

Undernutrition Over nutrition Malnourishment Vitamin B12 deficiency Some older adults have great challenges associated with eating and maintaining weight. They may be edentulous or have anorexia. Weight loss is associated with greater mortality in older adults than in patients who have not had recent weight loss. Clinically significant weight loss is usually considered to be about 4-5% of total body weight within 6-12 months. In older patients who do lose weight, they are less likely than younger adults to gain it back. This also increases risk of mortality.

An octogenarian asks the nurse practitioner if it is OK for him to have an alcoholic beverage in the evenings. There is no obvious contraindication. How should the nurse practitioner respond?

Yes, but not more that 4 days per week. Yes, but not more than 1-2 drinks per day. No, you will increase your risk of falling and injury. It depends on the type of alcohol you would like to consume. A good rule of thumb for alcohol consumption in older adults is no more than one to two drinks/day after age 65 years. If the patient is cognitively impaired, abstinence is recommended. The type of alcohol is not of great importance. Beer, wine, and hard liquor all contain alcohol, which has the potential to impair older adults. The reason alcohol should be limited or avoided is because of decreased lean body mass and decreased total body water in aging bodies.

An oral antifungal agent is commonly used to treat tinea unguium. The difficulty in treating an older adult with this is infection is:

absorption of the medication. applying the medication twice daily. tolerability of the medication. relative ineffectiveness of oral agents. The most efficacious agents used to treat toenail fungus are oral antifungal agents. They must be taken daily for 8-16 weeks (or longer) for adequate length of treatment. Additionally, the real difficulty lies in the ability of the older adult's liver to handle this medication. Oral antifungal agents require great amounts of the liver's resources for metabolism. A topical agent or toenail removal may be a better choice for an older adult.

A 13-year-old male has exhibited the first sign that he is experiencing sexual maturation. He has:

an increase in testicular size. an enlargement of the scrotum. an increase in length of the penis. scrotal and penile changes. A male with Tanner Stage II development will have an increase in testicular volume from 1.5 mL or less, to up to 6 mL. The skin on the scrotum will begin to thin, redden, and enlarge. The penile length will remain the same. Males begin sexual maturity later than females. In the United States, males begin sexual maturation about 2 years later than females. Maturity begins in girls about 9-12 years.

Two common causes of weight loss in older adults are:

anorexia and depression. depression and malignancy. malignancy and social isolation. financial limitations and hyperthyroidism. Malignancy is the most common cause of weight loss in the older adults. Depression is the second most common reason. Another reason that contributes to weight loss is social isolation. Many elders live alone and consequently eat alone. Many older adults have financial and mobility limitations that make eating and acquiring foods more difficult. Anorexia is not unusual in older adults, but there are a number of reasons for this. Some are physical, social, and psychosocial.

A criterion for medication choice in an older adult is:

long half-life to prevent frequent dosing. dosing of 3-4 times daily. pill color and shape for easy identification. half-life less than 24 hours. Many factors go into prescribing for older adults. Some important safety criteria include established efficacy, low adverse event profile, and half-life less than 24 hours with no active metabolites. Active metabolites would produce a longer effect of the drug in the patient. Dosing of a medication three to four times daily invites dosing and medication errors. Once- or twice-daily dosing is ideal. Pill color and shape is never a criterion for prescribing. Patients who are cognitively able will recognize the color, shape, and size of pills they take on a regular basis.

Screening for abdominal aortic aneurysm should take place:

once for all males aged 65-75 who have ever smoked. once for all men and women who have hypertension. annually after age 75 years for males and females. only if the patient has smoked and has hypertension. The prevalence of abdominal aortic aneurysm (AAA) is greater in men than women. American Heart Association and USPSTF recommend screening males once between the ages of 65-75 years if they have ever smoked. Smoking increases the risk of AAA. The USPSTF does not recommend routinely screening for AAA in women or screening for AAA in men who have never smoked. Screening may be considered in men aged 65-75 years if they have a first-degree relative who required repair of AAA.

A mammogram in a healthy 50-year-old female patient is an example of:

primary prevention. secondary prevention. tertiary prevention. quaternary prevention. This is an example of secondary prevention. Secondary prevention is represented by screenings intended to identify early course of a disease. In this example, a mammogram is intended to identify early breast cancer.

What is the recommendation from American Cancer Society for assessment of the prostate gland in a man who is 45 years old and of average risk for development of prostate cancer? He should have:

screening starting at 50 years of age. prostate-specific antigen (PSA) now. PSA and digital rectal exam now. digital rectal exam only. At age 50 years, males of average prostate cancer risk should have a PSA measurement with or without a digital rectal exam (DRE). If they are deemed to be of high risk because of a family history (first-degree relative with prostate cancer before age 65 years) or race (African American), screening discussions should take place at age 40-45 years. If the initial PSA is > 2.5 ng/mL, annual testing should take place. If the initial PSA is < 2.5 ng/mL, test every 2 years.