TIM3: Gero Case Questions

An 85-year-old woman has a history of hypertension controlled with medication. She is independent in instrumental activities of daily living and has no cognitive impairment. She went to the ED because of nausea, vomiting, and a recent increase in her abdominal girth. On examination, she was found to have a small-bowel obstruction, an adnexal mass, and omental adhesions consistent with stage IV ovarian cancer. The standard of care for stage IV ovarian cancer—chemotherapy followed by debulking surgery—has been shown to significantly extend patients' lives. The patient is willing to undergo chemotherapy if it is recommended. Which of the following is the most appropriate recommendation? A. Full-dose chemotherapy, then debulking surgery B. Immediate reduced-dose chemotherapy, then surgery C. Immediate reduced-dose chemotherapy without surgery D. Palliative surgery E. Enrollment in hospice

A. Full-dose chemotherapy, then debulking surgery

A 78-year-old man comes to the office because he has lost consciousness 3 times in the past month. History includes Parkinson disease and stable angina. Medications include aspirin and carbidopa-levodopa. Tilt table test is positive for autonomic dysfunction. Which of the following is the most appropriate treatment? A.Increase current dosage of carbidopa-levodopa. B. Initiate midodrine. C. Initiate prednisone. D. Discontinue aspirin; initiate clopidogrel.

B. Initiate midodrine.

A 75-year-old woman comes to the office for her 6-month follow-up visit. She lives independently and is independent in instrumental activities of daily living. She reports both a decline in her ability to walk long distances and difficulty crossing streets: the light changes before she can reach the opposite side. She has no numbness, tingling, or changes in sensation in her extremities. During the appointment, she at times uses the wall for support. Physical examination is otherwise unremarkable. What is the most appropriate next step? A. Refer to social work for long-term care options. B. Refer for an individualized, supervised exercise program. C. Refer to a neurologist. D. Obtain MRI of the head and spine. E. Obtain glucose, vitamin B12, and thyroid levels.

B. Refer for an individualized, supervised exercise program.

An 81-year-old woman comes to the office because of lower back pain for 2 weeks. The pain worsens when she sits or stands but is relieved when she lies in bed. History includes vertebral compression fracture 4 years ago and right femoral neck fracture 2 years ago. On physical examination, straight-leg raise tests are normal bilaterally. Strength of proximal and distal muscles is 5/5 in both legs. There is good mobility of the lumbar spine. The patient describes marked pain when pressure is applied to the sacrum. Radiography of the lumbar spine reveals diffuse osteoporosis and multilevel degenerative disc disease. Which of the following is the most likely cause of this patient's pain? A)Lumbar spinal stenosis B)Tumor affecting the lumbar spine C)Osteoporotic sacral fracture D)Lumbar disc disease E)Osteomyelitis of the L4 vertebrae

C)Osteoporotic sacral fracture

A 74-year-old woman comes to the clinic because she has difficulty falling and staying asleep. It takes her 1-2 hours to fall asleep, and she wakes up 2-4 times per night at least 4 nights per week. She describes a long history of intermittent insomnia, which has worsened over the past 3 months. She estimates that she sleeps ≤4 hours each night. History includes mild to moderate obstructive sleep apnea (apnea-hypopnea index of 15). She uses continuous positive-airway pressure (CPAP), but her inability to sleep interferes. She finds CPAP reasonably comfortable and does not think it contributes to her insomnia. Which of the following is most likely to improve her insomnia? A. Clonazepam B. Sertraline C. Cognitive-behavioral therapy D. Ramelteon

C. Cognitive-behavioral therapy

The 9-item Patient Health Questionnaire (PHQ‑9) and the Geriatric Depression Scale (GDS) are the screening tests for geriatric depression with the best validity to support their use in primary care practice. Which of the following statements is true? A. Both the GDS and the PHQ-9 are self-administered. B. Both the GDS and the PHQ-9 screen for suicidal thoughts. C. The PHQ-9 can be used to assess treatment efficacy. D. The GDS is more influenced by medical comorbidity than the PHQ-9. E. The GDS and PHQ-9 each requires >30 minutes to administer.

C. The PHQ-9 can be used to assess treatment efficacy.

An 81-year-old man comes to the office because he has had pain in his right calf for 6 months. Initially, he had pain after walking about one quarter mile, but now he has pain after walking 100 ft or with prolonged standing. The pain resolves completely when he sits. He has had no pain in his back or upper leg. On examination, dorsalis pedis and posterior tibial pulses are 2+ bilaterally. There is good hair growth on both lower legs. There is mild immobility of the lumbar spine. Straight-leg raise tests are normal bilaterally. He has mild weakness of the right great toe extensor, right hip abductor, and right hip extensor. Lumbar spine radiography shows diffuse degenerative disc changes throughout the lumbar region. Doppler ultrasonography indicates normal arterial blood flow. Which of the following treatments is most likely to be effective? A)Arterial bypass of the lower leg B)Angioplasty of lower leg vessels C)Epidural corticosteroid injections D)Laminectomy E)Physical therapy

E) Physical therapy

An 87-year-old white man comes to the office because he has had difficulty sleeping since the death of his best friend, who was with him in the army during World War II. He states bad memories about the war keep him awake at night. Hx includes chronic left leg pain (consequence of war injury), hypertension, hypercholesterolemia, and coronary artery bypass graft. Meds include ASA, simvastatin, and hydrochlorothiazide, and APAP prn. His wife died 10 years ago; he lives alone and is independent in ADLs. He attends a senior center daily for lunch, but he is considering taking a break because the people there "get on his nerves." The patient has a good relationship with his children and grandchildren. He is well groomed and pleasant. He admits to more frequent concerns about his health. He denies thoughts of suicide but at times thinks that he would be better off dead. He does not have a firearm. PE: he has lost 2.3 kg (5 lb) since his last visit 3 months ago. Cognition intact. Which of the following is the most appropriate treatment recommendation? A. No treatment is necessary because his symptoms are minimal. B. He requires hospitalization because he is expressing suicidal thoughts. C. His symptoms of irritability and poor sleep indicate the need for treatment of bipolar disorder. D. His comorbidities preclude treatment with antidepressants. E. Treatment with an SSRI should begin immediately.

E. Treatment with an SSRI should begin immediately.

Which of the following clinical tests is the best single predictor of institutionalization, disability, and morbidity in older adults?

Gait Speed

A 71-year-old man is diagnosed with stage 4 lung cancer. History includes oxygen-dependent COPD, 3-vessel CABG, stage III CHF, urge incontinence, and longstanding osteoarthritis. He has a 40 pack-year smoking history. He lives alone and has no relatives or close friends nearby. He is scheduled to begin chemotherapy shortly. After extensive conversation, during which hospice care is recommended, it is clear that the patient understands his limited prognosis. Nevertheless, he remains interested in pursuing chemotherapy. When should formal palliative care services be started for this patient?

Immediately

You are the new primary care physician for a 78 year-old-man with advanced Alzheimer's disease who lives in a nursing home. Other than his dementia, he is relatively healthy, and is able to participate in group activities. His nurse is very concerned about his chronic incontinence. She states that, since he has been admitted, he has chronically been wetting his diaper. She is concerned that she has noticed increasing breakdown in his perianal skin, and would like a treatment for his incontinence. What would be the initial best treatment for this patient? a. Pelvic muscle exercises b. Tolterodine (Detrol) c. An indwelling urinary catheter d. On a set schedule, encourage the patient to get up and void

On a set schedule, encourage the patient to get up and void (aka prompted Voiding)

An 85-year-old man with a history of benign prostatic hyperplasia and no history of prostate cancer or prostate procedures comes into your outpatient clinic complaining of chronic incontinence. He says that he is frustrated because he is nearly always wet, and doesn't notice when he is about to become incontinent. When he does go to the bathroom to void, he has difficulty initiating a urinary stream, and has some dribbling afterward. What type of incontinence does this patient most likely have?

Overflow incontinence

A 70-year-old otherwise healthy is seen in your clinic because of frequent episodes of incontinence. She says that these episodes happen without warning, usually in the context of coughing or sneezing and is worried it may start to interfere with her social life. Which of these interventions is the best initial step incontinence?

Pelvic muscle exercises

Pt on warfarin has been previously controlled but now has INR of 6.8 Which of the following medications would LEAST LIKELY to be contributing to his bleeding and altered INR? a. (Bactrim) b. Terazosin (Hytrin) c. Theophylline d. Amiodarone . e. Ginkgo biloba

Terazosin

An 87-year-old man comes into your clinic with his daughter. She is concerned about the fact that he has become increasingly forgetful over the last two years. He is widowed, and lives at home by himself. He is able to bathe, dress, and toilet himself. However, she has noticed that he has forgotten to pay several of his bills in the last several months, and sometimes takes a long time to come up with the names of his own children. Despite occasionally feeling lonely and missing his wife, he says he is in good spirits. Which of these would be most appropriate to start in this patient at this time? a) Sertraline (Zoloft) b) Donepazil (Aricept) c) Memantine (Namenda) - moderate to severe d) Quetiapine (Seroquel)

b) Donepazil (Aricept)

1. Which of the following symptoms is not a feature of delirium? a) Poor ability to concentrate on a specific question or task b) Inability to communicate verbally c) Acute onset often in relation to illness or injury d) Fluctuation in alertness or attention

b) Inability to communicate verbally

Which of the following it the most likely or common complication related to hospitalization? a. Transfusion reaction b. Adverse drug reaction c. Acquired infection d. Adverse event related to a diagnostic procedure

b. Adverse drug reaction

Which of the following is not a significant predictor of functional decline in a hospitalized elderly patient? a. Presence of delirium b. Marital status c. Advanced age d. Cognitive impairment

b. Marital status

Lab results also show an albumin of 2.5 mg/dl and a ferritin of 42 mg/dl. Her BMI is calculated to 17 kg/m2. In combination with her weight loss, there is high suspicion of malnutrition in this patient. Both blood and urine cultures return with growth of Escherichia coli and antibiotic therapy is initiated. Which of the following is not a predictor of malnutrition in this patient? a) Weight loss more than 10% in a 6-month period b) BMI below 21 kg/m2 c) Albumin less than 3.0 mg/dl d) The presence of dementia or depression- a. and b. e) All the above

c) Albumin less than 3.0 mg/dl

A 75-year-old man with a history of hypertension and coronary artery disease comes to your primary care clinic with his wife because of memory loss, visual hallucinations, and frequent agitation. On exam, she has a masked facies and some cogwheel rigidity. Which of the following is the most likely diagnosis? a) Alzheimer's disease b) Vascular dementia c) Dementia with Lewy bodies d) Pick's disease

c) Dementia with Lewy bodies

A 71-year-old man with a history of moderate Alzheimer's dementia is seen in a primary care office with his son with a chief complaint of "behavior problems". The patient lives with his son, who works as an attorney part-time. The son says he is frustrated because the caregiver he has recently received reports that he has been banging against doors and scratching the walls with his fingernails while she's in their home, which the patient rarely does when he is around. The patient is mobile and requires some assistance with most activities of daily living. His physical exam is only remarkable for a mini-mental exam of 17 out of 30. The son is looking for something that can "fix this problem". Which of these would be the best initial intervention? a) Quetiapine, 12.5 mg twice a day as needed for agitation b) Giving the caregiver a plan of activities to do with his father c) Donepezil, 5 mg a day d) Citalopram, 10 mg a day e) Firing the caregiver

c) Donepezil, 5 mg a day

74 yo w recurrent falls - hx of dementia, CHD, and CAD, HTN. PE reveals proximal muscle strength. Meds include Lisinopril, ASA, Metoprolol, Olanzapine, Simvastatin. Which of the following is NOT an evidenced-based intervention for decreasing her risk of falling? a) Discontinuing furosemide b) Balance and gait training exercises c) Initiating donepezil treatment d) A home safety visit to reduce hazards e) Discontinuing olanzapine

c) Initiating donepezil treatment

An 87-year-old woman is admitted for "nursing home placement" to the hospital. You are unable to contact the family for more information, but the ER note states she "lives alone." She appears disheveled with poor hygiene and has loose skin folds worrisome for significant weight loss. She is afebrile and no focal neurologic deficits are noted, but the patient exhibits blunted affect, lethargy, and poor memory. All of the following are appropriate for the initial diagnostic workup in this patient except: a) MiniCog b) PHQ 9 c) Lumbar puncture or CT scan of the brain d) Nutrition assessment (MNA) e) Complete blood count and comprehensive chemistry

c) Lumbar puncture or CT scan of the brain

The patient is found to be profoundly dehydrated with a sodium of 152 and a BUN: Creatinine ration of 40. She receives intravenous hydration and becomes more alert, but continues to eat less than 25% of her meals. She is also found to have profound depressive symptoms, as evidenced by the GDS, as well as anxiety symptoms. The decision to start an antidepressant is made. Which of the following antidepressants is least likely to contribute to anorexia in this patient? a) Nortriptyline b) Paroxetine c) Mirtazapine d) Sertraline e) Clonazepam

c) Mirtazapine

A 75-year-old man with diabetes and osteoarthritis is evaluated in your clinic for recurring falls. Which of the following is most predictive of future dependence in his activities of daily living? a) A T score on his bone density of -2.7 b) A greater than 20 point difference between sitting and standing systolic blood pressure c) Taking 23sec to rise from a chair, walk ten steps, turn around, and sit down in that same chair d) Impaired two-point discrimination in his lower extremities e) A mini-mental status exam score of 20 out of 30

c) Taking 23 seconds to rise from a chair, walk ten steps, turn around, and sit down in that same chair

Physiologic consequences of aging that contribute to functional decline while hospitalized include all of the following except: a. Baroreceptor insensitivity predisposing to syncope and falls b. Decreased visual acuity predisposing to delirium c. Decreased fat to lean body mass ratio causing reduced energy reserves d. Reduction in epidermal/dermal vascular supply increasing pressure ulcer risk

c. Decreased fat to lean body mass ratio causing (increased fat)

You are called because a 90-year-old nursing home patient of yours has been acting more confused over the past several days. Vital signs are normal and the patient has no signs or symptoms suggesting an infection, myocardial infarction, or dehydration. The possibility of her medications causing the increased confusion is raised. None of her medications are new and there have been no dosage changes within the past week. Which one of her following medications is the LEAST likely to be contributing to her increased confusion? a. Trazodone b. Phenytoin c. Diltiazem d. Clonazepam e. Naprosyn

c. Diltiazem

73-year-old woman with a history of pancreatic cancer comes into your clinic with a complaint of lower abdominal pain and bloating due to constipation x 4 days for the last few days. Her medications are: acetaminophen 650 mg three times daily, a 25 mcg fentanyl patch changed every 72 hours, and atorvastatin 10 mg daily. Which would you do first? a. Give docusate, 100 mg twice a day b. Give Miralax tablets, two twice daily c. Fleet enema d. Obtain a urine sample e. Give psyllium powder mixed with water, once a day

c. Fleet enema to start then Miralax for maintenance (NOTE: chronic opiate use Stimulants are best)

What's the first step in dealing with a patient with delirium? a) Modify the environment (diurnal lighting variation, sound reduction) b) Limit use of restraints c) Pharmacologic treatment d) Evaluation by history, exam and diagnostics

d) Evaluation by history, exam and diagnostics

Which of the following medications is least likely to precipitate delirium? a) Diphenhydramine b) Meperidine c) Propranolol (crosses BBB) d) Losartan

d) Losartan (remember: Propranolol crosses BBB)

Which diagnostic test is not appropriate for the routine initial evaluation of delirium? a) Complete blood count (CBC) b) Blood chemistry (Metabolic Panel) c) Random blood glucose (finger stick) d) Lumbar puncture (LP) CT scan of the brain.

d) Lumbar puncture (LP) CT scan of the brain.

A 67-year-old woman is seen in your office with a complaint of pain in her right leg. She had a laminectomy in her lumbar spine several months ago, and since then has had shooting pains in her leg which are generally worse at night. She would like you to prescribe a pain medication for her. Which would be the best initial choice in her case? a. Oxycodone 5 mg three times a day b. Ibuprofen 600 mg four times a day c. Tramadol 50 mg every six hours as needed d. Gabapentin (Neurontin) 100 mg QHS e. A lidocaine patch applied to the most painful area of the leg

d. Gabapentin (Neurontin) 100 mg QHS (neuropathic pain)

Pt taking pantoprazole, digoxin, clopidegrel, glyburide, simvastatin, and lisinopril. Which of the following actions would MOST LIKELY lead to a diagnosis and treatment of the patient's nausea and anorexia? a. Check hemoglobin and hematocrit, iron and TIBC, and increase Pantoprazole dose to b.i.d. b. Add metoclopramide and order a gastric motility study. c. Hold her simvastatin and order a liver panel and CPK d. Hold her digoxin and order a serum digoxin level e. Check her electrolytes and BUN and creatinine and order a renal ultrasound

d. Hold her digoxin and order a serum digoxin level

Pt fell getting out of shower - may have slipped on rug but doesn't remember. Taking Glipizide, Lisinopril, Amitryptiline, and APAP PRN. Which of these would you do first to decrease the risk of repeat falls? a) Recommend that the patient purchase hip protectors b) Start an exercise program directed by a physical therapist c) Convince the patient to redecorate her home for improved safety d) Lower her dose of Glipizide e) Change amitriptyline to another drug for neuropathy

e) Change amitriptyline to another drug for neuropathy (TCA - super anticholinergic - risk of syncope)