Transcript 1 - RCRMC Family Medicine Residency

VULNERABLE ELDERLY
A 70-year-old right-hand–dominant male has had a tremor in his right
hand for 5 years. It is now getting worse, and he is also developing a
tremor in his left hand. He says his walking speed has become slower,
and his wife thinks he is becoming more forgetful. There is no family
history of similar problems.
On examination his facial expressions seem diminished. He has a
resting tremor in both hands, but it is more prominent on the right. He
has a slightly stooped posture and you note a decreased arm swing
when he walks. There is some resistance when his arms are passively
flexed and extended at the elbows. His Mini-Mental State Examination
score is 27 out of 30.
Appropriate treatment at this time would include which of the following?
(Mark all that are true.)
A. Carbidopa/levodopa (Sinemet)
B. Donepezil (Aricept)
C.Pramipexole (Mirapex)
D. Primidone (Mysoline)
E. Propranolol (Inderal)
Answer
• A. Carbidopa/levodopa (Sinemet)
C.Pramipexole (Mirapex)
Parkinson’s disease is a progressive neurodegenerative disorder with an estimated
prevalence of 0.3% in the U.S. population. The cardinal signs and symptoms are
bradykinesia (patients may describe this as weakness), resting tremor, and rigidity. Postural
instability is considered by some to be the fourth cardinal sign. Essential tremor is generally
a bilateral action tremor, and there are usually no extrapyramidal symptoms. An essential
tremor may involve the head.
Treatment for Parkinson’s disease includes levodopa, dopamine agonists, catechol Omethyltransferase (COMT) inhibitors such as tolcapone, MAO inhibitors, NMDA-receptor
inhibitors such as amantadine, and surgery. Memantine has been shown in some studies to
be effective in early Parkinson’s disease (SOR B).
Carbidopa/levodopa has been the primary treatment for Parkinson’s disease with motor
symptoms. It is effective for controlling bradykinesia and rigidity. When combined with
levodopa, carbidopa increases cerebral levodopa bioavailability and decreases the peripheral
side effects of dopamine, such as nausea and hypotension (SOR A). Dopamine agonists
directly stimulate dopamine receptors and include bromocriptine, pergolide, pramipexole,
and ropinirole. Double-blind controlled studies comparing dopamine agonists with levodopa
have shown that levodopa is more effective at reducing symptom scores than dopamine
agonists, but causes more motor complications (SOR A). Levodopa/carbidopa is also
significantly less expensive. Primidone and propranolol can be used to treat essential tremor,
but not Parkinson’s disease (SOR A).
Dementia may occur, and the cholinesterase inhibitors donepezil and rivastigmine have
shown modest efficacy in treating dementia associated with Parkinson’s disease. This
patient’s mental status score is in the normal range so there is no need to treat with a
cholinesterase inhibitor at this time (SOR B).
2. A 75-year-old male with a history of stable angina
pectoris is found to
have persistently elevated blood pressure on three
visits over a
2-month period. There is no evidence of
renovascular hypertension on
physical examination or laboratory testing.
Which of the following would be appropriate at this
point? (Mark all that
are true.)
A Evaluation for excessive alcohol use
B Counseling about NSAID use
C Treatment with a Beta blocker
D Treatment with an ACE inhibitor
E Treatment with a diuretic
F Treatment with a calcium channel blocker
Answer
• A Evaluation for excessive alcohol use
B Counseling about NSAID use
C Treatment with a beta blocker
D Treatment with an ACE inhibitor
E Treatment with a diuretic
Randomized, controlled trials (RCTs) have shown
that consumption of more than two alcoholic
drinks/day is associated with elevated blood pressure
in elderly persons (SOR A). Multiple RCTs have
shown that blood pressure is increased in patients
using NSAIDs (SOR A). RCTs have also shown
improved survival in hypertensive patients treated
with β-blockers or diuretics (SOR A). ACE
inhibitors and angiotensin receptor blockers have
been shown in multiple RCTs to improve outcomes,
if tolerated. JNC-7 does not list calcium channel
blockers as first-line agents for hypertension (SOR
A).
An 81-year-old male with New York Heart Association Class II heart
failure complains of nocturia. He says he usually has to get up once during
the night, and has also noticed mild hesitancy and an occasional decrease
in the force of his urinary stream. He has not noted urinary frequency or
dysuria, and does not feel the urge to void again shortly after urinating. He
also denies hematuria. His American Urologic Association symptom score
is 5.
On examination there is no bladder distention, and he has a symmetrically
enlarged, nontender prostate. Results of his urinalysis are normal.
Which one of the following would be most appropriate at this time?
A. Observation only
B.A prostate-specific antigen (PSA) level
Prostate ultrasonography
An α-blocker such as tamsulosin (Flomax)
Urologic referral
Answer
• A. Observation only
This patient has a life expectancy of less than
10 years, so the potential harm from testing
for prostate cancer outweighs the potential
benefits (SOR C). The best management plan
is to continue to observe and to take no further
action unless the benefit clearly is greater than
the potential for harm.
If the patient had signs or symptoms of
bladder stones, urinary retention, urinary tract
infection, or renal failure, ultrasonography
would be appropriate. An α-blocker would not
be appropriate because of the potential side
effects of the treatment.
An 82-year-old male has diabetes mellitus, heart failure,
hypertension, and benign prostatic hyperplasia. His wife is 79
years old and has COPD, osteoarthritis, osteoporosis, and
mild cognitive impairment. Their combined medication
expenses are $5100 per year, and both are enrolled in a
Medicare Part D plan.
In order for them to qualify for the low-income subsidy under
the federal rules for Medicare Part D, which of the following
must be true? (Mark all that are true).
Both must qualify for Medicare Part A
Both must be enrolled in a Medicare Part D planBoth must be
eligible for both Medicare and Medicaid
At least one must be disabled
Their income level must fall below 150% of the federal
poverty level for a couple
Answer
• Both must qualify for Medicare Part A
• Both must be enrolled in a Medicare Part D
plan
• Their income level must fall below 150% of
the federal poverty level for a couple
Many older Americans who qualify for the low-income
subsidy to Medicare Part D do not know it. Those who
qualify have a reduced deductible ($50 instead of $250) and a
markedly reduced co-pay (15% instead of 100%) for
expenses incurred in the coverage gap ($2250–$5100).
In order for a married couple to qualify, both must qualify for
Medicare Part A, both must be enrolled in a Part D plan, and
their income must fall below 150% of the federal poverty
level for a couple. The Social Security Administration also
looks at other resources to determine eligibility, including real
property. Medicaid recipients are automatically deemed
eligible, and are not required to file an application. It is not
necessary for recipients to be eligible for Medicaid, however,
or to be disabled. A social worker is often helpful in the
application process.
An 83-year-old female nursing-home resident with
moderate Alzheimer’s disease is having increasingly
frequent frightening visual hallucinations at night,
despite the nursing home staff’s efforts to create a
comfortable routine.
Reasonable first-line nightly medications would
include which of the following? (Mark all that are
true.)Buspirone (BuSpar)Carbamazepine
(Tegretol)Lorazepam (Ativan)Olanzapine
(Zyprexa)Risperidone (Risperdal)
Answer
• Olanzapine (Zyprexa
• Risperidone (Risperdal)
Atypical antipsychotics such as olanzapine and
risperidone are the first-line drug of choice for
managing psychotic symptoms of dementia (SOR
A). The range of doses tolerated by demented
patients is narrow, however, and the FDA has issued
an alert for all drugs in this class noting that
mortality is increased in patients taking these drugs,
mostly from cardiovascular or infectious causes.
There have been no trials of buspirone for this
problem, and it is not recommended (SOR C). Side
effects limit the use of carbamazepine to second-line
therapy when antipsychotics fail (SOR B).
Lorazepam is recommended only for acute agitation
(SOR C).
A 73-year-old white male presents with palpable,
slightly scaly areas on his face and the back of his
hands. They are asymptomatic, except for being
occasionally itchy. He isn’t worried about them, but
his wife is.
Appropriate management options include which of
the following? (Mark all that are true.)
Observation only
Cryosurgery
Curettage
Topical fluorouracil (Carac, Efudex)
Topical imiquimod (Aldara)
Topical diclofenac (Solaraze)
Answer
• Cryosurgery
Curettage
Topical fluorouracil (Carac, Efudex)
Topical imiquimod (Aldara)
Topical diclofenac (Solaraze)
This patient has multiple actinic keratoses
(AK), which should be treated because they
can progress to squamous cell carcinoma.
Cryosurgery is effective for multiple AK, and
curettage is effective for patients with a
limited number of AK (SOR C). Topical
treatment with 5-fluorouracil, imiquimod 5%,
or diclofenac 3% gel should be considered for
patients with multiple lesions (SOR C).
Chemical peels are also effective, and may be
preferred because of the convenience of a
single application (SOR C).
An 80-year-old female complains of generalized weakness
and increasing difficulty carrying groceries and walking up
stairs. She has been widowed for 3 years, and has been
sedentary since the death of her husband. Her only medical
problems are osteoarthritis and hypertension controlled with
medication. She has no history of heart disease.
Which of the following would be appropriate components of
an exercise prescription for this patient? (Mark all that are
true.)Stress testing prior to exerciseWalking for a total of 30
minutes/day, 5 days a weekBalancing on one leg while
holding on to the counterStrength training using 1- to 2-lb
weights or soup cans, performing 10 repetitions 2–3 times per
weekAquatic exercises
Answer
• Walking for a total of 30 minutes/day,
• 5 days a weekBalancing on one leg while
holding on to the counter
• Strength training using 1- to 2-lb weights or
soup cans,
• performing 10 repetitions 2–3 times per
weekAquatic exercises
Regular exercise is associated with a decrease in all-cause morality and morbidity in middle-aged and
older adults. Studies have shown that modest increases in life expectancy are possible even in patients
who do not begin regular exercise until age 75. For elderly patients, the exercise prescription should
include a combination of aerobic exercise, resistance exercise, and balance/flexibility training.
The American College of Sports Medicine recommends exercise stress testing for all minimally active
older adults who plan to begin exercising at a vigorous intensity. Most elderly patients, however, can
safely begin a moderate aerobic and resistance training program without stress testing if they begin slowly
and gradually increase their level of activity (SOR C).
Aerobic exercise should consist of at least 30 minutes of moderate aerobic activity for most days of the
week (SOR A). This can consist of walking briskly, leisurely cycling, or other activities such as mowing
the lawn with a power mower, golfing using a pull cart, or swimming with moderate effort. The exercise
can be broken into shorter periods of at least 10 minutes.
Muscle strength declines by 15% per decade after age 50, and 30% per decade after age 70. Resistance
training can result in strength gains of 25%–100% or more in older adults. Equipment need not be
expensive, and the exercise can even consist of rising from a chair. Strength gains require that the effort
be significant enough that the patient becomes fatigued after 10–15 repetitions per set (SOR A).
Empiric evidence suggests that balance programs can improve stability and decrease the risk of falls (SOR
B). Before beginning aerobic exercise, deconditioned and sedentary elderly patients should be encouraged
to improve their functional ability with strength and balance training. This will reduce the risk of falling
while performing aerobic exercise.
Half of older adults cite musculoskeletal discomfort as the reason for not exercising. Exercising at a lower
intensity and using a range of exercises can help prevent discomfort. Aquatic exercises limit weightbearing, which can be helpful for patients with arthritis (SOR A).
A 78-year-old male with a previous history of
hypertension and chronic atrial fibrillation has a
transient ischemic attack (TIA). True statements
regarding anticoagulation and antiplatelet therapy in
this patient include which of the following? (Mark
all that are true.)
Treatment with warfarin (Coumadin) will reduce his
risk of recurrent stroke
Aspirin will be as effective as warfarin for reducing
his risk of stroke
The combination of aspirin and clopidogrel (Plavix)
is better than aspirin alone in reducing his risk of
stroke in this patient
Aspirin should be prescribed if there is a
contraindication to anticoagulation
The target INR in this patient is 2.0–3.0
Answer
• Treatment with warfarin (Coumadin) will
reduce his risk of recurrent stroke
• Aspirin should be prescribed if there is a
contraindication to anticoagulation
• The target INR in this patient is 2.0–3.0
Meta-analyses of randomized, controlled trials (RCTs) have shown that
anticoagulants reduce the risk of stroke in patients at high risk of stroke
who have atrial fibrillation (SOR A). Findings associated with a high risk
of stroke include a history of previous stroke, TIA, or embolic event; a
previous history of hypertension; poor left ventricular function; age >75;
rheumatic heart valve disease; and a prosthetic heart valve. In persons
without atrial fibrillation, anticoagulation with warfarin has not been
shown to be more effective than aspirin therapy for secondary stroke
prevention.
Aspirin can be used in patients who have contraindications to
anticoagulation, but it is not as effective (SOR A). An RCT has shown
that the combination of aspirin and clopidogrel insignificantly reduces the
risk of secondary stroke compared to aspirin alone, but significantly
increases the risk of life-threatening bleeding (SOR A). A 2002 metaanalysis of 21 RCTs for antiplatelet therapy in secondary stroke
prevention found that antiplatelet therapy reduces the risk of vascular
events (17.8% vs 21.4%, RRR 135, P <.001). No differences in outcomes
between different doses of aspirin were detected (SOR A).
Several RCTs and observational studies suggest that an INR below 2.0 is
not effective for stroke prevention and that an INR above 3.0
You are evaluating an 80-year-old female who has a
history of recurrent falls in recent months. Her
medical problems include hypertension, depression,
chronic atrial fibrillation, heart failure, and insomnia.
Her medications include sertraline (Zoloft),
alprazolam (Xanax) as needed for sleep, digoxin,
lisinopril (Prinivil, Zestril), and warfarin
(Coumadin).
Which of her medications may be contributing to her
falls? (Mark all that are true.)
Benzodiazepines
Digoxin
Lisinopril
Sertraline
Warfarin
Answer
• Benzodiazepines
Digoxin
Sertraline
A meta-analysis of 29 trials (none were randomized,
controlled studies) found a significant relationship between
the risk of falls and the use of type IA antiarrhythmic agents,
digoxin, and diuretics. There was no increased fall risk
associated with ACE inhibitors, calcium channel blockers, βblockers, centrally acting antihypertensive agents, or nitrates
(SOR B).
Studies have shown an increased risk of falling associated
with the use of either short-acting or long-acting
benzodiazepines (SOR A). One study done in a nursing-home
population showed a 44% increased rate of falls in people
currently using benzodiazepines. The rate of falls increased
with longer elimination half-lives. A prospective, multicenter
cohort study in community-dwelling women 65 years of age
or older showed that the use of either short-acting or longacting benzodiazepines was associated with frequent falls
compared with the rate for those not taking these drugs.
An 80-year-old male consults you because he has
become constipated. A routine screening was
negative 8 months ago. He admits that he has been
less active in the last month because of pain in his
knees. He also has been using an over-the-counter
antihistamine for “hay fever” symptoms.
Appropriate initial measures include which of the
following? (Mark all that are true.)
Increased intake of fluid and dietary fiber
Increased physical activity
Bulking agents (e.g., Metamucil)
Polyethylene glycol (MiraLax)
Low-dose stimulant laxatives
Answer
• Increased intake of fluid and dietary fiber
• Increased physical activity
Fluid softens stool and counterbalances the
effects of many medications that tend to dry
the stool. Fiber also softens stool consistency
by adding bulk (SOR C). Increased physical
activity stimulates bowel motility, decreasing
constipation (SOR B). Bulking agents should
not be used until nonmedical therapy (SOR B)
has been tried. Polyethylene glycol may cause
electrolyte disturbances and cramping, and
should not be used unless dietary changes and
increased physical activity fail to resolve the
problem (SOR B). Stimulant laxatives may
also produce cramping and electrolyte
disturbances (SOR B).
True statements regarding cataracts include which
of the following? (Mark all that are true.)
Family physicians should perform funduscopy,
visual acuity testing, and pinhole testing on all
patients suspected of having cataracts
Referral to an ophthalmologist is not necessary for
patients with suspected cataracts if their visual acuity
is 20/40 or better
Otherwise healthy older adult patients scheduled for
cataract surgery under local anesthesia do not require
routine preoperative medical evaluation
Outpatient surgery is recommended for cataract
extraction
Answer
• Family physicians should perform
funduscopy, visual acuity testing, and
pinhole testing on all patients suspected of
having cataracts
• Otherwise healthy older adult patients
scheduled for cataract surgery under local
anesthesia do not require routine
preoperative medical evaluation
• Outpatient surgery is recommended for
cataract extraction
Funduscopy, visual acuity testing, and pinhole
testing should be performed on all patients suspected
of having cataracts, to determine the severity of
visual impairment (SOR B). In patients with
cataracts whose visual acuity is relatively preserved,
glare sensitivity may adversely effect function, and
must be tested by an ophthalmologist (SOR C).
Local anesthesia for this brief procedure carries
minimal risk in healthy older adults (SOR A). There
is no benefit from inpatient stays after uncomplicated
cataract extraction, and there is a possibility for harm
(SOR B).
A 78-year-old female presents with diffuse abdominal pain,
abdominal distention, diminished bowel sounds, and nausea
with occasional vomiting. Her medical history includes type 2
diabetes mellitus, and well-controlled hypertension. She has a
previous history of right upper-quadrant colicky pain, but no
history of previous abdominal surgery.
A CBC reveals a hematocrit of 38.0% (N 36.0–46.0) and a
WBC count of 11,000/mm3(N 4300–10,800). Serum
electrolytes, amylase, and lipase are within normal limits. A
urinalysis is normal. Plain films of the abdomen show small
bowel obstruction, air in the biliary tract, and a calculus.
The most likely diagnosis is
diverticulitis
acute cholecystitis
gallstone ileus a
cute pancreatitis
Answer
• gallstone ileus
This patient has the classic triad of gallstone ileus on
the plain abdominal film. This condition occurs in
patients with a past history of gallbladder disease,
and is more common in females (SOR C).
Diverticulitis pain is usually more localized and is
not associated with calculous disease or with air in
the biliary tract (SOR C). Air in the biliary tract is
not found in cholecystitis, and unrelenting rightsided pain is more common than colicky pain (SOR
C). The pain of acute pancreatitis often radiates to
the back and is associated with elevated amylase
and, more specifically, lipase (SOR C)
An 84-year-old male with Parkinson’s disease
lives at home with his wife. At a routine
follow-up visit she tells you that she is
concerned because he likes to walk around
inside the house but has fallen twice in the
past 3 months.
Which gait assistive device should you
recommend?
A standard four-point walker
A two-wheel walker
A four-wheel walker
A wheelchair
Answer
•
A four-wheel walker
Four-wheel walkers are the best choice for
patients with Parkinson’s disease because
walking is easier to initiate than with a
standard four-point walker or a two-wheel
walker (SOR C). Patients are also less likely
to fall backward than with a four-point walker
(SOR C), because they must lift a four-point
walker before moving it forward. This often
involves bending backward slightly in the
process, and can result in falling backward in
patients with Parkinson’s disease. A
wheelchair would be too restrictive at this
point (SOR C).
Consequences of polypharmacy
in elderly patients can include
which of the following? (Mark all
that are true.)
Medication nonadherence
Adverse drug events
Age-related impairment of the
immune system
Drug-drug interactions
Drug-disease interactions
Answer
• Medication nonadherence
Adverse drug events
Drug-drug interactions
Drug-disease interactions
While there is evidence that multi-drug therapy can be important in
patients with certain conditions such as heart failure and diabetes mellitus,
as well as in those with multiple chronic conditions, the elderly are at
especially high risk for complications from these regimens. Underlying
disease, physiologic changes due to aging, and poor physical and
cognitive health increase the potential for drug-drug interactions, drugdisease interactions, and adverse drug events (SOR C). (Drug-disease
interaction is the adverse effect of a drug on the management of a disease,
e.g., elevation of blood pressure by NSAIDs or elevation of blood glucose
by diuretics.)
Physicians should prescribe medications with the lowest potential for
adverse events, drug-drug interactions, and drug-disease interactions, at
the lowest effective dosages. Medication use should be reviewed at
regular intervals in patients taking multiple medications, and drugs that
are no longer needed should be discontinued.
There is no evidence that taking multiple medications adversely affects the
immune system (SOR C).
An 87-year-old female has a 20-year history of type
2 diabetes mellitus. Her current medications include
metformin (Glucophage), lisinopril (Prinivil,
Zestril), and aspirin.
True statements regarding the care of this patient
include which of the following? (Mark all that are
true.)
Because of her age, her blood pressure targets are
higher than those for younger patients with diabetes
Quarterly hemoglobin A1c levels are indicated
An LDL-cholesterol level of 140 mg/dL would
suggest the need for intervention
Aspirin is no longer indicated because of the
patient’s age
Answer
•
An LDL-cholesterol level of 140 mg/dL
would suggest the need for intervention
This patient’s blood pressure target is the same as for
younger patients with diabetes: 130/80 mm Hg (SOR
B). There is no evidence that quarterly hemoglobin
A1c levels are necessary. Experts recommend annual
measurement (SOR C). Lifestyle intervention or
medication would be indicated if the patient’s LDLcholesterol level were above a threshold of 130
mg/dL (SOR B). Aspirin is still important for this
patient (SOR B). Some authorities would
recommend routine screening for proteinuria in
patients on ACE inhibitors, but no studies have
examined the effect on outcomes.
An 85-year-old female with Alzheimer’s disease of moderate
severity lives alone. She is having increasing difficulty caring
for herself, and her family is concerned about her safety. The
family is considering care options and asks for your opinion.
The patient has repeatedly stated that she wishes to remain in
her home and refuses assistance other than family. When
counseling the patient and family regarding appropriate
placement, factors to consider include which of the
following? (Mark all that are true.)The level and type of care
requiredPatient and family financesThe patient’s ability to
participate in decisionsThe progression rate of the
Alzheimer’s diseaseThe amount and type of help that family
can provide
Answer
• The level and type of care requiredPatient
and family finances
• The patient’s ability to participate in
decisions
• The progression rate of the Alzheimer’s
disease
• The amount and type of help that family can
provide
There are multiple options for care assistance to elders with impaired
function. These options include home care, assisted living, nursing-home
residential and skilled care, and hospice care. When choosing among
options, it is important to consider many variables, including 1) the
patient’s physical and cognitive health and related requirements for
assistance with activities of daily living; 2) whether the patient’s condition
is stable or rapidly changing; 3) the availability of rehabilitation services if
appropriate; 4) the availability of skilled nursing services if appropriate; 5)
the level of supervision required; 6) patient and family finances and
insurance coverage; and 7) life expectancy (SOR C). While patient
preference is important and should be honored when possible, patients
with worsening dementia may lose their competence to make decisions
about appropriate levels of care.
Patients with moderate Alzheimer’s disease often require 24-hour
supervision due to concerns about safety. This can be provided in the
home, in some assisted-living facilities, or in nursing homes. When
possible, a facility should be selected which optimizes the patient’s
functional status and quality of life while also providing the required
assistance.
A 72-year-old male with multiple myeloma
presents with worsening pain in the back and
ribs. He has tried both ibuprofen and
acetaminophen with codeine, but neither has
provided adequate pain relief.
Which one of the following would be the best
agent for pain control?
Amitriptyline
Meperidine (Demerol)
Morphine
Propoxyphene (Darvon)
Answer
• Morphine
Multiple studies have documented the effectiveness of
morphine for controlling cancer pain. A Cochrane review
calls it the gold standard (SOR A). However, it is important to
remember that opioid-induced constipation is common and
debilitating, and several studies and trials demonstrate the
effectiveness of a bowel regimen (including a bulk-forming
agent and motility agent) and a lack of tolerance to opioidinduced constipation (SOR A).
Orthostatic hypotension and anticholinergic side effects can
occur with amitriptyline use (SOR A), and there is an
increased risk of delirium and seizures with meperidine use
(SOR B). Trials have shown that propoxyphene use is
associated with an increased risk of hip fracture in the elderly,
and provides no better analgesia than acetaminophen or other
analgesics with better safety profiles (SOR B).
An 85-year-old retired college professor has had an acute
stroke. True statements regarding management of possible
depression following his stroke include which of the
following? (Mark all that are true.)
He should be screened for anxiety and depression within the
first month after the stroke
Treatment of mood disorders should focus on a single
disorder to avoid complicated treatment regimens
He should be placed on antidepressants prophylactically
If he has a persistent depressed mood >6 weeks after the
stroke, he should be offered antidepressant medication
If he has severe, persistent, or troublesome emotionalism, he
should be offered antidepressant medication
Answer
• He should be screened for anxiety and
depression within the first month after the
stroke
If he has a persistent depressed mood >6
weeks after the stroke, he should be offered
antidepressant medication
If he has severe, persistent, or troublesome
emotionalism, he should be offered
antidepressant medication
Depression commonly develops after a stroke
(SOR C), and psychiatric comorbidities may
require concurrent treatment for optimal
recovery (SOR B). There is insufficient
evidence to recommend prophylactic
antidepressant medication after a stroke (level
of evidence I). SSRIs have been found to be
safe and effective in post-stroke depression
(SOR A). People with severe, persistent, or
troublesome emotionalism or tearfulness
following a stroke should be offered
antidepressant drug treatment, with the
frequency of crying monitored to determine
the effectiveness of the treatment (SOR A).
A 91-year-old male with heart failure has a
creatinine clearance of 60 mL/min, a left
ventricular ejection fraction of 40%, and 1+
edema of the lower extremities. Appropriate
treatments include which of the following?
(Mark all that are true.)
Sodium restriction
ACE inhibitors
β-blockers such as carvedilol (Coreg)
Calcium channel blockers
Diuretics
Answer
• Sodium restriction
ACE inhibitors
β-blockers such as carvedilol (Coreg)
Diuretics
failure and a reduced left ventricular ejection
fraction (LVEF) who have evidence of fluid
retention (SOR C). ACE inhibitors have been
found to have a favorable effect on survival in
patients with heart failure (SOR A). Certain βblockers, such as carvedilol, have also been
found to have a favorable effect on survival in
patients with heart failure (SOR A). Calcium
channel blockers are not indicated as routine
treatment for heart failure in patients with
current or prior symptoms of heart failure and
reduced LVEF (SOR C).
Activities of Daily Living
(ADLs) include which of the
following? (Mark all that are
true.)
Meal preparation
Dressing
Bathing
Toileting
Transferring
Answer
• Dressing
Bathing
Toileting
Transferring
Activities of Daily Living are basic activities necessary for
personal care, and include dressing, bathing, toileting, and
transferring (SOR C). Other ADLs include eating and
drinking, ambulating, taking medications, personal hygiene,
and positioning and changing positions in a bed or chair.
Meal preparation is an instrumental activity of daily living
(IADL), whereas ability to feed oneself is a basic ADL. If
meal preparation is a patient’s only functional limitation,
independence can still be maintained with delivered meal
services such as Meals on Wheels. Other IADLs include
using the telephone, shopping, doing laundry, making and
keeping appointments, writing letters or other
correspondence, taking part in social and leisure activities,
managing finances, and driving or arranging transportation.
An 85-year-old male complains of depressed mood and
libido. He and his wife of more than 60 years have always
had a good sex life and he is distressed that both his interest
in sex and his ability to perform have decreased in the last 6
months. His only regular medications are a multivitamin and
an aspirin each day.
You consider the possibility of hypogonadism. True
statements regarding this problem include which of the
following? (Mark all that are true.)By 80 years of age, more
than 50% of men have testosterone levels in the hypogonadal
rangeGuidelines vary regarding the level of total testosterone
that defines hypogonadismTestosterone supplementation
should be considered when treating sexual dysfunction in
hypogonadal menMultiple studies have shown that
testosterone therapy is associated with decreased fracture
rates
Answer
• By 80 years of age, more than 50% of men
have testosterone levels in the hypogonadal
range
• Guidelines vary regarding the level of total
testosterone that defines hypogonadism
• Testosterone supplementation should be
considered when treating sexual
dysfunction in hypogonadal men
The Baltimore Longitudinal Study of Aging found
that more than 50% of men had testosterone levels in
the hypogonadal range by age 80 (SOR C).
Guidelines regarding the level of total testosterone
that defines hypogonadism vary, although many
studies use the American Association of Clinical
Endocrinologists definition (total testosterone <200
ng/dL) (SOR C). Improvement in sexual function
has been shown in multiple studies of hypogonadal
men treated with testosterone therapy. Other possible
benefits include improvement in lean muscle mass,
strength, cognition, mood, and bone density (SOR
B). While some studies have shown increases in
bone mineral density with testosterone therapy, none
has shown decreased rates of fractures (SOR B).
A 70-year-old male presents to your hospital’s urgent-care
facility with a 2-day history of fever and cough. His previous
history is significant for heart failure, and he smokes 1 pack
of cigarettes per day. He received pneumococcal vaccine at
age 64 but declined the current year’s influenza vaccine when
it was offered a month ago.
On examination his temperature is 39.4°C (102.9°F) and he
has a cough, hypoxia, and a new lobar infiltrate on a chest
radiograph. You arrange for admission to the hospital for
pneumonia.
True statements regarding this situation include which of the
following? (Mark all that are true.)Antibiotics should be
given immediatelyThe patient should be given influenza
vaccine 1 week after dischargeRepeat pneumococcal
vaccination is recommendedUp-to-date influenza vaccination
of hospital staff would likely improve this patient’s prognosis
Answer
• Antibiotics should be given immediately
• Repeat pneumococcal vaccination is
recommended
• Up-to-date influenza vaccination of hospital
staff would likely improve this patient’s
prognosis
For elderly patients with pneumonia, administration
of antibiotics within 8 hours of hospital arrival is
associated with lower 30-day mortality, and several
studies suggest that it is better to provide antibiotics
in less than 4 hours (SOR A).
It is safe (and preferred) to administer influenza
vaccine during hospitalization (SOR B). Repeat
pneumococcal vaccination is recommended after 5
years if the vaccine was given before age 65 (SOR
B). Vaccination of staff who care for vulnerable
elders may be even more important than vaccination
of the elders themselves (SOR B).
An 82-year-old male sees you because of a 2-month
history of headache in the right temporal area. He
says his right temple has also been tender to the
touch, and his jaw hurts when he chews his food. On
examination the right temporal artery seems
thickened and is tender to palpation.
Which one of the following would be the most
appropriate initial step?
An erythrocyte sedimentation rate CT of the
head Beginning corticosteroids Referral for
rheumatologic evaluation Referral for a temporal
artery biopsy
Answer
• Beginning corticosteroids
If there is a clinical suspicion of
temporal arteritis, corticosteroids
must be started immediately,
while the workup is being
conducted and before the results
have been obtained. A delay in
treatment can result in permanent
blindness (SOR B).
An 88-year-old female who lives in an assisted-living facility
complains of difficulty understanding the staff, and
sometimes becomes agitated when she misunderstands
information. Your examination reveals no cerumen
impaction, and an audiogram shows bilateral moderately
severe sensorineural hearing loss.
Techniques for improving communication with patients such
as this include which of the following? (Mark all that are
true.)
Shouting
Reducing background noise
Using shorter phrases
Facing the patient directly, preferably at eye level
Ensuring that vision correction is optimal
Answer
• Reducing background noise
• Facing the patient directly, preferably at eye
level
• Ensuring that vision correction is optimal
Raising volume excessively distorts both the sound
produced and facial movements associated with
speech (SOR C). Hearing selectivity is lost with age,
making it important to reduce background noise
(SOR C). Longer phrases tend to be easier for
elderly patients with hearing impairment to
understand, and provide more clues to meaning than
shorter phrases (SOR C). Seeing the speaker
provides additional cues, making it important for the
speaker to face the patient, and for care providers to
ensure that vision is corrected to the greatest extent
possible (SOR C).
An outbreak of influenza occurs at the nursing home
where you are the Medical Director. Control
measures recommended by the Advisory Committee
on Immunization Practices include which of the
following? (Mark all that are true.)Segregate patients
with suspected or confirmed influenzaRevaccinate
all residents who do not have symptomsGive all
residents oseltamivir (Tamiflu), 75 mg/day, for at
least 2 weeks unless they have a
contraindicationGive all residents amantadine
(Symmetrel), 10 mg/day, for at least 2 weeks unless
they have a contraindicationGive residents with
COPD or other lung disease zanamivir (Relenza),
one inhalation/day, for 2 weeks
Answer
• Segregate patients with suspected or
confirmed influenza
• Give all residents oseltamivir (Tamiflu), 75
mg/day, for at least 2 weeks unless they
have a contraindication
The recommendations of the Advisory Committee on Immunization Practices include
vaccinating all nursing-home residents and employees of nursing homes who have contact
with patients. Vaccination efforts should begin in October, but may continue throughout the
influenza season. The majority of patients will have antibody protection within 2 weeks after
vaccination.
When outbreaks occur in institutions, chemoprophylaxis should be administered to all
residents, regardless of whether they received influenza vaccine the previous fall, and should
continue for a minimum of 2 weeks (SOR C). If new cases continue to occur,
chemoprophylaxis should continue until 1 week after the end of the outbreak. Studies of
outbreaks of influenza A were mainly done with amantadine or rimantadine. Since resistance
to amantadine or rimantadine occurs rapidly during treatment, these drugs are not currently
recommended for treatment or chemoprophylaxis (SOR C). The FDA does not recommend
zanamivir for persons with COPD or other airway disease (SOR C). It also has not been
proven effective for prevention of influenza in nursing-home patients. Oseltamivir is given
orally twice a day for 5 days as treatment, and once daily for chemoprophylaxis (SOR C).
For patients with a creatinine clearance of 10–30 mL/min, the treatment dosage is reduced to
once a day and the prophylactic dosage to every other day.
Other outbreak control measures include instituting droplet precautions and segregating
patients with confirmed or suspected influenza, reoffering influenza vaccinations to
unvaccinated staff and patients, restricting staff movement between wards or buildings, and
restricting contact between patients and ill staff or visitors (SOR C).
Indications for checking the TSH level in
elderly patients include which of the
following? (Mark all that are true.)
The initial workup for dementia
The initial workup for depression
A BMI >28.0 kg/m2 and no recent
weight change
Routine monitoring of patients taking
lithium
Routine monitoring of patients taking
amiodarone (Cordarone)
Answer
• The initial workup for dementia
• The initial workup for depression
• Routine monitoring of patients taking
lithium
• Routine monitoring of patients taking
amiodarone (Cordarone)
Hypothyroidism may cause symptoms of
dementia or depression (SOR A). Patients on
lithium therapy may develop hypothyroidism
(SOR A), and patients on amiodarone therapy
are at risk for developing hypo- or
hyperthyroidism (SOR A). There is no
evidence that checking a TSH level is
beneficial in patients who are moderately
overweight with no recent weight changes
(SOR C).
An 88-year-old female falls at her nursing home and is
admitted to the hospital with a hip fracture. She was
ambulatory prior to this accident. Her chronic medical
problems include hypertension, coronary artery disease, mild
dementia, and osteoporosis.
Appropriate management strategies for this patient while in
the hospital include which of the following? (Mark all that are
true.)Begin β-blocker therapy prior to surgery and continue
until dischargeGive prophylactic antibiotics within 1 hour
before surgery and discontinue within 24 hours after
completion of the surgeryPlace an indwelling Foley catheter
prior to surgery and continue until dischargeScreen for
delirium daily for the first 3 days after surgeryBegin
ambulation by postoperative day 2
Answer
• Begin β-blocker therapy prior to surgery
and continue until discharge
• Give prophylactic antibiotics within 1 hour
before surgery and discontinue within 24
hours after completion of the surgery
• Check for delirium daily for the first 3 days
after surgery
• Begin ambulation by postoperative day 2
A systematic review found beneficial effects of perioperative β-blockade for preventing cardiac morbidity
associated with noncardiac surgery (SOR B). A recent retrospective cohort study found that perioperative
β-blockade was associated with no benefit, and with possible harm, in the lowest-risk patients. A survival
benefit was seen in high-risk patients. Perioperative β-blockade was associated with a greater risk of
hypotension.
The National Surgical Infection Prevention Project, a prospective double-blind randomized, controlled
trial of antimicrobial prophylaxis administered to patients undergoing elective gastrointestinal surgery
demonstrated that patients who did not receive prophylactic antibiotics were four times more likely to
experience wound infection and intra-abdominal sepsis after elective gastrointestinal surgery than those
who received antibiotic prophylaxis (SOR A).
Several observational studies suggest that the duration of catheterization is a significant risk factor for
catheter-associated urinary tract infection, and that indwelling urinary catheters are often overused
without an appropriate indication. Prospective studies have also shown an increased risk of bacteriuria and
infection associated with an increased duration of catheterization. The CDC has issued guidelines that
stress limiting use of indwelling urinary catheters to a carefully selected group of patients, limiting length
of catheterization, and advising against routine use solely for the convenience of patient-care personnel
(SOR A).
Evidence suggests that daily use of a delirium screening tool for elderly patients undergoing major
surgery can aid in the early detection of postoperative delirium (SOR B). One tool is the Confusion
Assessment Method, which uses four criteria to detect delirium: acute onset and fluctuating course,
inattention, disorganized thinking, and altered level of consciousness. Use of this screening allows for
earlier intervention.
Early ambulation is associated with better functional recovery, and with a 1-day reduction in hospital
stays in postoperative patients (SOR B).
You are asked to see an 82-year-old female
nursing-home resident with severe dementia
who has recently developed a pressure ulcer
over her coccyx. On examination you note a
shallow open ulcer 3 cm in diameter, shown
below.
Appropriate management options would
include which of the following? (Mark all that
are true.)Cleansing with normal
salineCleansing with hydrogen
peroxideWound debridementA thin film
dressingA hydrocolloid dressing
Answer
• Cleansing with normal saline
• A thin film dressing
The treatment of pressure ulcers is based on their
stage, although staging is not possible if the ulcer is
covered by a thick eschar. This patient has a stage II
ulcer. Cleansing with normal saline and the use of a
thin film dressing would be appropriate (SOR B).
Cleansing with hydrogen peroxide would not be
appropriate because it retards fibroblast proliferation
and wound healing (SOR B). Wound debridement
would be appropriate for a stage III ulcer (SORT B),
and hydrocolloid dressing is used for stage III or IV
ulcers (SOR C).
An 81-year-old female has recently developed symptoms of
mild cognitive impairment. She has multiple chronic medical
problems, including depression, hypertension, heart failure,
diabetes mellitus, and urinary incontinence. Her medications
include amitriptyline, digoxin, oxybutynin (Ditropan),
hydrochlorothiazide, and metformin (Glucophage).
Which of the patient’s medications could potentially be
causing her cognitive problems? (Mark all that are true.)
Amitriptyline
Digoxin
Hydrochlorothiazide
Metformin
Oxybutynin
Answer
• Amitriptyline
• Digoxin
• Oxybutynin
The use of anticholinergic medications is a
risk factor for developing mild cognitive
impairment (MCI) (relative risk = 5.12).
Many drugs have anticholinergic properties,
and up to 80% of patients on anticholinergics
will develop MCI. Even though they belong to
different classes of medications, amitriptyline,
digoxin, and oxybutynin all have
anticholinergic properties and can cause MCI
(SOR B). Hydrochlorothiazide and metformin
do not have anticholinergic properties, and
have not been associated with an increased
risk of MCI (SOR B).
An 89-year-old female was recently hospitalized for
treatment of a hip fracture. The patient lives alone, receives
home meal services, and has a house cleaner in once a week.
Her two children live out of the area. She has mild dementia,
osteoarthritis, and balance problems that have led to
occasional falls. She cannot tolerate more than 30 minutes of
treatment per day.
The patient wants to go home after discharge. What would
you recommend with regard to post-discharge rehabilitation
for this patient?
Inpatient rehabilitation at a freestanding rehabilitation
hospital Rehabilitation at a skilled nursing home Outpatient
rehabilitation services Home-based rehabilitation services No
further rehabilitation
Answer
• Rehabilitation at a skilled nursing home
Although many studies have attempted to determine which
type of rehabilitation is associated with the best patient
outcomes, there is no clear best practice. A Cochrane review
in 2003 found insufficient evidence to compare the effects of
care-home environments, hospital environments, and ownhome environments on rehabilitation outcomes in older
patients. One cohort study found no difference in outcomes
between rehabilitation hospitals and nursing-home
rehabilitation (SOR B).
The patient’s prior and current health status, and the amount
and quality of support and assistance he or she will need are
important factors in determining the site for rehabilitation. It
is recommended that patients with comorbid conditions, such
as heart disease or dementia, and those who do not have a
family member or caregiver at home to help, be admitted to
the rehabilitation section of a nursing home (SOR C).
Outpatient rehabilitation would be inappropriate at this time
A 76-year-old male has bilateral knee pain caused by
osteoarthritis, and asks what can be done to relieve his pain
and improve function. He is obese, but has no known cardiac
disease.
Which of the following would be appropriate advice? (Mark
all that are true.)A supervised exercise program can relieve
pain and improve functional statusNSAIDs should be tried
before acetaminophen for pain reliefCelecoxib (Celebrex) is
preferred as an anti-inflammatory agent in his age group,
based on past trialsAssistive devices (e.g., braces, elastic
bandages, insoles) have been shown to improve
functionReferral to orthopedic surgery is indicated for severe
hip or knee arthritis pain not responding to nonsurgical
measures
Answer
• A supervised exercise program can relieve
pain and improve functional status
• devices (e.g., braces, elastic bandages,
insoles) have been shown to improve
function
• Referral to orthopedic surgery is indicated
for severe hip or knee arthritis pain not
responding to nonsurgical measures
An 85-year-old male nursing-home patient has metastatic
prostate cancer. He says he has no appetite, and the nurses
have noted that he does not finish most of his meals. He
complains that he lost his glasses about 6 months ago and can
no longer read magazines or newspapers. He takes a total of
seven pills before breakfast.
He is 168 cm (66 in) tall and weighs 54 kg (119 lb). His BMI
is 19.1 kg/m2. He has lost 7 kg (15 lb) in the past 3 months.
Which of the following measures would you expect to
improve his appetite? (Mark all that are true.)Tell the nursinghome staff to have him eat alone in a quiet, peaceful
settingPrescribe a low-sodium, low-fat dietHave the staff give
his morning medications after breakfast instead of
beforeRecommend that he increase physical activity during
the dayHave his vision problems corrected
Answer
• Have the staff give his morning medications
after breakfast instead of before
• Recommend that he increase physical
activity during the day
• Have his vision problems corrected
Anorexia and weight loss are common problems in elderly
patients. Residing in a nursing home and a diagnosis of
cancer both increase the likelihood of these problems.
Having the patient eat by himself would likely be
counterproductive. People who eat with others have been
shown to eat about one-third more than those who eat alone
(SOR B). A low-sodium, low-fat diet would also be likely to
reduce the amount of food eaten. Patients with anorexia
should be offered whatever foods they like best (SOR C).
Giving the patient his medications after breakfast instead of
before could increase his food intake, as many medications
cause gastrointestinal irritation and suppress appetite (SOR
C). Exercise stimulates appetite, so increasing physical
activity could also be helpful (SOR B). Correcting vision
problems could improve the patient’s appetite because vision
plays a role in food appreciation (SOR B).
A 78-year-old female has experienced decreased
memory over a period of several years. She has no
reported behavioral problems. Her Mini-Mental
State Examination score is 17. She frequently has
problems generating the word she wants, and fails to
recognize her grandchildren on occasion.
Medications that have been shown to be beneficial in
this situation include which of the following? (Mark
all that are true.)
Estrogen
Memantine (Namenda)
Galantamine (Razadyne)
Risperidone (Risperdal)
Donepezil (Aricept)
Answer
• Memantine (Namenda)
• Galantamine
• Donepezil (Aricept)
This patient has moderate dementia. Randomized,
controlled trials (RCTs) have shown that estrogen is
not beneficial for dementia and has the potential for
harm if started at this age (SOR A). Several RCTs
have shown that treatment with the NMDA inhibitor
memantine has benefits as shown on objective
measurements (SOR A). Risperidone is indicated
only for psychosis in patients with dementia (SOR
B). Several RCTs have shown that anticholinesterase
agents such as donepezil and galantamine have
benefits based on objective measurements (SOR A).
True statements regarding acute abdominal pain in
geriatric patients include which of the following?
(Mark all that are true.)
Elderly patients with acute abdominal pain out of
proportion to physical findings and a history of
cardiovascular disease should be suspected of having
acute intestinal ischemia
Occlusive intestinal ischemia should be suspected in
patients with low-flow states or shock, especially
cardiogenic shock, who develop abdominal pain
Occlusive intestinal ischemia should be suspected in
patients taking vasoconstrictor substances or
medications (e.g., triptans, ergots, vasopressin)
Duplex sonography is the imaging procedure of
choice for diagnosing acute intestinal ischemia
Answer
• Elderly patients with acute abdominal pain
out of proportion to physical findings and a
history of cardiovascular disease should be
suspected of having acute intestinal
ischemia
Acute intestinal ischemia presents with significant
pain, often in the absence of physical findings. A
history of cardiovascular disease suggests the
widespread nature of vascular involvement (SOR B).
Elderly patients with low flow states as a result of a
cardiac event often manifest abdominal pain due to
relative (nonocclusive) bowel ischemia (SOR B).
Relative ischemia may be created by
vasoconstrictors, including triptans, ergots,
vasopressin, norepinephrine, and cocaine (SOR B).
Arteriography, rather than sonography, is indicated
in acute intestinal ischemia if treatment of the
underlying condition does not rapidly reverse the
abdominal symptoms (SOR B).
A 78-year-old male is admitted to the hospital in
septic shock. His chronic medical problems include
hypertension, benign prostatic hyperplasia, stage I
renal failure, and COPD. He has previously
expressed his desire for full resuscitation.
Appropriate treatment options at this time include
which of the following? (Mark all that are
true.)Intravenous antibiotics started after the
pathogen has been identifiedHydrocortisone, 400–
500 mg/day for 7 daysA fluid challenge of 500–1000
mL normal saline over 30 minutes, with additional
fluid based on responseLow-dose dopamine for renal
protectionBicarbonate therapy to improve
hemodynamics if the pH is >7.15
Answer
• A fluid challenge of 500–1000 mL normal
saline over 30 minutes, with additional fluid
based on response
Sepsis is defined as a systemic inflammatory response syndrome due to suspected or confirmed infection. The mortality
rate increases with age.
A panel of experts published guidelines for the management of severe sepsis and septic shock in 2004. Intravenous
antibiotics should be started within the first hour after sepsis is diagnosed, after appropriate cultures are obtained (SOR C).
Initial empiric therapy should include one or more drugs that have activity against the likely pathogen. The antimicrobial
regimen should be reassessed after 48–72 hours on the basis of culture results and clinical response. Once a causative
organism is identified, a narrow-spectrum antibiotic should be used if possible to prevent the development of resistance,
reduce toxicity, and lower cost.
The prevalence of adrenal insufficiency in septic shock is about 50%. One multi-center, randomized, controlled trial of
patients in severe septic shock showed a significant shock reversal and reduction of mortality with corticosteroid use in
patients with relative adrenal insufficiency (past ACTH cortisol <9 mcg/dL). A meta-analysis done in 2004 showed no
reduction of mortality with use of corticosteroids, except with long courses of low-dose corticosteroids. The most recent
study showed no benefit in 28-day mortality between low-dose hydrocortisone and placebo.
The degree of intravascular volume deficit in patients with severe sepsis varies. With venodilation and capillary leak, most
patients require large amounts of fluids during the first 24 hours of management (SOR C). Input/output ratio is of no utility
for guiding fluid resuscitation needs during this time. The patient must be closely monitored to evaluate the clinical
response and prevent pulmonary edema. Bicarbonate therapy for the purpose of improving hemodynamics or reducing
vasopressor requirements is not recommended for treatment of hypoperfusion-induced lactic acidemia with a pH >7.15
(SOR C).
When fluid challenges fail to improve blood pressure and organ perfusion, therapy with vasopressors should be started.
Dopamine increases mean arterial pressure and cardiac output by increasing stroke volume and heart rate. Norepinephrine
increases mean arterial pressure due to its vasoconstrictive effect, with little change in heart rate and less increase in stroke
volume compared to dopamine. Either may be used to correct hypotension in sepsis. However, a large randomized trial and
a meta-analysis comparing low-dose dopamine to placebo in critically ill patients found no difference in outcomes related
to peak serum creatinine, need for renal replacement therapy, urine output, or time to recovery of normal renal function.
The currently available evidence does not support administration of low doses of dopamine to maintain or improve renal
function (SOR A).
A 78-year-old female presents for evaluation of back
pain that has been present for several months and is
found to have several spinal compression fractures.
She has also had several unexplained falls over the
past year, and your evaluation reveals low vision.
You recommend bisphosphonate therapy and
calcium and vitamin D supplementation. Appropriate
additional measures to consider at this time include
which of the following? (Mark all that are true.)Bed
restReferral to a physical therapistReferral to an
ophthalmologistPermanent use of a trunk
orthosisSurgical interventions such as kyphoplasty or
vertebroplasty
Answer
• Referral to a physical therapist
• Referral to an ophthalmologist
• Surgical interventions such as kyphoplasty
or vertebroplasty
In patients with osteoporosis, inactivity and immobilization should both be
minimized (SOR C). Based on the initial condition of the patient, a
complete exercise program should be prescribed and coordinated with a
physical therapist, including weight-bearing aerobic activities for the
skeleton, postural training, progressive resistance training for muscle and
bone strengthening, stretching for tight soft tissues and joints, and balance
training. Proper exercise may improve physical performance/function,
bone mass, muscle strength, and balance, in addition to reducing the risk
of falling (SOR C). Other factors contributing to falls, such as low vision,
should be minimized or eliminated if possible (SOR C).
In patients with acute vertebral fractures or chronic pain after multiple
vertebral fractures, trunk orthoses can be considered to provide pain relief
by improving spine alignment and reducing loads on the fracture sites.
However, long-term bracing may lead to muscle weakness and further
deconditioning (SOR C). The physician should consider kyphoplasty or
vertebroplasty for individuals with painful vertebral fractures that fail to
respond to conservative management (SOR C).
You diagnose generalized anxiety disorder in
a 79-year-old female who was widowed 2
years ago. She is otherwise in good health, but
has a history of two falls in the last year, with
no serious injury resulting from either fall.
Which class of medications is most
appropriate for long-term treatment of this
patient?
A tricyclic antidepressant An SSRI A shortacting benzodiazepine A long-acting
benzodiazepine An atypical antipsychotic
Answer
• An SSRI
SSRIs are the treatment of choice for
long-term management of anxiety
disorders in the elderly (SOR B).
Benzodiazepines (either short- or longacting) and tricyclic antidepressants are
efficacious, but the long-term risks,
including the risk of falls, outweigh the
benefits (SOR B for TCAs, C for
benzodiazepines). Atypical
antipsychotics have not been shown to
be efficacious in the treatment of anxiety
disorders in the elderly (SOR C).
An 85-year-old female sees you for a routine visit. Her
medical problems include type 2 diabetes, hypertension,
osteoarthritis, depression, and urge incontinence. She
continues to have 2–3 episodes of incontinence per week,
which is similar to her previous symptoms. She also
complains of the recent onset of dry mouth.
She remains physically and socially active, has a good
appetite, and sleeps well. Her blood pressure is 120/70 mm
Hg, and her last hemoglobin A1c was 7.1%.
She currently takes the medications listed below. Which one
should you consider discontinuing?
Acetaminophen Metformin (Glucophage) Metoprolol (Toprol
XL) Sertraline (Zoloft) Tolterodine (Detrol LA)
Answer
• Tolterodine (Detrol LA)
At each visit it is important to review the
medication list of vulnerable elders to be sure
treatment goals are being achieved. If a
medication is not achieving its goal, the
options are to discontinue the medication, to
change the dosage, to substitute a different
medication, or to add a medication. In this
case, the lack of efficacy of tolterodine and
the reported side effect (dry mouth) argue for
discontinuation (SOR C). Nonpharmacologic
measures can be suggested for the urge
incontinence, and the patient seems to be
responding appropriately to the other
medications (SOR C).
A 75-year-old male complains of a chronic cough.
He has a 50 pack-year smoking history and currently
smokes ½ pack of cigarettes a day. His FEV1 is 60%
of predicted, and his FEV1/FVC ratio is 60%.
Appropriate treatment options at this time include
which of the following? (Mark all that are true.)
Inhaled corticosteroids on a scheduled basis
Short-acting bronchodilators as needed
Long-acting bronchodilators on a scheduled basis
Mucolytic agents on a scheduled basis
Continuous oxygen therapy
Answer
• Short-acting bronchodilators as needed
Long-acting bronchodilators on a scheduled
basis
The treatment of patients with COPD should
be based on the classification of severity of
their disease, which is determined by
spirometry. This patient’s COPD would be
classified as moderate, and his treatment
regimen should include a scheduled longacting bronchodilator and as-needed use of a
short-acting bronchodilator (SOR A). Inhaled
corticosteroids and mucolytic agents are
indicated for patients with severe COPD
(SOR A), and oxygen is indicated for those
with very severe COPD (SOR B).
A 72-year-old male comes to your office for preoperative
assessment prior to elective knee surgery. His medical
problems include osteoarthritis, COPD, hypertension, and
type 2 diabetes mellitus. He has no history of heart disease.
He has a 60-pack-year smoking history. He is unable to walk
more than 2 blocks or climb a flight of stairs due to knee pain
and shortness of breath. On examination his blood pressure is
125/75 mm Hg and you note decreased breath sounds and
occasional wheezes. Cardiac findings are unremarkable.
This patient’s risk factors for perioperative or postoperative
complications include which of the following? (Mark all that
are true.)His smoking historyHis inability to climb a flight of
stairsHypertensionCOPDType 2 diabetes mellitus
Answer
• His smoking history His inability to climb a
flight of stairs
• COPD
• Type 2 diabetes mellitus
Smoking increases the risk of postoperative
pneumonia (SOR A). Poor exercise tolerance
increases the risk of cardiovascular
complications, neurologic complications, and
unexpected transfer to the intensive-care unit
(SOR C). Controlled hypertension is not listed
as a risk factor for perioperative complications
(SOR C). COPD is a risk factor for
postoperative pneumonia (SOR A). Diabetes
mellitus increases perioperative
cardiovascular risk and is a major risk factor
for wound infection (SOR C).
Which one of the following
aspects of drug metabolism
changes least with age?
Distribution
Absorption
Hepatic clearance
Renal elimination
Answer
• Absorption
Despite age-related changes in small bowel surface area and
increases in gastric pH, changes in absorption are trivial or
clinically insignificant (SOR A). With aging, the body’s fat
compartment increases and the water compartment decreases,
increasing the volume of distribution for highly lipophilic
drugs, which may in turn increase their elimination half-life.
Rapid reductions in serum albumin seen with acute illness or
malnutrition may enhance drug effects because serum levels
of unbound drug may increase (SOR A). Overall hepatic
metabolism of many drugs through the cytochrome P-450
enzyme system decreases with aging, as does elimination of
drugs requiring multiple-stage metabolism (SOR A).
Creatinine clearance decreases an average of 8 mL/min/1.73
m2/decade, increasing the circulating levels of drugs
eliminated by the kidneys. Renal elimination is also dynamic,
in that illness, dehydration, or recent recovery from
dehydration may require adjustment of maintenance
medication dosages (SOR A).
True statements regarding the Physician
Quality Reporting Initiative (PQRI)
under Medicare Part B include which of
the following? (Mark all that are true.)
Participation is limited to licensed
physicians
It requires the physician to meet
predetermined quality goals
It requires the physician to report on
predetermined quality measures
It is mandatory for all physicians billing
under Medicare Part B
Answer
• It requires the physician to report on
predetermined quality measures
The Physician Quality Reporting
Initiative (PQRI) is currently
voluntary under Medicare Part B. It
requires physicians to report
predetermined quality indicators, but
not the achievement of performance
goals. A variety of health care
providers are eligible to participate
in this program, which results in a
bonus payment to those who
complete it successfully.
A 75-year-old male presents with acute, severe upper
abdominal pain with associated nausea and vomiting.
He reports that his symptoms seem to improve when
he leans forward. Serum amylase and lipase levels
are both greater than three times the upper limit of
normal.
Appropriate management would include which of
the following? (Mark all that are true.)Determining
risk factors for severityWithholding fluids for the
first 24 hoursGiving supplemental oxygenProviding
total parenteral nutrition if nutritional support is
neededOrdering ultrasonography to diagnose
suspected necrotizing pancreatitis
Answer
• Determining risk factors for severity
• Giving supplemental oxygen
This patient has acute pancreatitis. Assessing risk factors for more severe
disease is important for guiding management, and will help determine
how closely the patient should be supervised (SOR B). Aggressive fluid
resuscitation and improved delivery of oxygen prevent or minimize
pancreatic necrosis and improve survival (SOR B). Contrast-enhanced CT
is the best available test to distinguish interstitial from necrotizing
pancreatitis, particularly after 2–3 days of illness (SOR B).
There is compelling evidence that in severe acute pancreatitis gut barrier
function is compromised, resulting in intestinal permeability to bacteria
and to endotoxins which stimulate the production of nitric oxide and
cytokine that contribute to organ failure (SOR B). There is also evidence
of a higher incidence of gastric colonization with potentially pathogenic
enteric bacteria in severe disease, which may also contribute to septic
complications. Because enteral feeding stabilizes gut barrier function, it is
preferable to total parenteral nutrition.
Conditions contributing to
transient urinary incontinence
include which of the following?
(Mark all that are true.)Detrusor
muscle hyperactivityUrinary tract
infectionPoorly controlled
diabetesDeliriumSSRI use
Answer
• Urinary tract infection
• Poorly controlled diabetes
• Delirium
Consensus expert opinion recommends screening for
transient causes of urinary incontinence in patients
with a new onset of urinary incontinence. Transient
causes include delirium, infection, certain
medications, fecal impaction, polyuria, and impaired
mobility (SOR C). Detrusor muscle overactivity is
the usual cause of urge type incontinence, which is
typically a chronic condition (SOR C). Medications
thought to contribute to urinary incontinence include
diuretics, sedatives, and those that can cause urinary
retention. SSRIs do not have any of these
characteristics (SOR C).
A 78-year-old female who is on warfarin (Coumadin)
presents for follow-up after missing several appointments. On
examination she has new bruises on her neck and ears. She
reports that she often forgets whether she took her warfarin,
and sometimes takes a dose later than her usual time in case
she forgot. You ask her about her safety at home with her
caregiver, and she denies any mistreatment.
True statements regarding this situation include which of the
following? (Mark all that are true.)
Physical abuse is the most common type of elder
mistreatment
The location of the bruises on this patient is very suspicious
for physical abuse
Elder mistreatment reports have recently leveled off
Most reports of elder mistreatment come from physicians and
health care providers
Approximately half of elder mistreatment cases are
unreported
Answer
• The location of the bruises on this patient is
very suspicious for physical abuse
In a prospective survey of geriatric bruising that
included patients on anticoagulants, no accidental
bruising was noted on the ears, neck, genitals,
buttocks, or soles of the feet (SOR B). Although
often the most obvious because of physical markers
(bruising, lacerations, etc.), physical abuse has a
lower prevalence than neglect (SOR A). Numerous
studies have documented increasing reports of elder
abuse in recent years (SOR A). Although physicians
and health care providers are mandated reporters in
most states, less than a quarter of reports come from
them (SOR A). It is estimated that only one in five
cases of mistreatment cases is reported, and the
proportion of reported cases of financial exploitation
is even lower (SOR B).
An 82-year-old female with rheumatoid arthritis and hypothyroidism sees
you for a routine visit. She complains of generalized fatigue. A CBC
reveals a hemoglobin level of 10.9 g/dL (N 12.0–16.0) and a mean
corpuscular volume of 92 µm3 (N 80–100). Additional testing reveals the
following:
Reticulocyte count <2.0% (N 0.5–2.5)
Serum iron 52 µg/dL (N 60–100)
Total iron-binding capacity 224 µg/dL (N 250–400)
Serum ferritin 180 ng/mL (N 100–300)
Stool guaiac 3 negative tests
The patient underwent colonoscopy 2 years ago, and findings were
normal.
The patient’s low hemoglobin level is most likely due to
normal aging changes
iron deficiency anemia
vitamin B12 deficiency
anemia of chronic disease
blood loss
Answer
• anemia of chronic disease
Anemia is common in the elderly, and its prevalence
increases with age. The World Health Organization defines
anemia as a hemoglobin level <12 g/dL in women and <13
g/dL in men. There is a general misconception that lower
hemoglobin levels are a normal consequence of aging.
However, an underlying cause of anemia is found in almost
90% of elderly patients whose hemoglobin level is <12 g/dL
(SOR A).
The two most common causes of anemia in the elderly are
chronic disease and iron deficiency. In iron deficiency
anemia, the serum iron level and ferritin level are usually low
and the total iron-binding capacity (TIBC) is high. In anemia
of chronic disease the serum iron level and TIBC are often
both low and the ferritin level is normal. In anemia associated
with blood loss, the reticulocyte count is usually elevated.
With anemia related to vitamin B12 deficiency, there is often
macrocytosis (MCV >100 µm3), and either a low vitamin
At a routine visit, an 89-year-old female tells
you she has fallen twice at home within the
last 3 months. She denies any loss of
consciousness.
Your evaluation for this problem should
include which of the following? (Mark all that
are true.)
A review of her alcohol consumption
Orthostatic blood pressure measurement
Gait and balance evaluation
Visual acuity testing
Thallium or dobutamine stress testing
Answer
• A review of her alcohol consumption
Orthostatic blood pressure measurement
Gait and balance evaluation
Visual acuity testing
A cohort study found that alcohol consumption is a
significant risk factor for falls leading to injuries. Other
studies have also shown alcohol use to be a risk factor for
older adults presenting to the emergency department with a
fall (SOR B).
Some cohort studies have shown an association between
orthostatic hypotension and falls (SOR C). Detection and
treatment of gait and balance disorders reduces the risk of
falls as part of a multifactorial intervention (SOR B). Cohort
studies have shown that visual impairment increases the risk
for falls (SOR B).
Cardiovascular disease is not a major risk factor for falls
unless syncope is present, so stress testing would not be
helpful for preventing falls (SOR C).
Measures recommended for the primary
prevention of stroke include which of the
following? (Mark all that are true.)
Counseling adults to increase their
physical activity
Prescribing aspirin, 325 mg/day, for
healthy men over the age of 50
Counseling women who drink alcohol to
limit intake to 2 drinks per day
Annual high-sensitivity C-reactive
protein screening for older adults
Answer
• Counseling adults to increase their physical
activity
Increased physical activity is associated with a reduction in the risk of stroke
(SOR B). The Centers for Disease Control and Prevention and the National
Institutes of Health recommend at least 30 minutes of moderate-intensity activity
daily as part of a healthy lifestyle.
Aspirin is not recommended for the prevention of a first stroke in men (SOR A). It
is recommended for prevention of cardiovascular disease, including stroke, in
persons whose risk is sufficiently high for the benefits to outweigh the risks
associated with treatment (a 10-year risk of cardiovascular events of 6%–10%)
(SOR A). Aspirin can be useful for prevention of a first stroke in women whose
risk is sufficiently high for the benefits to outweigh the risks associated with
treatment (SOR B).
The U.S. Preventive Services Task Force recommends reduction of alcohol
consumption in heavy drinkers, using established screening and counseling
methods. For those who consume alcohol, consumption of no more than 2 drinks
per day for men and 1 for nonpregnant women is most consistent with evidence
regarding alcohol and stroke risk (SOR B).
Currently, no evidence supports the use of high-sensitivity C-reactive protein
screening of the entire adult population as a marker of general vascular risk. This
test can be useful in determining the intensity of risk factor modification in those
who are at moderate general cardiovascular risk based on traditional risk factors
(SOR B).
A 71-year-old male presents as a new patient after moving to an assisted living
facility. Records from his previous physician reveal that he has diabetic
neuropathy and hypertension, and that he had coronary artery bypass graft surgery
at age 62. Over the previous year he has had consistent systolic blood pressures of
130–138 mm Hg and diastolic blood pressures of 80–85 mm Hg. Recent
laboratory screening revealed an LDL-cholesterol level of 110 mg/dL, a
triglyceride level of 190 mg/dL, and a hemoglobin A1c level of 6.5%. He has a
BMI of 24. He stopped smoking a month ago when he moved to the assisted living
facility.
The patient’s current medications include metformin (Glucophage), 1000 mg
twice daily; atorvastatin (Lipitor), 20 mg daily; hydrochlorothiazide, 25 mg daily;
lisinopril (Prinivil, Zestril), 40 mg daily; metoprolol (Lopressor), 50 mg twice
daily; and a daily aspirin.
True statements regarding this situation include which of the following? (Mark all
that are true.)
The effects of smoking cessation on life expectancy in this age group are not wellquantified
Diabetic neuropathy is a relative contraindication to a structured exercise regimen
Increasing the hydrochlorothiazide dosage to 50 mg/day is advisable
Fenofibrate (Fenoglide, Lipofen) is indicated to lower triglycerides in this patient
The expected benefit from more aggressive lipid therapy is greater for this patient
than for a patient in his 50s with a similar profile
Answer
• The expected benefit from more aggressive
lipid therapy is greater for this patient than
for a patient in his 50s with a similar profile
Several studies document mortality and morbidity
improvement after smoking cessation in later life (SOR B).
Even light regular physical activity can have significant
benefits in functional scores and quality of life in older adults
(SOR B).
Although the patient’s blood pressure should be lowered from
its current level, hydrochlorothiazide dosages >25 mg/day are
seldom justifiable based on published evidence of outcomes
and adverse effects (SOR B). Although this patient’s
triglyceride level is in the high normal range, it may decrease
with an exercise regimen and more aggressive statin therapy.
The risk/benefit ratio for combined use of a fibrate and statin
in this case is not favorable (SOR B). Older adults with
known coronary heart disease (CHD) have higher absolute
risk reductions in CHD-related mortality with appropriate
dyslipidemia treatment compared to their younger
counterparts (SOR A).
An 86-year-old female complains of dizziness that has progressively
worsened over the past several months. She describes a feeling of
unsteadiness when standing or walking, and says that she is afraid this will
cause her to fall. Her medical history is significant for glaucoma, chronic
hearing loss, hyperlipidemia, and coronary artery disease.
On examination her blood pressure is 130/80 mm Hg with no orthostatic
changes. Her visual acuity is 20/30 on the right, and 20/50 on the left with
glasses. She has decreased high-frequency hearing in both ears. She is
slightly unsteady when standing up from sitting and when walking across
the room. Routine laboratory testing is unremarkable.
Appropriate treatment for this patient would include which one of the
following?
Epley maneuvers (canalith repositioning)
Vestibular and balance exercises
Meclizine (Antivert) as needed for dizziness
Hydrochlorothiazide/triamterene (Dyazide) daily
Referral for an endolymphatic shunt
Answer
• Vestibular and balance exercises
The elderly often suffer from multiple sensory and motor deficits, including problems with vision,
proprioception, coordination, and strength, which combine to produce an unsteady gait and
disequilibrium. Multiple medications may aggravate the imbalance. Patients with chronic disequilibrium
benefit most from a multifactorial approach to treatment, including correcting visual impairment,
improving muscle strength, reviewing and adjusting medications, and instruction on balance and
vestibular exercises.
Randomized, controlled trials have shown that vestibular rehabilitation exercises improve nystagmus,
postural control, movement-provoked dizziness, and subjective symptoms and distress (SOR A). A
retrospective study showed that physical therapy alleviated dizziness and improved gait and balance in
patients with vestibular and balance disorders (SOR B).
The Epley maneuver is beneficial for benign positional vertigo, which is felt to be caused by small otoliths
that migrate into the semicircular canal, causing intense sensations of movement when the head is turned a
certain way. The vertigo is brief, lasting less than a minute, and recurs when the provocative head
movement is repeated. The Epley maneuver is a series of head movements designed to move the otoliths
through the semicircular canals back to the utricle. It will not work for other causes of vertigo or dizziness
(SOR A).
Meclizine is beneficial for acute episodes of vertigo associated with acute labyrinthitis or vestibular
neuronitis, or cerebellar stroke. Vestibular suppressant medications are not recommended for chronic
symptoms (SOR C). Elderly patients are at increased risk of side effects from these medications, including
sedation, increased risk of falls, and urinary retention.
Hydrochlorothiazide/triamterene is used in the treatment of Meniere’s disease, a problem caused by an
increase in endolymphatic fluid pressure, which affects both vestibular and cochlear function. Affected
persons have repeated episodes of vertigo accompanied by unilateral hearing loss, ear pressure, and
tinnitus. Symptoms last a few minutes to several hours, and occur over a period of years. This medication
is not helpful for disequilibrium (SOR A).
An endolymphatic shunt is a specific treatment for Meniere’s disease unresponsive to other therapies.
A patient has an acute ischemic
stroke, but does not meet the
guidelines for thrombolytic
therapy. The treatment of choice
in this situation is
aspirin, 81 mg aspirin, 325
mg dose-adjusted, unfractionated
heparin high-dose, low molecular
weight heparin clopidogrel
(Plavix), 75 mg
Answer
• aspirin, 325 mg
Patients with an acute ischemic stroke presenting within 48 hours of
symptom onset should be given aspirin (160–325 mg/day) to reduce
stroke mortality and decrease morbidity. Contraindications include
allergy, gastrointestinal bleeding, and recent or planned treatment with
recombinant tissue type plasminogen activator (SOR A). The evidence is
insufficient at this time to recommend the use of any other antiplatelet
agent in this situation.
In the setting of acute stroke (48 hours or less), dose-adjusted,
unfractionated heparin is not recommended for reducing morbidity,
mortality, or early recurrent stroke. It is not efficacious and may be
associated with increased bleeding complications (SOR B). High-dose low
molecular weight heparin has not been associated with either benefit or
harm in reducing morbidity, mortality, or early recurrent stroke in patients
with acute stroke, and is therefore not recommended for this purpose
(SOR A). The effectiveness of clopidogrel has not been addressed by
studies that provide high-quality evidence.
An 88-year-old female with known coronary artery
disease and well-controlled hypertension presents
with severe exertional chest pain for the past 11
hours. An EKG shows ST elevation of 0.2 mV in the
aVL and aVF leads. Stat cardiac enzymes are
consistent with a myocardial infarction, and the
nearest catheterization lab is 2 hours away. The
patient’s recent medical history includes facial
trauma resulting from a fall 2 months ago.
Which one of the findings in this patient is an
absolute contraindication to fibrinolytic therapy?
Her age Her hypertension The EKG findings The
remote time of onset The recent history of facial
trauma
Answer
• The recent history of facial trauma
Fibrinolytic therapy is contraindicated in patients with a
history of facial trauma or significant closed head injury
within the previous 3 months (SOR A). There is no absolute
age contraindication to thrombolytic treatment in acute
myocardial infarction, although combination therapy with
glycoprotein IIb/IIIa inhibitors is contraindicated in those
over age 75 (SOR B). While uncontrolled hypertension is a
contraindication to fibrinolytic therapy, controlled
hypertension is not (SOR A). ST elevation >0.1 mV in two
adjacent limb leads meets the guidelines for therapy (SOR A).
Guidelines state that there is A-level evidence for treating
symptoms that began within the previous 12 hours, and Blevel evidence for treating symptoms that began within the
previous 12–24 hours. The use of fibrinolytic therapy is not
recommended more than 24 hours after the onset of
symptoms.
For patients at the end of life,
treatments shown to be effective
for managing pain include which
of the following? (Mark all that
are true.)
Acupuncture
NSAIDsBisphosphonates
Opioids
Exercise
Answer
• NSAIDS
• Bisphosphonates
Opioids
There is strong evidence to support
the use of NSAIDs, opioids,
bisphosphonates, and radiotherapy
or radiopharmaceuticals for pain
(SOR A). Bisphosphonates should
specifically be used for bone pain
(SOR A). There is insufficient
evidence to recommend acupuncture
or exercise for pain management in
patients at the end of life.
At a routine visit, a 78-year-old male describes a number of changes that
have developed over the past several months, including decreased sleep
due to early awakening, a loss of interest in his hobbies, decreased
appetite, and an overall lack of pleasure. Some of his close friends and an
older sister have died recently, and he says his friends have told him that
his speech and movement seem slower. He has no suicidal thoughts or
plans. He is otherwise healthy and takes no medications except a diuretic
for hypertension, an α-blocker for benign prostatic hyperplasia, and a
daily aspirin. He has never had symptoms like these in the past. His vital
signs are stable, but he has lost 5 kg (11 lb) since you saw him 6 months
ago. His physical examination is otherwise unremarkable.
Which one of the following is true regarding this situation?
The patient should be reassured that his sadness is normal given recent
events, and encouraged to continue his usual activities
Antidepressant medications are the first-line treatment for this problem
The patient is likely to respond well to antidepressant medications because
he has atypical symptoms
The patient is likely to respond well to antidepressant medication because
he has never taken them in the past.
Answer
• Antidepressant medications are the first-line
treatment for this problem
Depression in the elderly should not automatically be ascribed to
demoralization over financial or medical problems or other concerns.
General principles of diagnosis and treatment of adults with major
depressive disorder also apply to elderly patients (SOR A). The patient’s
weight loss, persistence of symptoms, slowed speech, and anhedonia
indicate that at the least this episode should be considered to be moderate
major depression. First-line treatment for moderate to severe depression is
antidepressants, usually SSRIs (SOR A).
The patient does not have atypical symptoms of depression (weight gain,
excessive sleepiness, excessive appetite); even if his depression were
atypical it would be likely to respond to antidepressants, as atypical,
psychotic, and melancholic symptoms usually respond well to
antidepressant medications (SOR A). Patients with a positive response to
antidepressants during a previous episode are likely to respond well
subsequently. It is not possible to predict medication response in an
antidepressant-naive patient (SOR A).
Nursing-home reforms enacted as part of the
Omnibus Budget Reconciliation Act of 1987
include which of the following? (Mark all that
are true.)
Expanded Medicare coverage for nursinghome custodial care
Restrictions on the use of physical restraints
Restrictions on the use of psychoactive
medications
Significant improvement in measures of
quality of care
Minimum training and staffing requirements
Answer
• Restrictions on the use of physical restraints
• Restrictions on the use of psychoactive
medications
• Minimum training and staffing
requirements
The Omnibus Budget Reconciliation Act (OBRA) of
1987 included extensive nursing-home reforms.
OBRA established training guidelines and minimum
staffing requirements, and strengthened residents’
rights, including limits on the use of restraints and
psychoactive medications. The law also requires a
periodic comprehensive assessment of all nursinghome residents. This assessment, known as the
Minimum Data Set (MDS), focuses on clinical issues
related to quality care. Although some evidence
suggests that OBRA and later regulations have
decreased the prevalence of pressure ulcers and the
use of restraints, the impact on overall quality of care
has been difficult to quantify.
Pain management in the vulnerable
elder requires a comprehensive
treatment plan which includes which
of the following? (Mark all that are
true.)
Elimination of pain
Formation of personal goals
Decreased physical activity
Methods to improve sleep
Interventions to manage stress
Answer
• Formation of personal goals
Methods to improve sleep
Interventions to manage
stress
Complete elimination of pain is not a
reasonable goal, since adverse effects of
potent analgesics are not well tolerated in the
vulnerable elderly. In addition, complete
elimination of pain may eliminate protective
pain (SOR C). Individual variations in
underlying functional status determine goals
(SOR C). Physical activity improves both
perception of well-being and tolerance of pain
(SOR B). Adequate sleep enhances the ability
to function and tolerate pain (SOR C).
Elevated stress levels heighten awareness of
pain (SOR A).
An 83-year-old male has had three episodes of acute gout in
the past 18 months. During the first episode he was found to
have monosodium urate crystals in synovial fluid from the
involved joint. He has mild hypertension that is well
controlled on an ACE inhibitor alone. His creatinine level is
normal.
True statements regarding urate-lowering therapy for this
patient include which of the following? (Mark all that are
true.)
Probenecid is the recommended first-line agent for uratelowering therapy
The target serum uric acid level is <6 mg/dL
Modifiable risk factors such as obesity, diuretic use, dietary
purine, and alcohol intake should be addressed even if the
patient is on urate-lowering therapy
When initiating urate-lowering therapy, prophylaxis with
low-dose colchicine for 6 weeks is recommended to reduce
Answwer
• The target serum uric acid level is <6
mg/dL
• Modifiable risk factors such as obesity,
diuretic use, dietary purine, and alcohol
intake should be addressed even if the
patient is on urate-lowering therapy
Patients with recurrent gout attacks, tophi, or
ongoing arthropathy with radiographic evidence of
joint damage should receive urate-lowering therapy
to prevent complications (SOR C). Allopurinol is the
recommended first-line agent for urate-lowering
therapy (SOR C). The target serum uric acid level
during urate-lowering therapy is <6 mg/dL (SOR B).
Modifiable risk factors should be addressed to
achieve the optimal response to therapy (SOR B).
Prophylaxis with low-dose colchicine should be
continued for 3–6 months to reduce the risk of flareups (SOR B).
An 85-year-old female comes to your office for the
first time. Her previous physician recently retired.
When you review her medical history, she tells you
she has osteoarthritis, depression, and diabetes
mellitus. She has brought all her medications with
her, and you note that she takes acetaminophen,
hydrochlorothiazide, glyburide (DiaBeta), metformin
(Glucophage), and sertraline (Zoloft).
Which one of her medications should you consider
discontinuing?
Acetaminophen
Hydrochlorothiazide
Glyburide
Metformin
Sertraline
Answer
• Hydrochlorothiazide
It is important to review the
medication list of vulnerable elders
at each office visit. Each medication
should have a clear indication
documented in the chart (SOR C). In
this case, there is no apparent
indication for a diuretic. The
acetaminophen, diabetes
medications, and antidepressant are
indicated to address a diagnosed
problem.
True statements regarding hospice services include
which of the following? (Mark all that are true.)
The Medicare hospice benefit pays for nursing-home
room and board
All medications being taken at the time of hospice
enrollment are covered by the Medicare hospice
benefitIf a patient lives longer than 6 months after
hospice enrollment, the Medicare hospice benefit
expires
Bereavement services for the family and caregivers
is covered for at least a year after death
Hospices are subject to both state and federal
evaluation
Answer
• Bereavement services for the family and
caregivers is covered for at least a year after
death
Hospices are subject to both state and
federal evaluation
Although one can be enrolled in hospice while
in a nursing home, the Medicare hospice
benefit does not pay for room and board. Only
medications related to the hospice diagnosis
are covered. An unlimited number of 60-day
extensions are available if the disease does not
run its expected course. The Medicare hospice
benefit covers bereavement for 13 months.
State evaluation of hospice facilities is
mandatory for state licensure, and federal
evaluation is required for Medicare
reimbursement.
An 86-year-old female is brought to your office by her daughter because
the mother has developed a large breast mass. The patient’s medical
history is significant for hypothyroidism and mild to moderate dementia.
Your examination and a mammogram indicate that the mass may be
malignant.
The daughter wants the patient to have a biopsy, but the patient refuses,
saying, “I’m old and I don’t care if I die.“ The patient has no history of
depression and the mass is not causing any pain.
What factors should be taken into account when assessing the patient’s
ability to make her own decisions? (Mark all that are true.)
The patient’s ability to express a choice clearly
The patient’s ability to understand the treatment options
The patient’s ability to say how the procedure would affect her condition
Whether the patient has a living will
The presence or absence of depression
Answer
• The patient’s ability to express a choice
clearly
The patient’s ability to understand the
treatment options
The patient’s ability to say how the
procedure would affect her condition
The presence or absence of depression
Physicians should evaluate patients for decision-making capacity when there is an abrupt
change in mental status, when patients refuse recommended treatment, when patients
consent too hastily to risky or invasive treatment, or when the patient has a known risk
factor for impaired decision-making. Risk factors include chronic neurologic or psychiatric
conditions, a significant cultural or language barrier, and a low education level.
Decision-making capacity is specific to the event requiring the decision. Patients may be
able to decide some aspects of their care, but not others.
Assessment of the patient’s decision-making capacity should include determination of the
patient’s ability to
understand the recommended treatment and alternatives (SOR C)
appreciate how that information applies to their own situation (SOR C)
reason with that information, supported by facts and the patient’s own values (SOR C)
communicate and express a choice clearly (SOR C)
The patient should also be evaluated for depression, since untreated depression may affect
decision-making capacity (SOR C). Incapacity is not the same as incompetency, however.
Incompetency is a decision made in court and is associated with loss of legal rights.
If the patient is judged to be incapable of making his or her own decision, then the patient’s
living will or advance directives should be used when making end-of-life decisions (SOR
C).