Geriatric Medicine: Addressing the Unique Needs of Older Adults, Exams of Nursing

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Week 5 Chapter 4: Lesbian, Gay, Bisexual, Transgender Medicine in Older Adults Test Questions

1. An 86-year-old female comes to your office for a wellness visit. Her blood pressure is 125/70 mmHg, pulse 69 beats per min, and respiratory rate 18 breaths per min. She is well appearing and reports she is up to date on her routine vaccinations. She introduces her partner of 35 years whom she would like to make medical decisions for her in case she becomes unable to make decisions for herself. She reports that she and her partner are not married. She asks if she needs any further documentation to ensure her goals of care are followed. Which one of the following would be the most appropriate recommendation for this patient and her partner? a. Advise them to complete a POLST. b. Advise them that they have adequate documentation to be recognized legally. c. Advise them to file an advanced directive. d. Respond that although they lack documentation, her partner will be recognized de facto. Answer: c.
2. An 81-year-old transgender female with history of depression and hyperlipidemia presents to your clinic for routine care. She endorses a history of smoking, currently smoking 1 pack per day, and occasionally drinks a glass of wine, although she denies illicit drug use. She reports she takes atorvastatin 20 mg and subcutaneous estrogen therapy. Which of the following is the most important next step in this patient’s primary care? a. Counseling on starting aspirin b. Counseling on alcohol cessation c. Counseling on smoking cessation d. Counseling on mammogram Answer: c.
3. An 84-year-old male with history of stroke without residual deficit, systolic heart failure, and type 2 diabetes presents to clinic for follow-up. He is independently living in a retirement community and still works part time on a golf course. He currently takes aspirin 81 mg, metoprolol tartrate 25 mg BID (twice a day), furosemide 20 mg BID, and lisinopril 10 mg daily. He reports his last colonoscopy was 8 years ago, with no abnormality. He reports he is sexually active with men and women, engaging in receptive oral, receptive anal, and penetrative sex. He states he has had over three sexual partners in the last year with intermittent condom use. What sexually transmitted infection testing should be offered? a. Urine testing

b. Urine testing, blood testing c. Urine testing, blood testing, anal swab d. Urine testing, blood testing, anal swab, and oropharyngeal swab Answer: d. Chapter 23: Urinary Incontinence Test Questions

1. Which of the following is true about tolterodine? a. It should be avoided in men with prostatic hypertrophy. b. It increases the risk of constipation compared with oral oxybutynin. c. It acts by ablating detrusor spasms. d. It has greater risk of adverse effects with its twice-daily formulation. Answer: d
2. An 82-year-old man, Mr. A, complains of worsening nocturia, occurring four times per night. His other lower urinary tract symptoms are slow stream, occasional urgency, and urgency-related leakage once weekly. Medical problems include poorly controlled hypertension, diastolic heart failure, hyperlipidemia, osteoarthritis, and prediabetes. His medications include lisinopril 20 mg daily, metoprolol succinate 75 mg daily, atorvastatin 10 mg daily, metformin 500 mg twice daily, hydrocodone- acetaminophen as needed, and aspirin 81 mg daily. Amlodipine 5 mg daily was recently added by his cardiologist. On review of systems, Mr. A complains that nocturia is causing daytime fatigue, and he is more constipated. Physical examination is notable for blood pressure 162/83 mmHg, heart rate 60 beats per minute, clear lungs, soft abdomen, enlarged prostate, and 21 pretibial edema. Your next step in management should be: a. Stop hydrocodone-acetaminophen and add naproxen. b. Stop amlodipine and increase lisinopril. c. Add afternoon furosemide. d. Add tamsulosin. Answer: b
3. The daughter of a 79-year-old woman notes that her mother, who has dementia and lives with her, is wetting herself when she attends her new day program. Program staff have requested that “something be done” as she is requiring a clothes change nearly every time she is there. She cannot describe the circumstances of leakage, saying “it just comes.” Leakage is uncommon at home. Her medications include donepezil and acetaminophen. Physical examination is normal. Initial treatment approach will require intervention by which of the following?

a. Mrs. A’s physician b. Mrs. A’s daughter c. Day program staff d. Physical therapist through a home care agency Answer: c

4. Ms. J, who is 82 years old, complains of urine leakage while playing golf. This has gotten worse over the past year, and she rarely makes it through nine holes without feeling like she needs to “run into the bushes and go.” Leakage is usually small volume, but causes her extreme embarrassment because she is afraid she will smell of urine. She has tried limiting caffeine in the morning before she golfs and avoiding drinking water while playing, to no effect. She also tried “those Kegler” exercises in the past without success. Which of the following is the most appropriate recommendation for Ms. J? a. Bladder training b. Referral for biofeedback training in pelvic muscle exercise c. Trial of solifenacin d. Trial of topical estrogen Answer: a Chapter 32: Sexual Health Test Questions
5. What is the most common cause of erectile dysfunction in older men? a. Psychological stress b. Adverse drug reaction c. Atherosclerosis d. Autonomic neuropathy Answer: c
6. Which is the most reasonable first step in the treatment of older men with erectile dysfunction? a. Sex therapy b. Testosterone c. Yohimbine

d. Sildenafil Answer: d

3. A 72-year-old woman reports vaginal dryness that interferes with coitus. Her medical history includes type 2 diabetes, hypertension, and osteoarthritis. Medications are glyburide, chlorthalidone, and acetaminophen. What would be your first step in therapy? a. Stop glyburide b. Stop chlorthalidone c. Stop acetaminophen d. Start topical vaginal lubricant Answer: b
4. A 70-year-old woman reports sexual pain with deep penetration only. What is the most likely cause of her problem? a. Vaginal atrophy b. Provoked vulvar vestibulodynia c. High-tone pelvic floor dysfunction d. Endometriosis Answer: c Chapter 46: Cancer Test Questions
5. A 79-year-old woman with a 1.5-cm breast cancer underwent lumpectomy. Pathology revealed ductal carcinoma that is hormone receptor negative (estrogen receptor 0%, progesterone receptor 1%) and HER2/neu negative. Surgical margins were adequate and uninvolved with cancer. Sentinel lymph node sampling was negative for lymph node involvement. She has good performance status and no activities of daily living (ADL) or instrumental (IADL) dependencies. What treatment would you recommend? a. Adjuvant chemotherapy b. Adjuvant chemotherapy with irradiation c. Adjuvant irradiation only d. Hormonal therapy only e. None of the above Answer: d.

2. An 86-year-old man with no ADL deficits who has stopped driving because of macular degeneration is evaluated for a urinary tract infection associated with urinary retention. The consulting urologist places a Foley catheter and sends a prostate- specific antigen (PSA) level that comes back 12 ng/mL. Three months later after the Foley has been removed and he has had a good response to tamsulosin, his PSA is still 10 ng/mL. What is the appropriate next step in managing this man’s prostate problem? a. Transrectal ultrasound and biopsy b. Empiric finasteride c. Bone scan d. Repeat PSA in 6 months e. Observation Answer: d
3. In which of the following patients is chemical or surgical castration likely to prolong survival? a. A 78-year-old man with advanced dementia and prostate cancer metastatic to the bone. b. A 78-year-old man who had a radical prostatectomy 10 years earlier and now has a PSA level of 5.7 ng/mL. A year ago it was 0.1 ng/mL. A bone scan is negative and an abdomen-pelvis computed tomography (CT) is negative. c. A 78-year-old man who had a radical prostatectomy and external beam radiation therapy 10 years earlier now has a PSA level of 24.5 ng/mL. A CT scan of the pelvis shows an enlarged pelvic lymph node, and a bone scan is positive in the pelvis. d. A 78-year-old man with prostate cancer limited to the prostate with a Gleason score of 6. e. None of the above. Answer: c.
4. On admission to the hospital, an 85-year-old woman was found to have a fungating mass on her right breast. The mass is 9 cm in diameter, partially ulcerated, and associated with edema of the arm and obvious pain. The patient has no children and had lived alone until recently, when a neighbor became concerned for what appeared to be a progressive loss of memory and neglect of the house. A nephew living in another city eventually came to take care of the situation and arranged for the admission. The patient appears confused and withdrawn; her appearance is disheveled, but she seems to be independent in her ADLs. The medical history is negative for any serious illnesses. She was able to drive her own car until shortly before this admission. The nephew does not wish to authorize hospice “right now.” A positron-emission tomography scan was negative for metastatic disease. In addition to determining the cause of her delirium, which of the following is the best way to address the breast mass?

a. Tamoxifen should be initiated immediately. If no response is seen in 3 months, the patient should receive chemotherapy. b. The mass should be biopsied to study hormone receptor and HER2/neu antigen status. c. The patient should undergo surgery as initial treatment. d. The initial treatment should be radiation therapy. e. No treatment is indicated because the patient’s average life expectancy is less than 1 year, and during this period of time the tumor is unlikely to cause local complications. Answer: b.

5. A 78-year-old man has an emergency partial colectomy for lower gastrointestinal bleeding. A localized colonic adenocarcinoma is completely resected. The surgeon did not dissect lymph nodes for metastatic sampling. The patient wants to know if he should have chemotherapy. Should he? a. Yes because without knowing his complete staging it would be safer. b. No because he can be followed with serial carcinoembryonic antigens and CT scans. c. Yes because the severe bleeding indicates advanced disease. d. No because he is too old and will not likely have any problems during his lifetime. e. No because the chemotherapy is too toxic Answer: b.
6. An 80-year-old woman has no weight loss, no pain, and no distention but over 2 years increasingly complains of constipation despite adequate medical treatment. A colonoscopy is negative. An abdominal CT is performed. It reveals well-circumscribed pelvic masses, the largest adherent to the ovarian ligament. The best first step is: a. Referral to a gynecological oncologist. b. Transcutaneous CT guided biopsy. c. Because it is unrelated to her symptoms advise observation. d. Refer to hospice because massive ovarian cancer is unlikely to be curable. e. Invite her to return with a family member and have a long talk about the diagnostic and therapeutic options. Answer: e. Chapter 49: Infectious Diseases Test Questions

1. An 85-year-old man with chronic obstructive pulmonary disease presents to your office with his daughter with the complaint of new onset chest pain, shortness of breath, and cough. He is clearly tachypneic and has tactile fremitus and egophany and crackles heard at the right lung base. His daughter just wants you to give him an antibiotic pill so that she can take him home. You are concerned that he might need to be hospitalized and require IV antibiotics. What statement is true? a. All older adults with pneumonia must be treated for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas infection. b. Treatment decisions for pneumonia are based on its severity, the presence of comorbid illnesses, and a prior history of MRSA or Pseudomonas respiratory infection. c. All older adults with pneumonia must be treated in hospital. d. Pulse oximetry, respiratory rate, and chest radiography would not be helpful for the diagnosis and management of pneumonia in older adults. Answer: b
2. An 80-year-old woman that you follow in a nursing home has an acute decline in her mental status. She has a fever >100° F, but no other focal complaints or findings on physical examination except for a chronic indwelling urinary catheter. What statement is true? a. Fever in an older adult with an indwelling urinary catheter is an appropriate indication to start empiric antibiotic therapy. b. Older adults with an indwelling urinary catheter are less likely to have bloodstream infection than older adults without a catheter. c. It is not necessary to obtain a urine culture; empiric antibiotic treatment is sufficient. d. She only needs antibiotic treatment for 3 days. Answer: a
3. An 82-year-old woman receives oral amoxicillin-clavulate for a skin abscess on her leg. She develops new onset of frequent watery stool that persists for several days after the antibiotic is stopped. You obtain a stool for Clostridium difficile antigen, toxin, and polymerase chain reaction (PCR). The antigen and PCR are both positive. She has never had C. difficile infection before. What one statement is the best answer regarding her management? a. Metronidazole is the treatment of choice for C. difficile infection. b. Older adults with their first episode of C. difficile require a longer duration of treatment with vancomycin. c. Fecal transplantation is the treatment of choice for C. difficile infection. d. Either vancomycin or fidaxomicin are recommended for the first episode of C. difficile infection. Answer: d

Chapter 51: Benign Prostate Disease Test Questions

1. A 75-year-old man presents with the chief concern, “I may have a bladder infection.” Further questioning reveals for several months he has been needing to void every couple of hours (can’t sit through a whole ball game), feels he must go as soon as he feels the urge (he tried putting it off and had urinary leakage), and is getting up two to three times at night to void. He denies delay in voiding or straining to initiate voiding, slow stream, feeling of incomplete emptying, or dribbling after completion of urination. He also denies dysuria and abdominal pain. Which of the following best describes the category or type of his lower urinary tract symptoms? a. Prostatism b. Overactive bladder c. Postmicturition d. Storage (irritative) e. Voiding (obstructive) Answer: d
2. A 70-year-old man has bothersome lower urinary tract syndrome (LUTS) associated with benign prostatic hyperplasia (BPH). His symptoms are no longer well managed with lifestyle modifications. He is interested in medication to reduce his urinary symptoms but is concerned about possible side effects. He notes that he is recently married and sexual activity is very important to him. Which of the following medications would be most appropriate for this patient? a. Alfusozin b. Ditropan c. Dutasteride d. Tamsulosin e. Tadalafil Answer: a
3. A 66-year-old man complains of nocturia (three to four times a night), hesitancy, and incomplete emptying of the bladder. Physical examination reveals an enlarged, nontender prostate, about 40 g in size without discrete nodules. Urinalysis reveals hematuria without leukocyte esterase. Upon further evaluation, the hematuria is attributed to his BPH. The patient declines surgical options at this time. Which of the following medications would be most appropriate? a. Oxybutynin b. Doxazosin

c. Finasteride d. Silodosin e. Tadalafil Answer: c

4. Mr. Quince is a 68-year-old patient who describes several months of urinary frequency and a sensation of incomplete emptying with no associated dysuria, hematuria, or fever. Physical examination reveals a slightly enlarged but nontender prostate, a postvoid residual urine volume of 20 mL, and a urinalysis with 15 white blood cells (WBCs) and 5 red blood cells (RBCs). Urine culture reveals 30,000 colony- forming units of Escherichia coli. You see a report from last year that shows urinalysis with 10 WBCs and 4 RBCs that was obtained as part of a routine evaluation. What is the most appropriate next step in the management of Mr. Quince’s symptoms? a. Start an alpha-blocker. b. Start a 5-alpha-reductase inhibitor. c. Start combination therapy with an alpha-blocker and a 5-alpha-reductase inhibitor. d. Start a 4-week course of ciprofloxacin. Answer: d
5. Mr. Roberts, a 72-year-old patient who has sought medical care on an intermittent basis in the past, complains of aching discomfort in his perineal area, urinary urgency, and frequency for the past few years. He also complains of insomnia and intermittent anxiety that he attributes to loneliness after his wife’s death about a year ago. Digital rectal examination (DRE) reveals a slightly enlarged, nontender prostate with no palpable nodules. Perineal examination is normal. Bladder scan is unremarkable and postvoid residual urine volume is 50 mL. Urinalysis shows no WBCs or RBCs. Urine culture is negative. Previous treatment has included dietary modification and alpha-blocker medication. What is the most appropriate next step? a. Start an 8-week course of ciprofloxacin. b. Start a 5-alpha-reductase inhibitor. c. Perform urodynamic testing. d. Screen for depression. Answer: d
6. Mr. Hunter, a 69-year-old man, complains of urinary frequency and urgency that have increased over the past several months. There is no dysuria, hematuria, or sensation of incomplete voiding. He drinks 2 cups of coffee daily and diet cola multiple times a day. His International Prostate Symptom Score (IPSS) is 6, with a bother score of 1 indicating mild voiding symptoms with low impact on his quality of life. His medical history includes hypertension, coronary artery disease, and benign prostatic hyperplasia. Current medications are aspirin, metoprolol, and hydrochlorothiazide.

Physical examination reveals normal sized prostate. Which of the following is the best next step? a. Urinalysis b. Cystoscopy c. Lifestyle modifications d. Tamsulosin e. Finasteride Answer: c

7. Two years later Mr. Hunter reports progression of his urinary symptoms and desires “a pill to make this better.” His current IPSS is 17, with a bother score of 3 indicating moderate voiding symptoms with moderate impact on his quality of life. On review of systems he notes that his vision has worsened, especially in his left eye. His ophthalmologist has recommended cataract surgery. For which of the following medications would initiation of therapy be delayed until after cataract surgery? a. Finasteride b. Tamsulosin c. Tadalafil d. Oxybutynin Answer: b
8. Several years later, Mr. Hunter, who is now 75 years old, seeks additional intervention for his urinary symptoms that have progressed further. He now experiences slow urinary stream, hesitancy, straining, and a feeling of incomplete emptying in addition to the previous urinary urgency and frequency. At times, he has noted blood in his urine. He has had five urinary tract infections (UTIs) in the past 2 years. His current IPSS is 24, with a bother score of 5 indicating severe voiding symptoms with high impact on his quality of life. Mr. Hunter’s updated medical history includes hypertension, coronary artery disease, benign prostatic hyperplasia, cataract surgery 4 years ago, and two falls within the past year while rushing to the bathroom during the night. Current medications are aspirin, metoprolol, finasteride, and tamsulosin. Physical examination reveals an enlarged, nontender prostate, about 50 g in size without discrete nodules. Upon further evaluation, the intermittent hematuria is attributed to BPH. Postvoid residual volume is 110 mL. Uroflowmetry reveals urinary flow rate of 12 mL/s. Which of the following is the best next step in management? a. Start tadalafil. b. Switch from tamsulosin to silodosin. c. Switch from finasteride to dutasteride. d. Perform surgical resection of prostate.

Answer: d Week 6 Chapter 17: Delirium Test Questions

1. A 67-year-old female with a history of congestive heart failure and myocardial infarction is admitted to the hospital because of increasing altered mental status and decreased arousal over the last week. Physical examination reveals a confused woman with right lower lobe crackles and a pulse oximetry of 86% on room air. While you are interviewing the patient, she is irritable, paranoid, and inattentive, which her family tells you is out of character. You notice waxing and waning in her alertness and impaired short-term memory during your examination. Which one of the following features present in this patient best distinguishes delirium from depression or dementia? a. Irritability b. Inattentiveness c. Paranoia d. Aggressiveness Answer: b
2. A 72-year-old man with colonic diverticulosis was admitted to the hospital with gastrointestinal bleeding and abdominal pain. He underwent colonoscopy under conscious sedation using fentanyl and midazolam. The following day, the patient was positive on the Confusion Assessment Method performed by the geriatric consultation services. Presence of delirium in this patient predisposes him to all of the following except: a. Higher risk of institutionalization b. Increased risk of dementia c. Shorter length of stay in the hospital d. Increased mortality Answer: c
3. A 78-year-old male who resides at a nursing home has Lewy Body dementia, frequent falls, visual hallucinations, and sleep disturbances. He is transferred to your hospital with poor oral intake and confusion of 3 days duration. Physical examination reveals a thin man with dry mucous membranes, tachypnea, tachycardia, and confusion. To reliably identify delirium in this patient in a time-efficient manner (<5 minutes), what will be your instrument of choice? a. Folstein Mini-Mental State Examination (MMSE)

b. Confusion Assessment Method (CAM) c. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) d. Glasgow Coma Scale (GCS) e. Delirium Rating Scale - Revised 1998 (DSR-R98) Answer: b

4. An 84-year-old woman complains of nausea and vomiting for the past 3 days. She has a history of multiple abdominal surgeries, adhesions, and recurrent hospitalizations for partial small bowel obstruction. She has visual and hearing impairment and is currently taking oxybutynin for neurogenic bladder. You recognize she is high risk for development of delirium. Interventions that may prevent the onset of delirium among older adult hospitalized patients include all of the following except: a. Early mobilization b. Ensuring 6 hours of uninterrupted sleep per night c. Treating volume depletion d. Treating anxiety with lorazepam e. Ensuring access to hearing and visual aids Answer: d
5. A 78-year-old man with multi-infarct dementia, chronic kidney disease, congestive heart failure, and uncontrolled hypertension was hospitalized with a heart failure exacerbation. He was initially treated with diuretics and salt restriction and his condition stabilized. On day 3 of his hospital stay, he developed confusion, restlessness, and combativeness. Utilization of sitter, redirection, calming music, and reassurance are unsuccessful. When safety of the patient and staff are in jeopardy and nonpharmacologic approaches have failed, which of the pharmacologic agents would be the best choice for treating the agitation associated with his delirium? a. Melatonin b. Haloperidol c. Diazepam d. Gabapentin e. Diphenhydramine Answer: b Chapter 18: Alzheimer’s Disease and Other Dementias Test Questions

1. A 69-year-old female presents to your office for routine primary care. Her elder sister was recently diagnosed with Alzheimer disease, and she wonders what steps she can take to reduce her own risk of developing dementia. Which of the following statements about the prevention of dementia is true? a. There is moderate quality evidence to support daily use of vitamin B12 and fish oil to prevent risk of cognitive decline. b. Risk of dementia is modulated by nonmodifiable risk factors, such as genetics, family history, and educational attainment, and there are no behavioral interventions that can be taken to reduce risk of developing dementia. c. There is moderate quality evidence to suggest control of cardiovascular and metabolic risk factors, such as blood pressure, weight, and blood sugar, may reduce risk of dementia. d. There is moderate to low quality evidence supporting cannabinoids may reduce rates of progression from mild cognitive impairment to dementia. Answer: c
2. A 78-year-old male was recently diagnosed with Alzheimer disease. He scored 23/ on his Montreal Cognitive Assessment chap21 (MoCA) and his clinical presentation is consistent with mild disease. He returns to clinic with his family to discuss possible initiation of pharmacotherapy. You consider beginning donepezil 5 mg daily for 4 weeks, with a plan to increase to 10 mg daily if he tolerates the lower dose. Which of the following is not a common side effect of donepezil? a. Thrombocytopenia b. Bradycardia c. Vivid dreams d. Gastrointestinal distress Answer: a Chapter 19: Depression Test Questions
3. The remission rate of depressed patients who are 65 years and older to initial antidepressant treatment is: a. 30% b. 40% c. 70% d. 80% Answer: a

2. Which of the following groups has the highest rate of suicide in older adults? a. Asian males b. Hispanic males c. White males d. Black males Answer: c
3. Which of the following is not a risk factor for late-life depression? a. Family history of depression b. Disability c. History of stroke d. History of a myocardial infarction e. Loss of a loved one Answer: a
4. Which of the following is not a side effect of selective serotonin reuptake inhibitors in older adults? a. Extrapyramidal symptoms b. Gastrointestinal bleeding c. Gastrointestinal irritation d. Hyponatremia e. Increase in suicidal ideation Answer: e
5. You want to start pharmacologic treatment for depression in an older patient who is taking numerous medications. You are concerned about drug–drug interactions. Which of the following antidepressants is the least likely to cause such an interaction? a. Citalopram b. Fluoxetine c. Paroxetine d. Venlafaxine e. Bupropion

Answer: a Chapter 21: Dizziness Test Questions

1. Randall Johnson, an 80-year-old man with a history of high blood pressure and hypothyroidism, presents to your office with ongoing dizziness. He feels it has worsened since the summer months began. He states it is worst when he gets up from his chair on his front porch to stand or when he is working in his garden. If he stands still for a few minutes, the dizziness typically resolves on its own. If he tries to move too quickly, he has felt like he may pass out, but has not yet done so. He denies changes in vision or hearing. He has had no recent changes in his medication. On examination today, he is a frail-appearing older man in no acute distress. Vitals show a blood pressure of 118/71 mmHg with a pulse of 55 beats per minute. Heart and lung exams are benign. What is the most likely cause of his dizziness? a. Orthostatic hypotension b. Benign positional paroxysmal vertigo c. Overcontrol of thyroid d. Ménière disease Answer: a
2. Joyce Mitchell is a 73-year-old frail female with a history of frequent falls, who presents with rapid onset of nausea, vomiting, sweating, and horizontal nystagmus. She also reports hearing loss in the right ear. After testing and further questioning, you diagnose the patient with vestibular neuritis. What is the best initial course of treatment? a. Vestibular rehabilitation b. Supportive care with antinausea and antivertigo medication c. Fluids d. Epley maneuver Answer: b
3. Pedro Lopez is an 89-year-old male who presents to you with the complaint that he continuously experiences the feeling that a fall is imminent. He appears comfortable when seated, but is notably unsteady and imbalanced when erect, walking with a broad-based gait. Which of the following is not a standard treatment modality for this condition? a. Assistive device, such as a cane b. Physical therapy focusing on balance training c. Meclizine

d. Hearing and vision amplification Answer: c Test Questions

1. Which of these is true regarding the relationship of frailty with cognition? a. Cognitive frailty is synonymous with dementia. b. Patients with Alzheimer disease do not have higher rates of frailty. c. Neither the frailty index or Fried frailty criteria include cognition assessment. d. Currently, to be considered cognitively frailty it requires a MMSE score over 26. Answer: d
2. Which of these clinical vignettes are not part of the Fried frailty paradigms? a. Mrs. P has a caregiver comb her hair now because of inability to hold her arm up long enough to brush it herself. b. Mr. J has just been diagnosed with congestive heart failure after a recent admission to the hospital for a myocardial infarction. c. Mr. K has been losing weight for the last year despite family support of bringing food and negative workup for more insidious cause. d. Mrs. T tells you she spends the majority of her time in her chair and only walks to the bathroom now because she gets too fatigued for minor home care tasks. Answer: b
3. Which of these statements about frailty are false? a. Neither prominent frailty model currently uses age as a component for defining frailty b. Individuals who are prefrail have a higher likelihood of becoming robust than those with frailty. c. Clinical diagnosis of anxiety or depression do not have any effect on frailty rates. d. Frailty diagnosis has proved valuable in preoperative assessment of patients likely to do well with surgical interventions. Answer: c
4. John P. is an 81-year-old male with extensive cardiac history, including three vessel coronary artery bypass graft when he was in his 60s, hypertension, diabetes mellitus, osteoarthritis, sciatica, and progressive macular degeneration. His vitals today are blood pressure 146/86 mmHg, heart rate 67 beats per minute, respiratory rate 21 breaths/min, and temperature 98.7° F. He is here with his only son and has been living in an assisted living since his wife died 3 years ago. His Montreal cognitive

assessment (MoCA) 1 month ago was 23/30. He has no advance directive in the chart. He tells you he’s “been slowing down” a lot lately. He does not go down to the dining room because it is too taxing, he has been slowly losing weight because food does not taste good, he has fallen four times in the last year. He has no specific concerns to discuss today. What is the most important thing that can be addressed at today’s visit? a. His elevated blood pressure noted on today’s vitals. b. Repeating his MoCA testing to assess for cognitive change. c. Suggest completion of an advance directive at visit with his goals of care in mind for moving forward in his care. d. Review his last colonoscopy report and discuss further screening procedures. Answer: c Chapter 31: Sleep Disorders in Older Individuals Test Questions You have recently assumed directorship of a nursing home that has a 30-bed dementia unit. The nursing home does not have an onsite pharmacist. You go to the dementia unit for patient observation and chart review. Immediately, you notice that although it is 9:00 AM, and most of the patients have been taken out of their rooms and placed in the dayroom, they are dozing in their wheelchairs. The window blinds block about half of the sunlight, and without the overhead fluorescent lighting, the room would be considered dimly lit. The nurses have just finished administering the morning medications. You begin focused chart review, concentrating on patient medications, cognitive/functional status, and comorbidities. When you are finished, you note that of the 28 patients currently living in this facility, seven of them are receiving a low-moderate dose of an atypical antipsychotic (quetiapine, olanzapine, risperidone, etc.) before bedtime, but only one of these patients has any history of recurrent visual hallucinations and delusions. All of these individuals have either moderate-to-severe dementia from Alzheimer disease or vascular/Alzheimer overlay listed among their problems. You ask the charge nurse why these patients are receiving these medications, and he replies that his counterpart on the night shift stated that many of these patients did not sleep through the night, cried out from their rooms, woke other patients, and seriously disrupted the limited staff’s ability to manage the facility. The night nurse thus asked the previous attending to prescribe medications that would help these individuals sleep through the night.

1. What further diagnostic steps are required in the seven patients receiving atypical antipsychotics? a. All patients should receive 1 week of actigraphy monitoring both on and off their current antipsychotic. b. All patients should be immediately referred for cognitive behavioral therapy for insomnia (CBTI). c. All patients should receive referral to both psychiatry and neurology, neuroimaging, and screening polysomnography to identify underlying sleep disorder.

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

2. What is an appropriate step in the initial management of the seven patients receiving atypical antipsychotics? a. No action is necessary, because one potential indication for atypical antipsychotic use is refractory behavioral disturbance in persons with significant dementia. b. Taper to discontinue the atypical antipsychotic; after a 2-week washout, begin therapy with zolpidem. c. Taper to discontinue the atypical antipsychotic, and create day programs that allow patients to develop a sleep deficit/need through the morning/afternoon/early evening. d. Start modafinil or a similar short-acting stimulant to minimize daytime sleepiness. Answer: c
3. What aspects of sleep hygiene may make your facility more conducive for nighttime sleep? a. Bright lights to illuminate pathways to bathrooms. b. Judicious restraint use to ensure patients remain in bed overnight. c. Allow patients with greater degree of dementia an opportunity for an afternoon nap to improve their cognitive status. d. Neutralizing antiseptic smells, minimize movement of equipment through halls, maintain quiet hours where staff can speak in areas away from residents, avoid using overhead announcement systems. Answer: d
4. Which of the following statements regarding programs to increase daytime engagement in persons with dementia is true? a. Daytime exercise programs are contraindicated in this population because of high risk of fall and fracture. b. Daytime programs are designed to maintain client wakefulness, and as such can cover a broad range of topics, including music, art, exercise, dance, and cognitive tasks (puzzles, etc.), and should be designed with patient cognitive and physical status, cultural beliefs, social support, and available staffing in mind. c. Daytime programs that lack a physical exertion component do not contribute to physiologic need for sleep, and are thus less effective than programs that require client physical exertion.

d. Daytime programs must include moderate to rigorous intensity physical exercise (3– mets) to generate an appropriate sleep deficit in nursing home residents. Answer: b Chapter 40: Stroke and Transient Ischemic Attacks Test Questions

1. An 85-year-old man with newly diagnosed nonvalvular atrial fibrillation comes to the office for a follow-up. He has a history of essential hypertension, type 2 diabetes mellitus, hyperlipidemia, and stage 3B chronic kidney disease. He takes lisinopril, atorvastatin, metformin, and aspirin. He lives in an assisted living facility and uses a walker for ambulation. He has fallen twice in the past year. On physical examination, his heart rate is normal but his rhythm is irregularly irregular. His blood pressure is 135/70 mmHg. Which medication change would be most appropriate for reducing his stroke risk? a. Current medications are appropriate. b. Continue aspirin and start warfarin with international normalized ratio goal 2–3. c. Stop aspirin and begin apixaban 5 mg twice a day. Answer: c.
2. A 79-year-old woman was admitted to the hospital a month ago with an acute left middle cerebral artery ischemic stroke. On examination, she had right hemiparesis, mild motor aphasia, and dysphagia. After discharge, she was transferred to a skilled nursing facility where she has been working with physical, occupational, and speech therapy. Despite initial progress, in the last 2 weeks, she has lost her appetite, and complains of insomnia and difficulty concentrating. Which would be the next best step in management? a. Start escitalopram 5 mg orally daily. b. Start eszopiclone 1 mg orally at bedtime. c. Start a high calorie supplement twice a day. d. Change the time at which she gets physical therapy. Answer: a.
3. An 82-year-old woman with a past medical history of essential hypertension and type 2 diabetes mellitus, and who currently smokes, was brought to the hospital after collapsing at home. The onset of her symptoms was 1 hour before arrival to the emergency room. On examination, she is awake, alert, and oriented to person, place, and time. She has moderate dysarthria, right gaze preference, left hemineglect, and left face, arm, and leg weakness. Her blood pressure is 190/90 mmHg and her glucose is 110 mg/dL. What diagnostic test should be done first? a. Complete blood count and basic metabolic panel b. A STAT noncontrast head computed tomography (CT)

c. A two-dimensional echocardiogram d. Urinalysis Answer: b. Chapter 52: Parkinson’s Disease Test Questions

1. A clinical prodrome of nonspecific symptoms of Parkinson disease (PD) include all the following except: a. Hyposmia b. Bradykinesia c. Constipation d. Fatigue Answer: b
2. The National Institute of Neurologic Disorders and Stroke (NINDS) criteria require a confirmatory autopsy for PD to be described as “definitive” but would rate as “probable” if three of the four primary clinical features were present for at least 3 years. Which of the following lists three primary clinical features of PD? (Choose one) a. Fatigue, postural instability, gait dysfunction b. Rigidity, resting tremor, urinary urgency c. Rigidity, bradykinesia, resting tremor d. Freezing, sleep disturbance, arthralgias Answer: c
3. Imaging plays a limited role in diagnoses of PD but is central in making diagnosis of: a. Multiple system atrophy (MSA) b. Progressive supranuclear palsy c. Dementia of Lewy body type d. Normal pressure hydrocephalus Answer: d
4. Key neurotransmitter-based therapeutic strategies for PD include all the following except: a. Increase glutamatergic stimulation

b. Decrease cholinergic stimulation c. Increase dopaminergic stimulation d. Decrease glutamatergic stimulation Answer: a

5. Treatment for early PD in an otherwise healthy older patient without significant functional impairment should begin with: a. Catechol-o-methyl transferase (COMT) inhibitors b. Dopamine agonist c. Levodopa d. Careful observation Answer: d Week 7 Chapter 1: Principles of Primary Care in Older Adults Test Questions
6. Which one of the following is most true about the rule of fourths? a. One-fourth of geriatric problems are iatrogenic. b. Little can be done to prevent three-fourths of the problems of aging. c. For every medical complaint a patient presents with, a careful assessment can identify three other diagnoses. d. What used to be called normal aging can be largely explained by processes that are not normal. e. A good way to conduct a geriatric assessment is to use four categories: mental, physical, psychosocial, and environmental. Answer: d
7. Which one of the following is most true about aging changes? a. Stage 3 and 4 sleep decreases. b. Renal perfusion is not reduced, but renal function is reduced. c. Hearing acuity declines beginning in middle age. d. Prostatic enlargement occurs only in a minority of men. Answer: a

3. An old woman who is cared for by attentive, cautious, concerned family is particularly likely to suffer from which one of the following complications after an episode of gastroenteritis? a. Immobility related to overconcern b. Continued vomiting caused by too-rapid feeding c. Diarrhea resulting from administration of milk products d. Constipation related to overtreatment of diarrhea Answer: a
4. Which one of the following is most true about psychological aging? a. Disengagement tends to promote better psychological health than continued engagement. b. Most older adults do not worry about memory loss. c. Happiness declines starting in middle age. d. Ageism can lead to isolation and depression. Answer: d
5. Of the following conditions, which one is most common and most often preventable? a. Falls b. Frailty c. Cognitive impairment d. Iatrogenic disease e. Depression Answer: d Chapter 6: Cultural Competency and Cultural Humility in Caring for Older Adults Test Questions
6. Which of the following is true about cultural humility? a. It is typically accomplished through professional development courses. b. It can only be achieved by underrepresented minority groups. c. It places emphasis on power imbalances and promotes interpersonal sensitivity through partnerships with and learning from patients.

d. It rarely considers the biologic, socioeconomic, and racial impacts of upstream structural factors on health disparities. Answer: c

2. Racial disparities have been a part of US healthcare for many decades. How might this impact the expectations of older Black Americans? a. Reluctance to participate in medical research because of unethical studies in the past b. Underrepresentation of Black physicians in the geriatric workforce c. Cumulative effects of differences in access to healthcare providers d. All of these Answer: d
3. Dementia is a relatively common condition in the geriatric population. It becomes more common as people age. Which is the most appropriate description of “personhood” as it relates to people with dementia? a. Personhood is a universal concept that is defined the same way in all cultures. b. The ability to relate to others as people, rather than preserving cognitive independence, is an important aspect of “personhood.” c. The ability to recognize family members by name is an important aspect of “personhood.” d. A deterioration in cognitive function demonstrates the decreasing value of older adults in society. Answer: b
4. Immigrant families bring cultural traditions into healthcare decisions. With regard to older adults, which of the following is true? a. End-of-life care is particularly sensitive to cultural beliefs and should be explored carefully with the patient and family, as appropriate. b. Clinicians should assume that all cultures value autonomy of the individual over the family unit. c. It is considered rude to offer interpreters when talking to patients who do not speak English, when family members are present. d. Most cultures outside of the United States believe that life support should not be used after age 65 years. Answer: a Chapter 8: Ethics Test Questions

1. Which of the following statements is true? a. Decision-making capacity can be determined only by a psychiatrist. b. A diagnosis of dementia precludes competent decision making. c. Lack of decision-making capacity should not be presumed if the patient goes against medical advice. d. Expression of a choice is sufficient to indicate decision-making capacity. Answer: c
2. Which of the following statements concerning advance directives is true? a. The Supreme Court has established a standard advance directive form. b. The living will is used to appoint a healthcare agent to make medical decisions if an individual loses decision-making capacity. c. A DNR order is not equivalent to a do-not-treat order. d. Periods of acute illness are the most appropriate times to begin discussions with patients about advance directives. Answer: c
3. The following are components of the open disclosure of medical error, except: a. An apology to the injured patient. b. An explanation of the error in lay language. c. A best guess as to why the error occurred. d. An assurance that a full investigation will take place. Answer: c
4. Mrs. Gloth is an 84-year-old woman whom you are admitting to the nursing home. Her son takes you aside and tells you that she has metastatic ovarian cancer but has not been told the diagnosis. He asks that you not tell her, because she would “lose all hope and die.” Which of the following is an appropriate response? a. Tell the son that you are going to immediately inform the patient of her diagnosis. b. Tell the son that he can count on you to respect his wishes. c. Suggest that you discuss this further after getting to know the patient and family a little better. d. Find out from the son what the family has been telling her about her health, so you will maintain a consistent story. Answer: c

5. Dr. Smith is obtaining informed consent from Mr. Jones to perform a colonoscopy, because the patient had blood in his stool and Dr. Smith is concerned that this might indicate the presence of carcinoma of the colon. Mr. Jones is able to recite back to Dr. Smith what a colonoscopy is, how it is done, and that a colonoscopy is performed to look for cancer. He then tells Dr. Smith that he is refusing the procedure; he knows he does not have cancer because he has not experienced any bleeding. Of the following required elements for Mr. Jones’s decision-making capacity, which is impaired? a. Understanding b. Appreciation c. Ability to express a choice Answer: b
6. George Hall is a 91-year-old man visiting his physician to receive the results of a recent computed tomography scan of his abdomen. He is cognitively intact and still works 2 days a week. He is accompanied by his daughter Eleanor. She takes the doctor aside before the appointment and says, “Please do not tell my father any bad news. It would just kill him.” If the physician were to agree, which ethical principles might this violate? a. Paternalism b. Autonomy c. Authenticity d. None of the above e. Answers a, b, and c Answer: b
7. Lenore White is an 80-year-old woman who smokes two packs of cigarettes per day. She is hospitalized for pneumonia because she has presenting symptoms of cough and fever. On her second day of hospitalization, she asks the nurse to please wheel her outside so she can smoke a cigarette. The nurse feels uncomfortable agreeing to this and speaks to her clinical nurse manager. What two ethical principles are in conflict? a. Beneficence and community b. Nonmaleficence and justice c. Autonomy and justice d. Autonomy and nonmaleficence Answer: d
8. Ms. Greta Thornberg is an 88-year-old woman admitted to the hospital with a diagnosis of squamous cell carcinoma of the lung with metastases to liver. She has