Questions
Each of the following questions or incomplete statements is followed by suggested answers or completions. Select the ONE BEST ANSWER in each case.
1. Which of the following symptoms is more likely to represent myocardial ischemia in older patients?
A) Chest pain
B) Dyspnea
C) Diaphoresis
D) Back pain
E) Jaw pain
View Answer
Answer and Discussion
The answer is B. Exertional angina (chest pain) is the most common manifestation of myocardial ischemia in young and middle-age persons. Because of their more sedentary lifestyle or possibly a difference in pathophysiology, this may not be true in elderly patients. Instead of exertional chest pain, ischemia may be more commonly manifested as dyspnea in elderly patients. Other elderly patients with CAD may be completely asymptomatic, although silent ischemia may be demonstrated by stress testing or Holter monitoring.
Tresch DD. Diagnostic and prognostic value of ambulatory electrocardiographic monitoring in older patients. J Am Geriatr Soc. 1995;43:66–70.
Tresch DD, Saeian K, Hoffman R. Elderly patients with late onset of coronary artery disease: Clinical and angiographic findings. Am J Geriatr Cardiol. 1992;1:14–25.
Instead of exertional chest pain, ischemia may be more commonly manifested as dyspnea in elderly patients.
2. Which of the following statements is true regarding thrombolytic therapy when treating elderly patients with myocardial infarction (MI)?
A) Elderly patients are frequently overtreated with thrombolytics.
B) Elderly patients with non-Q-wave MIs should receive thrombolytics.
C) Streptokinase is more expensive to use than tPA.
D) tPA is associated with a higher risk of hemorrhagic stroke when compared to streptokinase in elderly patients.
E) Up to 75% of elderly patients have absolute contraindications to thrombolytics.
View Answer
Answer and Discussion
The answer is D. Despite a wealth of evidence in favor of thrombolytic treatment for elderly MI patients, the therapy is commonly not used in this age group. The reasons for this are numerous and include delay in seeking medical assistance, misdiagnoses due to atypical presentation, increased contraindications, and higher prevalence of non-Q-wave MIs. Additionally, physicians are reluctant to use thrombolytics in the elderly population for fear of hemorrhage, although most studies show that intracerebral hemorrhage is not significantly increased in elderly MI patients who receive thrombolytics. Only approximately one-third of elderly patients presenting with acute MI have any contraindications to thrombolytic therapy, and less than 5% have absolute contraindications. In regard to patients with non- Q-wave infarction or unstable angina, repeated studies have demonstrated that thrombolytic therapy has no benefits in these patients regardless of age. In regard to choice of specific thrombolytic agent, initial studies comparing streptokinase (approximate cost: $200 per patient) and tissue-type plasminogen activator (approximate cost: $2,200 per patient) found that both drugs increased the survival rate equally. The Global Utilization of Streptokinase and Tissue Plasminogen Activator (tPA) for Occluded Coronary Arteries (GUSTO) trial, which was designed specifically to compare thrombolytic agents, reported a significant advantage with tPA for the overall study population. Patients over age 75, however, had a significantly higher risk of hemorrhagic stroke when treated with tPA than with streptokinase, and the incidence of death or nonfatal disabling stroke was not significantly different between the two therapies in this age group. Therefore, streptokinase may be appropriate in patients over the age of 75 years.
The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329:673–682.
3. A 75-year-old man presents with exertional dyspnea and generalized weakness. On examination, you discover a high-pitched, blowing diastolic murmur and a wide pulse pressure with bounding pulses. The most likely diagnosis is?
A) aortic stenosis
B) aortic insufficiency
C) mitral stenosis
D) mitral insufficiency
E) coarctation of the aorta
View Answer
Answer and Discussion
The answer is B. The prevalence of aortic regurgitation increases with age. Unlike aortic valve stenosis, aortic valvular insufficiency is rarely caused by degenerative aortic valve disease. Acute aortic valvular insufficiency may be due to infective endocarditis, aortic dissection, trauma, or rupture of the sinus of Valsalva. Chronic aortic insufficiency can be caused by valve leaflet disease, including rheumatic heart disease, congenital heart disease, rheumatoid arthritis, ankylosing spondylitis, or myxomatous degeneration. Chronic aortic insufficiency may also be caused by aortic root disease secondary to systemic hypertension, syphilitic aortitis, cystic medial necrosis, ankylosing spondylitis, rheumatoid arthritis, Reiter's disease, systemic lupus erythematosus, Ehlers–Danlos syndrome, and pseudoxanthoma elasticum. Symptoms of aortic valvular insufficiency are the same in older persons as they are in younger ones. Usually, the main symptoms are related to heart failure, with exertional dyspnea and weakness being common symptoms. In some elderly patients, symptoms of dyspnea and palpitations may be more common at rest than with exertion. Nocturnal angina pectoris, often accompanied by flushing, diaphoresis, and palpitations, may occur; this is thought to be related to the slowing of the heart rate and the drop of arterial diastolic pressure. The classic findings of a high-pitched, blowing diastolic murmur and a wide pulse pressure with an abruptly rising and collapsing pulse should make the diagnosis of aortic valvular insufficiency easily recognized in elderly patients.
Tresch DD, Jamali I. Chapter 34: Cardiac Disorders. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998. WB Saunders. Accessed online 4/7/06.
4. Once symptoms develop in elderly patients with aortic stenosis (without intervention), the survival is approximately
A) 6 months or less
B) 1–3 years
C) 3–5 years
D) 5–7 years
E) survival is unaffected with symptomatic aortic stenosis
View Answer
Answer and Discussion
The answer is B. Once symptoms develop in patients with critical aortic valve stenosis, the clinical course is rapidly downhill. Symptoms and left ventricular dysfunction are progressive, and the average survival is approximately 1–3 years.
Tresch DD, Jamali I. Chapter 34: Cardiac Disorders. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998. WB Saunders. Accessed online 4/7/06.
5. A 69-year-old female presents with peripheral edema, orthopnea, and dypsnea on exertion. She has gained 10 pounds in the last 3 days. She is otherwise healthy. You suspect congestive heart failure. Appropriate first-line medication includes which of the following?
A) Diltiazem
B) Lisinopril
C) Nitroglyercin
D) Metoprolol
E) Hydralazine
View Answer
Answer and Discussion
The answer is B. Due to the results of numerous studies showing that ACE inhibitors are beneficial in relieving symptoms and preventing progressive ventricular deterioration, it is recommended that they should be the initial therapy utilized in patients with heart failure. In patients with moderate to severe heart failure due to systolic left ventricular dysfunction, the use of ACE inhibitors alone has not been found to be successful in relieving the signs and symptoms of volume overload. There is no question, however, that ACE inhibitors, such as digitalis and diuretics, are beneficial in improving the symptoms and prolonging survival in symptomatic patients with left ventricular systolic dysfunction. In the CONSENSUS trial, which demonstrated significant benefits in the use of ACE inhibitors in symptomatic patients, the mean age of the patients was over 70 years, and, at this age, ACE inhibitors were well tolerated. In asymptomatic elderly patients with depressed left ventricular systolic dysfunction, the use of ACE inhibitors is more controversial. The SOLVD trial demonstrated that asymptomatic patients with a depressed left ventricular ejection fraction of less than 35% demonstrated no benefit in survival, although a significant reduction in progression to clinical heart failure with a decrease in hospitalizations was noted. In the SAVE trial, ACE inhibitors were found to be beneficial in improving long-term survival and reducing the development of heart failure and recurrent myocardial infarction in patients with reduced left ventricular systolic function following acute MI, regardless of the patient's age.
The CONSENSUS Trial Study Group: Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med. 1987;316:1429–1435.
The SOLVD Investigators: Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med. 1992;327:685–691.
Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction: Results of the Survival and Ventricular Enlargement Trial. N Engl J Med. 1992;327:669–677.
6. A 75-year-old man is brought in to your office by his wife. She complains that he is not the same over the last 6 months. His memory is failing him, he has difficulty walking (especially when he initiates walking), and he is incontinent of urine. Which of the following is the most likely diagnosis based on his history?
A) Alzheimer's disease
B) Parkinson's disease
C) Normal-pressure hydrocephalus
D) Pick's disease
E) Progressive supranuclear palsy
View Answer
Answer and Discussion
The answer is C. Normal-pressure hydrocephalus (NPH) is a cause of dementia in the elderly. It may be caused by previous insult to the brain, usually as a result of a subarachnoid hemorrhage or diffuse meningitis that presumably results in scarring of the arachnoid villi over the brain convexities where cerebrospinal fluid (CSF) absorption usually occurs. However, elderly NPH patients seldom have a history of predisposing disease. NPH classically consists of dementia, apraxia of gait, and incontinence, but many patients with these symptoms do not have NPH. Typically, motor weakness and staggering are absent, but initiation of gait is hesitant—described as a “slipping clutch” or “feet stuck to the floor” gait—and walking eventually occurs. NPH has also been associated with various psychiatric manifestations that are not categorical. NPH should be considered in the differential diagnosis of any new mental status changes in the elderly. CT or MRI and a lumbar puncture are necessary for diagnosis. On CT or MRI, the ventricles are dilated. CSF pressure measured by a lumbar puncture is normal. A limited improvement after removing about 50 mL of CSF indicates a better prognosis with shunting. Radiographic or pressure measurements alone do not seem to predict response to shunting. Shunting CSF from the dilated ventricles sometimes results in clinical improvement, but the longer the disease has been present, the less likely shunting will be curative.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1811, 1814.
7. Which of the following is more commonly seen in patients with Lewy body dementia when compared to Alzheimer's dementia?
A) Hallucinations
B) Lip smacking
C) Tremor
D) Emotional lability
E) Repetitive behavior
View Answer
Answer and Discussion
The answer is A. Although difficult to know for sure, Lewy body dementia may be the second most common dementia after Alzheimer's disease. Lewy bodies are hallmark lesions of degenerating neurons in Parkinson's disease and occur in dementia with or without features of Parkinson's disease. In Lewy body dementia, Lewy bodies may predominate markedly or be intermixed with classic pathologic changes of Alzheimer's disease. Symptoms, signs, and course of Lewy body dementia resemble those of Alzheimer's disease, except hallucinations (mainly visual) are more common and patients appear to have an exquisite sensitivity to antipsychotic-induced extrapyramidal adverse effects.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1811, 1814.
8. A patient with Pick's disease is brought in by his caregiver. She complains that he has become increasingly more apathetic and, at times, sexually inappropriate, and is smacking his lips more frequently. You suspect
A) elder abuse
B) medication side effects
C) development of Kluver–Bucy syndrome
D) toxin exposure
E) chronic hypoxia
View Answer
Answer and Discussion
The answer is C. Pick's disease is a less common form of dementia, affecting the frontal and temporal regions of the cerebral cortex. Patients have prominent apathy and memory disturbances. They may show increased carelessness, poor personal hygiene, and decreased attention span. Although the clinical presentation and CT findings in Pick's disease can be quite distinctive, definitive diagnosis is possible only at autopsy. The Klüver–Bucy syndrome can occur early in the course of Pick's disease, with emotional blunting, hypersexual activity, hyperorality (bulimia and sucking and smacking of lips), and visual agnosias.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1820.
9. A 75-year-old female presents with rather severe shoulder and hip pain that has been progressively worse over the last 3 months. She complains of morning stiffness and low-grade fevers, malaise, and weight loss. She has no headache or visual disturbance, and EMG study of her lower extremities was normal. Her labs reveal a normocytic–normochromic anemia and her erythrocyte sedimentation rate (ESR) was found to be 60 mm/h. Appropriate management at this time includes
A) referral for a temporal artery biopsy
B) initiation of prednisone
C) initiation of an NSAID
D) referral to physical therapy
E) referral to orthopedics for consideration of joint replacement
View Answer
Answer and Discussion
The answer is B. The true prevalence, etiology, and pathogenesis of polymyalgia rheumatica (PMR) are not entirely known. In some, the condition is a manifestation of underlying temporal arteritis. Although most patients are not at significant risk for the complications of temporal arteritis, they should be warned of the possibility and should immediately report such symptoms as headache, visual disturbance, and jaw muscle pain on chewing. PMR usually occurs in patients older than 60 years, and the female:male ratio is 2:1. Onset may be acute or subacute. PMR is characterized by severe pain and stiffness of the neck and shoulders and hips; morning stiffness; stiffness after inactivity; and systemic complaints, such as malaise, fever, depression, and weight loss. There is no selective muscle weakness or evidence of muscle disease on electromyography (EMG) or biopsy. Normochromic–normocytic anemia may be present. In most patients, the ESR is dramatically elevated, often >100 mm/h, usually >50 mm/h. C-reactive protein levels are usually elevated (>0.7 mg/dL) and may be a more sensitive marker of disease activity in certain patients than is ESR. PMR is distinguished from rheumatoid arthritis (RA by the usual absence of small joint synovitis (although some joint swelling may be present), erosive or destructive disease, rheumatoid factor, or rheumatoid nodules. PMR is differentiated from polymyositis by usually normal muscle enzymes, EMG, and muscle biopsy, as well as by the prominence of pain over weakness. Hypothyroidism can present as myalgia, with abnormal thyroid function tests and elevated creatine kinase (CK). PMR is differentiated from myeloma by the absence of monoclonal gammopathy, and from fibromyalgia by the systemic features and elevated ESR. PMR usually responds dramatically to prednisone initiated at doses of at least 15 mg/day. If temporal arteritis is suspected, treatment should be started immediately, with 60 mg/day to prevent blindness. As symptoms subside, corticosteroids are tapered to the lowest effective dose, regardless of ESR. Some patients are able to discontinue corticosteroids in less than 2 years, whereas others require small amounts for years. Rarely do patients respond adequately to salicylates or other NSAIDs.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:278–279.
10. When dealing with a dying patient, the patient's family should
A) be contacted only when they request it
B) be thoroughly informed of the details that death may present to them
C) be kept away from the patient to prevent bad associations and memories
D) be contacted about an autopsy only after death has occurred
E) never be approached about organ donation until after death has occurred
View Answer
Answer and Discussion
The answer is B. The family should be thoroughly informed of the changes that the patient's body may exhibit directly before and after death. They should not be surprised by irregular breathing, cool extremities, confusion, a purplish skin color, or somnolence in the last hours. A discussion about autopsy can occur either before or just after death. Families may have strong feelings, either in favor of or against it. The discussion of autopsy should not be left to a covering physician or house officer who has not had previous contact with the family. Discussions about organ donation, if appropriate, should take place before death or immediately after death.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2762–2768.
The family should be thoroughly informed of the changes that the patient's body may exhibit directly before and after death.
11. In the elderly, a rise in the systolic blood pressure with no change in the diastolic blood pressure most likely suggests
A) anemia
B) thyrotoxicosis
C) aortic insufficiency
D) stiffening of the arteries
E) none of the above
View Answer
Answer and Discussion
The answer is D. Stiffened blood vessels also have an impact for blood pressure determination in later life. Systolic blood pressure rises throughout life in Western populations, whereas diastolic pressure peaks and plateaus in middle age and later life. “Normal” blood pressure has been defined by determining the cardiovascular risk associated with a given blood pressure. The presence of an isolated rise in the systolic pressure without a diastolic rise (isolated systolic hypertension) is fairly unique to older patients and, unlike younger patients, does not necessarily imply anemia, thyrotoxicosis, or aortic insufficiency, which can cause a bounding pulse and wide pulse pressure in the young.
Duthie EH Jr. Chapter 1: History and Physical Examination. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998. WB Saunders. Accessed online 4/2/06.
12. Causes for orthostatic blood pressure in the elderly include all of the following except
A) declining baroreceptor sensitivity
B) decreased arterial compliance
C) increased venous tortuosity
D) decreased renal sodium conservation
E) increased plasma volume
View Answer
Answer and Discussion
The answer is E. Determination of orthostatic blood pressure should be routinely performed in geriatric patients. Although a number of factors, such as declining baroreceptor sensitivity, diminished arterial compliance, increased venous tortuosity, decreased renal sodium conservation, and diminished plasma volume, could combine to cause a drop in orthostatic blood pressure among older patients, there is no clear evidence that the pressure drops solely as a function of age. However, a blood pressure drop when changing from the supine to the upright position is common among geriatric patients (possibly as many as 30% of unselected patients may experience a 20-mmHg or more drop in systolic pressure). Diseases and medications that cause the problem are common offenders.
Duthie EH Jr. Chapter 1: History and Physical Examination. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998. WB Saunders. Accessed online 4/2/06.
13. When caring for the elderly, it is important to remember the following about measurement of body temperature:
A) Serious infections often adversely affect the patient's temperature.
B) Norms for fever are adjusted based on the patient's age.
C) The elderly have a tendency toward disturbances of temperature regulation.
D) Temperature variations do not occur in the elderly population based on comparisons with younger patients.
E) Temperatures should not be recorded in the elderly because of their notorious inaccuracy.
View Answer
Answer and Discussion
The answer is C. Temperature determination in the elderly is the same as it is in other patients. Norms for fever or hypothermia have not been adjusted for age. Elderly people do have a tendency toward disturbances of temperature regulation (hypothermia or hyperthermia). It is possible that some elderly patients, like others, may present with serious infections that do not produce much temperature rise.
Duthie EH Jr. Chapter 1: History and Physical Examination. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998. WB Saunders. Accessed online 4/2/06.
14. Which of the following is true regarding respiratory rate in the elderly?
A) Subtle differences in age-adjusted respiratory rate are present and should be adjusted for in the evaluation of the elderly patient.
B) Respiratory rates in the elderly are 5% higher than age-adjusted controls.
C) Respiratory rates and patterns do not change as the patient ages.
D) Elevated respiratory rates do not represent concern in elderly patients.
E) Respiratory rates do not correlate with disease in elderly patients.
P.291
View Answer
Answer and Discussion
The answer is C. Respiratory rate and patterns do not change significantly with age. An elevated respiratory rate may be a subtle clue to a serious medical illness (e.g., acidosis, hypoxia, central nervous system disturbance) and should be detected and evaluated as in any other patient.
Duthie EH Jr. Chapter 1: History and Physical Examination. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998. WB Saunders. Accessed online 4/2/06.
15. While examining a 65-year-old woman for her yearly well-woman exam, you note a palpable right ovary. The remainder of her examination is entirely normal. The most likely diagnosis is
A) cecal fecolyth
B) polycystic ovary syndrome
C) normal variant
D) ovarian carcinoma
E) fibroid tumor
View Answer
Answer and Discussion
The answer is D. The presence of a palpable ovary in an elderly woman should raise a suspicion of some pathology, especially malignancy.
Duthie EH Jr. Chapter 1: History and Physical Examination. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998. WB Saunders. Accessed online 4/2/06.
16. From admission to discharge, what percentage of elderly patients lose independence in one or more of the basic activities of daily living?
A) Approximately 1–3 %
B) 10%
C) 25–35%
D) 50%
E) More than 75%
View Answer
Answer and Discussion
The answer is C. From hospital admission to discharge, 25% to 35% of elderly patients lose independence in one or more of the basic activities of daily living. The loss of independent functioning during hospitalization is associated with important complications including prolonged length of hospital stay, greater risk of institutionalization, and higher mortality rates.
Palmer RM. Acute hospital care of the elderly: Minimizing the risk of functional decline. Cleve Clin J Med. 1995;62:117–128.
17. Factors known to precipitate delirium in elderly hospitalized patients include
A) physical restraints
B) the addition of three or more medications
C) use of bladder catheter
D) malnutrition
E) all of the above
View Answer
Answer and Discussion
The answer is E. Dementia is the single most important risk factor for the development of delirium or acute confused state. Delirium is found at admission or during hospitalization in about 25% of elderly patients admitted for acute medical illnesses. Patients with baseline dementia and severe systemic illness are predisposed to delirium. Factors known to precipitate delirium include the use of physical restraints, the addition of more than three medications to the regimen, the use of a bladder catheter, malnutrition, and any iatrogenic event.
Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and inter-relationship with baseline vulnerability. JAMA. 1996;275:852–857.
18. A 65-year-old man presents to your office complaining of a right-hand tremor. The patient reports the tremor is worse with sustained positions and stressful situations. Surprisingly, a shot of scotch makes the tremor better. He also reports a positive family history for tremors. There are no signs of bradykinesia or rigidity. The most likely diagnosis is
A) Parkinson's disease
B) essential tremor
C) Huntington's disease
D) caffeine withdrawal
E) alcohol withdrawal
View Answer
Answer and Discussion
The answer is B. Essential tremor is the most common movement disorder. This postural tremor may have its onset anywhere between the second and sixth decades of life, and its prevalence increases with age. It is slowly progressive over a period of years. An essential tremor is characterized by a rapid, fine tremor that is made worse with sustained positions. The frequency of essential tremor is 4 to 11 Hz, depending on which body segment is affected. Proximal segments are affected at lower frequencies, and distal segments are affected at higher frequencies. Although typically a postural tremor, essential tremor may occur at rest in severe and very advanced cases. It most commonly affects the hands but can also affect the head, voice, tongue, and legs. It usually affects patients older than 50 years. The tremor may be intensified by stress, anxiety, excessive fatigue, drugs (e.g., caffeine, alcohol withdrawal, steroids), or thyroid disorders. In many cases, the patient may report relief with alcohol use and a positive family history for tremors. Senile tremors tend to increase with age. Parkinson's disease is differentiated by the presence of a pill-rolling tremor at rest, masked face, bradykinesias, and rigidity. Parkinson's also shows a favorable response to the administration of L-dopamine and does not improve with the use of alcohol. Treatment of essential tremors involves the treatment of the underlying disorder and the use of propranolol (Inderal), primidone (Mysoline), diazepam (Valium), and methazolamide (Neptazane). Primidone may be preferred because of the exercise intolerance associated with the high-dose beta blockers. Patients who have a very-low-amplitude rapid tremor are generally more responsive to these agents than those who have a slower tremor with greater amplitude. Patients who have a tremor of the head and voice may also be more resistant to treatment than patients with an essential tremor of the hands. In severe cases, surgery may be considered.
Smaga S. Tremor. Am Fam Physician. 2003;68:1545–52,1553.
19. Which of the following tests is indicated in the initial workup of urinary incontinence?
A) Renal ultrasound
B) Urodynamic studies
C) Post-void residual
D) Urine cytology
E) Intravenous pyelogram
View Answer
Answer and Discussion
The answer is C. Urinary incontinence is often seen in the elderly. In most cases, the evaluation of urinary incontinence requires only a history, physical examination, urinalysis, and measurement of post-void residual urine volume. The initial purposes of the evaluation are to identify conditions requiring referral or specialized workup and to detect and treat reversible causes that may be present. Causes may include infection, atrophic urethritis, pelvic floor weakness (usually related to previous childbirth), medications (e.g., diuretics), altered mental status, or overflow incontinence related to obstruction (e.g., fecal impaction, prostatic hypertrophy). If the patient does not require referral and a reversible cause is not identified, the next step is to categorize the patient's symptoms as typical of urge or stress incontinence and treat the patient accordingly. Urge incontinence results from bladder contractions that overwhelm the ability of the cerebral centers to inhibit them. These uncontrollable contractions can occur because of inflammation or irritation within the bladder resulting from calculi, malignancy, infection, or atrophic vaginitis–urethritis. They can also occur when the brain centers that inhibit bladder contractions are impaired by neurologic conditions such as stroke, Parkinson's disease, or dementia; drugs such as hypnotics or narcotics; or metabolic disorders such as hypoxemia and encephalopathy. Stress incontinence is caused by a malfunction of the urethral sphincter that causes urine to leak from the bladder when intraabdominal pressure increases, such as during coughing or sneezing. Classic or genuine stress incontinence is caused by pelvic prolapse, urethral hypermobility, or displacement of the urethra and bladder neck from their normal anatomic alignment. Stress incontinence can also occur as a result of intrinsic sphincter deficiency, in which the sphincter is weak because of a congenital condition or denervation resulting from α-adrenergic-blocking drugs, surgical trauma, or radiation damage. Treatment involves the strengthening of pelvic floor muscles with Kegel exercises, voiding schedules, and biofeedback. Tolterodine (Detrol) and extended-release oxybutynin chloride (Ditropan XL) are used as a first-line treatment option for overactive bladder, which contributes to incontinence because of favorable side effect profiles. A trial of therapy may be attempted before formal urodynamic studies are ordered. If treatment fails or a presumptive diagnosis of urge or stress incontinence cannot be reached, the final step would be to perform more sophisticated tests or refer the patient for testing to define the cause and determine the best treatment.
Culligan PJ, Heit M. Urinary Incontinence in Women: Evaluation and Management, Am Fam Physician. 2000;62:2433–44, 2447, 2452.
20. Increasing age is associated with many effects on the kidney. These effects include which of the following?
A) Increase in renal size
B) Increase in serum creatinine
C) Decreased glomerular filtration rate
D) Increase in renal blood flow
E) Decreased threshold for glucose
View Answer
Answer and Discussion
The answer is C. Many changes occur within the kidney as a result of increasing age. There is a gradual decrease in renal size; a decrease in renal blood flow; and, most importantly, a decrease in glomerular filtration rate, which can have a significant effect on drug metabolism. In most cases, serum creatinine remains essentially unchanged. In many cases, the doses of renal-metabolized medications need to be reduced in patients with decreased creatinine clearance. Additionally, the renal threshold for glucose increases with increasing age, and there is a decrease in maximal urinary concentration.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:422.
Many changes occur within the kidney as a result of increasing age. There is a gradual decrease in renal size; a decrease in renal blood flow; and, most importantly, a decrease in glomerular filtration rate, which can have a significant effect on drug metabolism. In most cases, serum creatinine remains essentially unchanged.
21. When comparing middle-age patients with hyperthyroidism to elderly patients with hyperthyroidism, elderly patients are more likely to have
A) restlessness
B) hyperactive appearance
C) atrial fibrillation
D) weight gain
E) goiter
View Answer
Answer and Discussion
The answer is C. The most common cause of hyperthyroidism in the elderly is Graves’ disease or toxic diffuse goiter. Graves’ disease is an autoimmune disorder that results from the action of a thyroid-stimulating antibody on thyroid-stimulating hormone receptors. Thyroid-stimulating hormone receptor antibodies are detectable in the serum of approximately 80% to 100% of untreated patients with Graves’ disease. Hyperthyroidism in the elderly is often more difficult to diagnose than in younger patients. Only 25% of those affected present with symptoms that are typical in younger patients, such as restlessness and hyperactive appearance. Elderly patients are more likely to show weight loss, new-onset atrial fibrillation, and withdrawal or depression. Other complications include cardiac failure, angina, myocardial infarction, and osteoporosis with an increased risk of bone fractures. Older patients have a lower incidence of goiter. Behavioral changes in younger patients include anxiety, emotional lability, insomnia, lack of concentration, restlessness, and tremulousness. In contrast, elderly patients show apathy, lethargy, pseudodementia, and depressed moods.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:321–324.
22. Which of the following is a risk factor for the development of pressure ulcers in hospitalized patients?
A) Blanchable erythema
B) Lymphocytosis
C) Increased body weight
D) Moist skin
E) None of the above
View Answer
Answer and Discussion
The answer is E. Pressure ulcers occur more often in patients who have nonblanchable erythema, lymphopenia, immobility, dry skin, and decreased body weight. Patients with these risk factors need aggressive mobilization to avoid developing pressure sores.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:281–288.
23. When assessing for urinary retention, which of the following post-void residuals represents the threshold for an abnormal finding?
A) 25 ml
B) 50 ml
C) 100 ml
D) 200 ml
E) 500 ml
View Answer
Answer and Discussion
The answer is C. If the residual volume is >100 mL, bladder weakness or urinary retention should be considered.
Brandeis GH, Resnick NM. Chapter 18: Urinary incontinence. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998. WB Saunders. Accessed online 4/2/06.
24. An 80-year-old man is brought in by his wife. She complains that her husband has had a noticeable change in his personality. He is impulsive and at times inappropriate with his behavior. Although he has difficulty naming objects, his memory, ability to calculate, and his visuospatial skills appear to be intact. The most likely diagnosis is
A) Alzheimer's dementia
B) Pick's disease
C) Parkinson's disease
D) Wilson's disease
E) Lewy body dementia
View Answer
Answer and Discussion
The answer is B. Pick's heterogeneous disease and other frontotemporal dementias (FTD) are a heterogeneous group of disorders that share several clinical features with AD such as rate of progression and duration. Many FTD patients are also aphasic and manifest preserved motor integrity. The language disturbance characteristic of Pick's disease initially includes anomia, but there is a more stereotyped and perseverative verbal output than that found in AD. Unlike AD, in the early stages of FTD, memory, calculation, and visuospatial function are relatively well preserved. The most striking feature of this disorder is an extravagant change in the patient's personality, including disinhibition, impulsivity, inappropriate jocularity, and intrusiveness.
Reichman WE, Cummings JL. Chapter 26: Dementia. In: Duthie EH Jr, ed. Practice of geriatrics, 3rd ed. 1998 WB Saunders. Accessed online 4/2/06.
25. Which of the following medications used in the treatment of benign prostatic hypertrophy (BPH) works by inhibiting the transformation of testosterone to dihydrotestosterone?
A) Finasteride (Proscar)
B) Doxazosin (Cardura)
C) Terazosin (Hytrin)
D) Tamsulosin (Flomax)
E) Prazosin (Minipress)
View Answer
Answer and Discussion
The answer is A. Benign prostatic hypertrophy (BPH) is a condition associated with enlargement of the prostate gland that gives rise to obstructive urinary symptoms. The condition affects men older than 50 years and is characterized as adenomatous hyperplasia. Enlargement of the gland is usually asymptomatic until bladder outlet obstruction occurs. Symptoms reported by patients include decreased force and caliber of the urinary stream, incomplete voiding, hesitancy, frequency, overflow incontinence, retention, nocturia, and dribbling after urination. Acute urinary retention may be precipitated by prolonged attempts to retain urine, immobilization, exposure to cold, anesthetics, anticholinergic and sympathomimetic drugs, or ingestion of alcohol. Physical examination consistent with BPH shows an enlarged bladder and an enlarged prostate, which is usually firm and symmetrical. The median furrow may be absent. Hard nodules found within the gland are more worrisome for cancer. Laboratory findings may show an elevated prostate-specific antigen (PSA), usually <10 ng/dL, and elevated creatine when there is obstruction severe enough to lead to renal impairment. Post-void residuals are usually large and may predispose to infection. The most common cause of hematuria in older men is BPH. Medical treatment involves the use of 5 alpha reductase inhibitors finasteride (Proscar) or dutasteride (Avodart), which may help to shrink the prostate by blocking the transformation of testosterone to dihydrotestosterone. The drawbacks of the 5 alpha reductase inhibitors are that they require 6 to 12 months to work, they are expensive, and regrowth of the prostate occurs after the discontinuation of the medication. Other medications that help with voiding dysfunction are the α-adrenergic blockers prazosin (Minipress), doxazosin (Cardura), and terazosin (Hytrin), which are also used in the treatment of hypertension. Tamsulosin (Flomax) is a newer α-adrenergic blocker that does not significantly affect blood pressure. Definitive therapy is surgical. Although sexual potency and continence are usually retained, approximately 5% to 10% of patients experience some postsurgical problems. Transurethral resection of the prostate is preferred. Larger prostates (usually >75 g) may require open surgery using the suprapubic or retropubic approach, permitting enucleation of the adenomatous tissue from within the surgical capsule. The incidence of impotence and incontinence is much higher than after transurethral resection of the prostate. Alternative surgical approaches include intraurethral stents, microwave thermotherapy, high-intensity–focused ultrasound thermotherapy, laser ablation, electrovaporization, and radiofrequency vaporization.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2042–2045.
26. Which of the following statements regarding osteoporosis is true?
A) Routine screening of women older than 65 years is not recommended.
B) Dual-energy x-ray absorptiometry (DXA) scans result in more radiation exposure than qualitative computed tomography (CT).
C) T scores are used to diagnose osteoporosis.
D) Plain x-rays are a good diagnostic test for assessment of osteoporosis.
E) Medicare will not pay for bone-density examination.
View Answer
Answer and Discussion
The answer is C. Osteoporosis afflicts 75 million persons in the United States, Europe, and Japan and results in more than 1.3 million fractures annually in the United States. Osteoporosis is defined as the loss of bone below the density for mechanical support. It occurs when there is a loss of bony matrix and mineral composition of the bone, which is defined as osteopenia. Those most commonly affected are white and Asian postmenopausal women. Bones typically affected include vertebrae, wrist, humerus, hip, and tibia. Risk factors include menopausal state, positive family history, small bone structure, decreased calcium intake, lack of exercise, smoking, excessive alcohol use, and chronic steroid use. All postmenopausal women who present with fractures, as well as younger women who have risk factors, should be evaluated for the disease. Physicians should recommend bone mineral density testing to younger women at risk and postmenopausal women younger than 65 years who have risk factors for osteoporosis other than being postmenopausal. Bone mineral density testing should be recommended to all women 65 years and older regardless of additional risk factors. The most widely used techniques of assessing bone mineral density are DXA and quantitative CT. Of these methods, DXA is the most precise and the diagnostic measure of choice. Quantitative CT is the most sensitive method but results in substantially greater radiation exposure than DXA. Bone densitometry reports provide a T score (the number of standard deviations above or below the mean bone mineral density for gender and race matched to young controls) or a Z score (comparing the patient with a population adjusted for age, gender, and race). Osteoporosis is the classification for a T score of more than 2.5 standard deviations below the gender-adjusted mean for normal young adults at peak bone mass. A T score of -1.0 to -2.5 represents osteopenia. Z scores are not used for the diagnosis. Medicare pays for bone density examination at age 65 for initial diagnosis and for follow up after 24 months. Other indications for screening at an earlier age include when estrogen deficiency is present in a woman at clinical risk for osteoporosis, vertebral abnormalities are present (e.g., osteopenia, vertebral fractures, osteoporosis), the patient has been exposed to long-term (more than 3 months’ duration) glucocorticoid therapy, the patient has primary hyperparathyroidism, or the patient requires monitoring to assess response to osteoporosis drug therapy. Plain x-rays are not adequate for the detection of osteoporosis, because as much as 30% of bone mass can be lost before it becomes apparent on x-ray. More advanced cases may reveal decreased radiodensity of vertebrae, anterior wedging of vertebrae, and compression fractures. Prevention involves the use of calcium and vitamin D supplementation, exercise, and avoidance of smoking and heavy alcohol use. Thiazide diuretics may also help to decrease urinary excretion of calcium in patients with secondary hyperparathyroidism. In established cases, the bisphosphonates [alendronate (Fosamax) and risedronate (Actonel)] and a selective estrogen receptor modulator (SERM) [raloxifene (Evista)] are used for treatment. Additionally, calcitonin (Calcimar) may also be used to prevent vertebral fractures; it does not appear to prevent nonvertebral fractures.
South-Paul JE. Osteoporosis: Part 1. Evaluation and assessment. Am Fam Physician. 2001;63:897–904, 908.
27. Which of the following is not considered in deciding to screen for conditions in the elderly?
A) The exact age of the patient
B) The risk of dying from the condition
C) The potential benefits of screening
D) The direct and indirect harms of screening
E) The patient's values and preferences
View Answer
Answer and Discussion
The answer is A. The decision to screen for medical conditions depends on multiple factors (i.e., burden of the disease, diagnostic accuracy of the test, consequences of false-positive and false-negative results, and the outcome of early detection of disease). In elderly patients, deciding when to discontinue specific interventions, such as cancer screening, requires individual discussion of potential benefits and risks. Steps to individualize decision making for screening tests include: (1) estimate the life expectancy of the patient; (2) estimate the risk of dying from the condition; (3) determine the potential benefits of screening; (4) weigh the direct and indirect harms of screening; and (5) assess the patient's values and preferences.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:7–8.
28. Which one of the following statements about presbycusis is true?
A) Women are more commonly affected than men.
B) Low-frequency tones are affected first.
C) The condition cannot be treated with amplification.
D) The condition can lead to depression.
E) The condition does not affect the ability to interpret speech.
View Answer
Answer and Discussion
The answer is D. Presbycusis, a progressive, high-frequency hearing loss, is the most common cause of hearing impairment in geriatric patients. Exposure to loud noises and genetic factors play a role in the etiology. Men are more commonly affected with sensory neural hearing loss. It usually begins after 20 years of age and affects the high-frequency tones first (18 to 20 kHz). Patients often report trouble hearing normal conversations in crowds. This type of hearing loss decreases the ability to interpret speech, which can lead to a decreased ability to communicate and a subsequent increased risk for social isolation and depression. Hearing loss in the elderly can also adversely affect physical, emotional, and cognitive well-being. Questionnaires such as the Hearing Handicap Inventory for the Elderly–Screening version have been shown to accurately identify persons with hearing impairment. The reference standard for establishing hearing impairment, however, remains pure tone audiometry, which can be performed in the physician's office. Combining the Hearing Handicap Inventory for the ElderlyScreening version questionnaire with pure tone audiometry has been shown to improve screening effectiveness. Appropriate interventions include periodic screening to provide early detection of hearing impairment, cautious use or avoidance of ototoxic drugs, and support for the obtaining and continued use of hearing aids.
Miller KE, Zylstra RG, Standridge JB. The geriatric patient: a systematic approach to maintaining health. Am Fam Physician. 2000;61:1089–1104.
Presbycusis, a progressive, high-frequency hearing loss, is the most common cause of hearing impairment in geriatric patients.
29. Which of the following statements is true regarding the abdominal aortic aneurysms (AAA)?
A) Screening has not been shown to be cost effective.
B) Computed tomography is the test recommended for screening of AAA.
C) All women and men who are 65 years or older should be screened once for AAA.
D) One-time screening with ultrasound for AAA in men 65 to 75 years of age who have ever smoked is recommended.
E) Ultrasound is specific but not sensitive for the screening of AAA.
View Answer
Answer and Discussion
The answer is D. Ultrasound is the standard imaging tool for the detection of an AAA. In experienced hands, it has a sensitivity and specificity approaching 100% and 96%, respectively, for the detection of infrarenal AAA. The U.S. Preventive Services Task Force recommends screening for AAA in patients who have a relatively high risk of dying from an aneurysm. Major risk factors include age 65 years or older, male sex, and smoking at least 100 cigarettes in a lifetime. The guideline recommends one–time screening with ultrasound for AAA in men 65 to 75 years of age who have ever smoked. No recommendation was made for or against screening in men 65 to 75 years of age who have never smoked, and it recommended against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age.
U.S. Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med. 2005;142:198–202.
30. The threshold for considering elective repair of an AAA is
A) 4.0 cm
B) 4.5 cm
C) 5.0 cm
D) 5.5 cm
E) 6.0 cm
View Answer
Answer and Discussion
The answer is D. Patients with aneurysms ≥5.5 cm should be considered for elective AAA repair. Because most clinically diagnosed AAAs are repaired, their long-term natural history is difficult to predict. The 1-year incidence of rupture is 9% for aneurysms 5.5 to 6.0 cm in diameter, 10% for 6.0 to 6.9 cm, and 33% for AAAs of 7.0 cm or more. Patients with an aneurysm <5.5 cm in diameter should have follow-up serial ultrasounds. Smoking is the biggest risk factor for the development of aneurysms.
Kent KC, Zwolak RM, Jaff MR, et al. Abdominal aortic aneurysm. Am Fam Physician. 2006;73:1198–1204, 1205–1206.
31. Which of the following classes of drugs has shown modest improvement in cognitive symptoms associated with Alzheimer's disease?
A) Cholinesterase inhibitors
B) Dopamine agonists
C) Norepinephrine antagonist
D) Serotonin reuptake inhibitors
E) None of the above
View Answer
Answer and Discussion
The answer is A. Treatment with cholinesterase inhibitors can provide mild improvement of symptoms, temporary stabilization of cognition, or reduction in the rate of cognitive decline in some patients with mild to moderate Alzheimer's disease. Approximately 20% to 35% of patients treated with these agents exhibit a 7-point improvement on neuropsychologic tests (equivalent to 1 year's decline and representing a 5% to 15% benefit over placebo). Before treatment is started, it is important to inform the family of the expected (modest) benefits of cholinesterase inhibitors. Four cholinesterase inhibitors are currently available: donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl), and tacrine (Cognex). These agents raise acetylcholine levels in the brain by inhibiting acetylcholinesterase.
Cummings JL, Frank JC, Cherry D. Guidelines for managing alzheimer's disease: Part II. Treatment. Am Fam Physician. 2002;65:2525–2534.
Rogers SL, Doody RS, Mohs RC, et al. Donepezil improves cognition and global function in Alzheimer disease: a 15-week, double-blind, placebo-controlled study. Donepezil Study Group. Arch Intern Med. 1998;158:1021–1031.
32. Which of the following is most consistent with signs and symptoms of retinal detachment?
A) Pain associated with the eye
B) Seeing flashes of light
C) Photophobia
D) Excessive tearing
E) Conjunctival injection
View Answer
Answer and Discussion
The answer is B. Retinal detachment usually affects individuals older than 50 years. It does not cause pain or erythema of the eye. Bilateral spontaneous detachments are present in as much as 25% of those affected. Retinal detachment can be caused by retinal tears, retinal holes, or by other causes, including ocular melanoma and metastatic tumors. Warning symptoms include floaters, flashes of light (photopsia), or blurred vision. As detachment progresses, the patient may report a “curtain or shade coming down” phenomenon. Macular involvement leads to central visual loss and a worse prognosis. Patients suspected of retinal detachment should undergo emergent ophthalmologic evaluation. Prognosis is best if there is no macular involvement. Without treatment, total detachment usually occurs within 6 months. Treatment of retinal tears or holes is accomplished with laser photocoagulation, cryotherapy, or a scleral buckle. Uncomplicated retinal detachment can be repaired in up to 90% of cases.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:919–920.
33. Which of the following statements about pharmacokinetics in the elderly is true?
A) Body fat stores decrease, and, thus, fat-soluble medications have decreased distribution and there is less risk for toxicity.
B) The glomerular filtration rate is reduced in the elderly, which can lead to a decreased clearance of medication and an increased risk for toxicity.
C) The volume of body water is increased in the elderly, which may require increased dosages of water-soluble medications.
D) Accumulation of active metabolites does not occur in the elderly secondary to rapid clearance.
E) Hepatic metabolism of drugs increases as patients age.
View Answer
Answer and Discussion
The answer is B. In the United States, approximately two-thirds of persons 65 years or older take prescription and nonprescription (over-the-counter) medications. Women take more drugs than men, because they are, on average, older, and they use more psychoactive and antiarthritic drugs. At any given time, an average older person uses four to five prescription drugs, two over-the-counter drugs, and fills 12 to 17 prescriptions a year. The frail elderly use the most drugs. Drug use is greater in hospitals and nursing homes than in the community; typically, a nursing home resident receives seven or eight drugs. Changes that occur in the elderly often affect the medications that are administered to them. As patients age, they increase their body stores of fat. Because of this, fat-soluble medications have increased distribution and a longer half-life in the body. Although expression of drug-metabolizing enzymes in the cytochrome P-450 systems does not appear to decline with age, the overall hepatic metabolism of many drugs by these enzymes is reduced. The glomerular filtration rate in the elderly is also reduced, which can lead to a decreased clearance of medications and an increased risk for toxicity. The volume of body water is also reduced in the elderly and the administration of water-soluble medications can lead to toxicity with some medications. All these changes must be considered when administering medication to the elderly. Increased sensitivity with aging must be considered when drugs that can have serious adverse effects are used. These drugs include morphine, pentazocine, warfarin, angiotensin-converting enzyme inhibitors, diazepam (especially given parenterally), and levodopa. Some drugs’ effects are reduced with aging (e.g., glyburide, β-blockers) and should also be used with caution, because serious dose-related toxicity can still occur, and signs of toxicity may be delayed. Many drugs produce active metabolites in clinically relevant concentrations. Examples are some benzodiazepines (e.g., diazepam, chlordiazepoxide), tertiary amine antidepressants (e.g., amitriptyline, imipramine), antipsychotics (e.g., chlorpromazine, thioridazine; not haloperidol), and opioid analgesics (e.g., morphine, meperidine, propoxyphene). The accumulation of active metabolites (e.g., N-acetylprocainamide, morphine-6-glucuronide) can cause toxicity in the elderly as a result of age-related decreases in renal clearance; toxicity is likely to be severe in those with renal disease.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2535.
34. Which one of the following features can usually distinguish delirium from dementia?
A) There is a lack of long-term memory loss with delirium.
B) The time span over which symptoms develop differs.
C) There is an absence of long-term memory loss with dementia.
D) There is a loss of orientation with delirium.
E) None of the above.
View Answer
Answer and Discussion
The answer is B. Delirium is a condition that usually develops in an acute situation (over a period of hours to days) and is characterized by confusion, agitation, loss of orientation, lack of attention, hallucinations, paranoia, disturbed sleep–wake cycles, and loss of perception. The condition is a transient global disorder of cognition and consciousness. The delirious patient may also have psychomotor and emotional disturbances. In most patients, delirium due to a medical disease is reversible with treatment of the underlying condition. The symptoms of delirium tend to fluctuate in their course. The etiology may be related to toxin exposure, withdrawal from narcotics or alcohol, medications, vitamin deficiencies, infection, trauma, or structural abnormalities affecting the brain (e.g., tumor, abscess). The best treatment is to correct the underlying cause. Dementia, however, is a slow, progressive condition that may take months to years to develop.
Gleason OC. Delirium. Am Fam Physician. 2003;67:1027–1034.
35. Which of the following is the predominant component of dementia?
A) Confusion
B) Anxiety
C) Depression
D) Memory loss
E) Paranoia
View Answer
Answer and Discussion
The answer is D. Dementia is a condition characterized by the loss of intellectual abilities and the impairment of usually short-term memory. Most patients are older than 65 years. Dementia usually has a slow, progressive, and remitting course. The condition is characterized by a decline in intellectual functioning to the extent that the patient is unable to perform the usual activities of daily living. Memory deficit is a predominant component of dementia, and the deterioration of intellectual functioning may occur over months to years. Dementing diseases in the elderly include Alzheimer's disease (now known as dementia of the Alzheimer's type), vascular dementia (previously called multi-infarct dementia), and other disorders. The precise mechanisms of the dementias are generally unclear, and no effective cures are available. There is usually no history of prior psychiatric illness, and patients affected typically perform poorly on cognitive tests. Sundowning (confusion, loss of orientation) at night in unfamiliar surroundings is common. As many as 15% of dementias are reversible, and, thus, physiologic causes must be ruled out. Treatable causes include medication side effects, depression, hypothyroidism, dehydration, infection, schizophrenia, Wernicke–Korsakoff syndrome, liver or kidney failure, electrolyte abnormalities, hypoglycemia, vitamin deficiency (e.g., vitamin B12), subdural hematoma, normal pressure hydrocephalus, neoplasm, and stroke. The workup should be individualized but in many cases consists of electrolytes, complete blood count, thyroid-stimulating hormone, vitamin B12, Venereal Disease Research Laboratory (VDRL), liver function tests, erythrocyte sedimentation rate, urine and plasma heavy metal screens, electrocardiogram, CT or magnetic resonance imaging of the head, chest x-ray, electroencephalogram, O2 saturation, and lumbar puncture.
Santacruz KS, Swagerty D. Early diagnosis of dementia. Am Fam Physician. 2001; 63:703–713, 717–718.
36. Which of the following is true regarding the use of tacrine (Cognex)?
A) The drug has been shown to cause renal failure and thus serum creatinine must be monitored.
B) The drug is associated with hepatotoxicity and requires the monitoring of liver function tests.
C) The drug is favored over others in its class due to its once daily dosing.
D) The drug has an exceptionally long half-life.
E) Tacrine is considered a first-line agent in the treatment of Alzheimer's disease.
View Answer
Answer and Discussion
The answer is B. The pharmacologic characteristics and side effects of tacrine make it a second-line agent. Unlike the newer cholinesterase inhibitors, tacrine causes elevation of liver enzyme levels in 40% of treated patients; thus, biweekly liver tests are necessary during the period of dosage escalations and every 3 months thereafter. Because tacrine has a short half-life, it must be administered four times daily.
Cummings JL, Frank JC, Cherry D. Guidelines for managing alzheimer's disease: Part II. Treatment. Am Fam Physician. 2002;65:2525–2534.
37. Which of the following is the most common cause of cognitive impairment in elderly patients?
A) Alcohol-induced encephalopathy
B) Multi-infarct dementia
C) Alzheimer's disease
D) Parkinson's associated dementia
E) Pick's disease
View Answer
Answer and Discussion
The answer is C. Alzheimer's disease is the most common cause of cognitive impairment in elderly persons, with an incidence that doubles every 5 years after the age of 60 years. This disease afflicts approximately 4 million Americans and is estimated to cost the U.S. economy $60 billion annually.
Cummings JL, Frank JC, Cherry D. Guidelines for managing alzheimer's disease: Part I. Assessment. Am Fam Physician. 2002;65:2525–2534.
38. Which of the following is not commonly seen in Lewy body dementia?
A) Dementia
B) Delirium
C) Visual hallucinations
D) Bradykinesia
E) Tremor
View Answer
Answer and Discussion
The answer is E. A useful acronym to remember the cardinal features of dementia with Lewy bodies is DDaVP: Dementia, Delirium (fluctuating cognition), and Visual hallucinations with Parkinsonism. Although bradykinesia, rigidity, and falls are common to those affected, tremor often is absent in dementia with Lewy bodies.
Neef D, Walling AD. Dementia with Lewy bodies: an emerging disease. Am Fam Physician. 2006;73:1223–1229, 1230.
A useful acronym to remember the cardinal features of dementia with Lewy bodies is DDaVP: Dementia, Delirium (fluctuating cognition), and Visual hallucinations with Parkinsonism.
39. The leading cause of injury-related visits (in patients older than 65 years) to the emergency room in the United States is which of the following?
A) Motor vehicle accidents
B) Falls
C) Elder abuse
D) Exposure to extremes of temperature
E) Self-induced injury related to depression
View Answer
Answer and Discussion
The answer is B. Falls affecting the elderly are a major cause of morbidity. Falls are the leading cause of injury-related visits to emergency departments in the United States, and the primary etiology of accidental deaths in persons older than 65 years. They may result in severe injury, including hip or other bone fractures; bruises; and subdural hematomas, as well as dehydration and hypothermia if the patient is not found. Many factors play a role in the cause of falls, including muscle weakness, lack of coordination, poor vision, joint stiffness, autonomic dysfunction, increased reaction time, dementia or delirium, and medications. The physician should always search for precipitating causes such as stroke, cardiac arrhythmias, hypoglycemia, orthostasis, or environmental causes. Precautions should include proper lighting, short-pile carpet, railings, and walkers or canes for those with gait disorders. A visit to the patient's home or living environment may be helpful in determining dangerous conditions. All reversible problems should be corrected. When the cause of a fall is not determined or a patient remains at high risk for falls, referral to a falls prevention program may be warranted.
Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61:2159–2168, 2173–2174.
40. Which one of the following laboratory findings is seen with aging?
A) Increase in creatinine clearance
B) Increased aspartate aminotransferase
C) Decreased serum creatinine
D) Decreased incidence of false-positive rapid plasma reagin tests
E) Increase in fasting glucose levels
View Answer
Answer and Discussion
The answer is E. For the most part, many laboratory normal values remain the same for elderly patients. However, there are some exceptions. With increasing age, there is usually
· Decline in renal function, as is evident by a 10% decrease in creatinine clearance per 10 years after 40 years of age.
· Increasing fasting blood glucose (1 mg/dL for every 10 years), although most patients remain within the normal limit values.
· Increased alkaline phosphatase.
· Increased incidence of false-positive rapid plasma reagin tests for syphilis.
Other tests, including electrolytes, serum creatinine, and liver function tests, usually remain the same.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:2535–2545.
41. Which one of the following defines a stage II pressure ulcer?
A) A break in the skin with surrounding erythema and induration.
B) An ulcer with penetration of the deep fascia, exposing bone or underlying muscle.
C) A localized area of nonblanchable, erythematous skin.
D) A full-thickness ulcer that extends to the subcutaneous layer but not through the underlying fascia.
View Answer
Answer and Discussion
The answer is A. Pressure ulcers are quite common in elderly debilitated patients if they are not adequately cared for. Between 3% and 11% of nursing home and hospital patients suffer from pressure ulcers. Precipitating factors include constant pressure, moisture (incontinence), shearing forces, and friction. The ulcers may form as quickly as in 2 to 3 hours if the patient is not repositioned. If patients are placed on their sides, they should be positioned at a 30-degree angle to avoid excessive pressure over the greater trochanter and lateral malleolus. Soft pillows, padded chairs, and egg-crate mattresses can help decrease the risk of ulcer formation but are not a substitute for repositioning. Doughnut-type cushions are not helpful and can cause decreased circulation to the tissue in the center of the doughnut and worsening of any existing ulcers. Alternating air mattresses and waterbeds have been shown to help reduce the incidence of pressure ulcers.
Pressure ulcers are classified as follows:
· Stage I—a localized area of nonblanchable, erythematous skin.
· Stage II—a break in the skin with surrounding erythema and induration.
· Stage III—a full-thickness ulcer that extends to the subcutaneous layer but not through the underlying fascia. Risk for infection is high, and the use of antibiotics may be required.
· Stage IV—ulcer penetrates the deep fascia exposing bone or underlying muscle.
Mild pressure sores (stages I and II) require all the prophylactic measures mentioned previously to prevent necrosis. The area should be kept exposed, free from pressure, and dry. Stimulating the circulation by gentle massage can accelerate healing. Ulcers that have not advanced beyond stage III may heal spontaneously if the pressure is removed and the area is small. New hydrophilic gels and hydrocolloid dressings speed healing. Stage IV ulcers require débridement or more extensive surgery. When the ulcers are filled with pus or necrotic debris, dextranomer beads or newer hydrophilic polymers may hasten débridement without surgery. Conservative débridement of necrotic tissue with forceps and scissors should be instituted. Some ulcers may be débrided by cleansing with 1.5% hydrogen peroxide. Whirlpool baths may assist débridement. More advanced ulcers with fat and muscle involvement require surgical débridement and closure. For cellulitis, a penicillinase-resistant penicillin or a cephalosporin is necessary. A culture is generally not helpful in choosing an antibiotic, because surface growth is often polymicrobial.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1011–1017.
42. An 85-year-old nursing home patient was seen in a local physician's office during the day for a corneal abrasion. The patient had antibiotic drops instilled, and the eye was patched. At 10:00 p.m., the nursing staff calls reporting that the patient is very confused. The most appropriate action is to
A) remove the eye patch
B) prescribe haloperidol
C) have the patient taken to the emergency room
D) reassure the nursing staff and see the patient the next day
E) restrain the patient to protect him from injury
View Answer
Answer and Discussion
The answer is A. Sensory deprivation, such as patching an elderly patient's eyes, may lead to an acute case of delirium. Even small alterations in the elderly patient's environment can lead to confusion. In cases of corneal abrasions, an elderly patient should receive topical ophthalmic antibiotics. Although eye patching traditionally has been recommended in the treatment of corneal abrasions, multiple well-designed studies show that patching does not help and may hinder healing. Topical anesthetics should not be used for corneal abrasions, because they interfere with the healing process; however, they may be useful in the initial evaluation to help relieve discomfort.
Wilson SA, Last A. Management of corneal abrasions. Am Fam Physician. 2004;70:123–128, 129–130.
43. Which of the following defines a durable power of attorney?
A) A written advance directive that assigns one person as a decision-making proxy should the user become incapacitated.
B) A written advance directive in which a competent person indicates health-care preferences while cognitively and physically intact.
C) A detailed written directive that describes in questionnaire format what type of treatment a person would or would not want in various medical situations.
D) The ability of attorneys to sue physicians for negligence.
E) None of the above.
View Answer
Answer and Discussion
The answer is A. A durable power of attorney is defined as a written advance directive that assigns one person as a decision-making proxy should the user become incapacitated. A living will is a written advance directive in which a competent person indicates health-care preferences while cognitively and physically intact. A medical directive is a detailed written directive that describes in questionnaire format what type of treatment a person would or would not want in various medical situations.
Krane MK. Respecting end-of-life treatment preferences. Am Fam Physician. 2005;72:1263–1268, 1270.
44. You are called by the nursing supervisor at the local nursing home where you manage patients. She reports the outbreak of influenza A in three of the patients. What is your most appropriate response?
A) You place patients in isolation and call if any further episodes occur.
B) You order amantadine (Symmetrel) for all contacts.
C) You order rimantadine (Flumadine) for all contacts.
D) You order zanamivir (Relenza) for all contacts.
E) You order treatment with oseltamivir (Tamiflu) for any patients who develop symptoms of influenza.
View Answer
Answer and Discussion
The answer is C. Chronically ill and elderly persons have a higher incidence of side effects while taking amantadine and rimantadine. Both medications can cause gastrointestinal effects such as anorexia and nausea. However, amantadine has significantly more side effects relating to the central nervous system than rimantadine, including confusion, anxiety, insomnia, hallucinations, and falls in nursing home residents. Amantadine also has significantly higher discontinuation rates (up to 17%). Because of this higher incidence of adverse effects and higher discontinuation rates, rimantadine should be the drug of choice in the prophylaxis and treatment of influenza A in nursing home residents.
Keyser LA, Karl M, Nafziger AN, et al. Comparison of central nervous system adverse effects of amantadine and rimantadine used as sequential prophylaxis of influenza A in elderly nursing home patients. Arch Intern Med. 2000;160:1485–1488.
Kingston BJ, Wright CV Jr. Influenza in the nursing home. Am Fam Physician. 2002;65:75–78.
45. Glucosamine has been shown to be helpful in the treatment of
A) low back pain
B) neck pain
C) hip and knee pain
D) diffuse myalgias
E) none of the above
View Answer
Answer and Discussion
The answer is C. Sufficient evidence exists from studies of persons with hip or knee osteoarthritis to support the use of glucosamine as a safe and effective alternative treatment.
Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treating osteoarthritis. Cochrane Database Syst Rev. 2005;2:CD002946.
46. Which of the following is necessary to diagnose menopause?
A) Estrogen levels < 30mg/dl
B) FSH level > 35 mg/dl
C) An abnormal progesterone challenge test
D) None of the above
View Answer
Answer and Discussion
The answer is D. Menopause is defined as the absence of menses for 6 months. The average age of onset is 51 years. Symptoms of menopause are common and include hot flashes, night sweats, mood swings with emotional lability and irritability, depression, insomnia, vaginal dryness, dyspareunia, dysuria, and urinary incontinence. Hormone replacement therapy (estrogen with or without progestin) was the primary treatment for the symptoms and long-term risks associated with menopause. However, recent evidence fails to confirm the protective effect of estrogen on cardiovascular disease risk. Menopause can be confirmed by measuring follicle-stimulating hormone levels; however, this is not necessary for the diagnosis. Follicle-stimulating hormone levels higher than 35 support a menopausal state. Also, a progesterone challenge test (13 days of progestin) resulting in no withdrawal bleeding indicates a lack of estrogen and the menopausal state.
Cutson TM, Meuleman E. Managing menopause. Am Fam Physician. 2000;61:1391–1340, 1405–1406.
Menopause is defined as the absence of menses for 6 months.
47. Which one of the following statements concerning cataracts is true?
A) They are usually unilateral.
B) Asymptomatic lens opacities should be removed because of risk to the retina.
C) Ultraviolet light exposure may contribute to the progression of cataract formation.
D) The cataracts require a slit-lamp examination to be seen.
E) Surgery is rarely helpful for advanced cataract formation.
View Answer
Answer and Discussion
The answer is C. Cataracts are lens opacities that result in a painless loss of vision in patients usually older than 60 years. The prevalence of cataract increases with age from <5% in persons younger than 65 years to approximately 50% in those 75 years of age and older. They are usually bilateral and develop gradually over many years. Exposure to ultraviolet light may contribute to the progression of cataract formation. Typical symptoms related to cataracts include decreased visual acuity, particularly at night, with excessive glare in bright light or sunlight. Most cataracts can be visualized with a handheld ophthalmoscope; however, slit-lamp examination may be more revealing. Cataract surgery is the most common surgical procedure covered by Medicare, with more than 1 million procedures performed annually. This surgery should be considered when the cataract reduces vision function to a level that interferes with everyday activities. The mere presence of lens opacities—that is, lens opacities not associated with decreased visual function—is not an indication for surgery in most instances. Cataract surgery is an outpatient procedure performed under local or topical anesthesia. More than 90% of patients undergoing cataract surgery experience visual improvement and improved quality of life if there is no ocular comorbidity. Complications of cataract surgery are unusual and occur in less than 1% of surgeries. Potentially serious complications include glaucoma, bleeding, infection, vitreous loss, retinal detachment, and loss of vision.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:122–124.
48. A nurse calls to report that a hospitalized patient fell and is now complaining of severe left-hip pain. On arriving at the patient's room, you noticed the woman's left leg is shorter than the right and is externally rotated. The most likely diagnosis is
A) left-fibular fracture
B) stable left-hip fracture
C) left–anterior cruciate ligament injury
D) unstable left-hip fracture
E) unstable right-hip fracture
View Answer
Answer and Discussion
The answer is D. Hip fractures represent significant morbidity and mortality as well as health-care costs to the elderly. Fractures of the femoral neck are classified as being stable or unstable. Stable fractures include stress or impacted fractures. Patients usually report minimal pain and may be able to walk with only mild groin pain and perhaps a limp. The physical exam is unremarkable. Both stress and impacted fractures may be treated nonoperatively; however, impacted fractures are at an increased risk to become displaced and are, therefore, usually corrected with internal fixation to stabilize a reduction and allow earlier weight bearing. Patients who are demented, nonambulatory, or poor surgical candidates should be treated by nonsurgical means. Conservative measures to protect the injured extremity, prevent decubitus ulcers, and avoid pneumonia should be instituted. Unstable fractures include displaced and comminuted fractures that can be life threatening for the elderly. Most patients report considerable pain with any movement of the hip. The physical exam usually shows the affected extremity is externally rotated and shorter in length than the unaffected side. Treatment consists of surgical reduction and internal fixation followed by traction.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:386–388.
49. A 65-year-old woman presents to your office complaining of leakage of urine when she coughs or sneezes. The most likely diagnosis is
A) urinary tract infection
B) urge incontinence
C) neurogenic bladder
D) stress incontinence
E) interstitial cystitis
View Answer
Answer and Discussion
The answer is D. Stress urinary incontinence is defined as bladder outlet incompetence and the loss of urine with coughing, sneezing, straining, lifting, or any activity that requires a Valsalva maneuver and associated increased abdominal pressure. In women, the usual cause is a loss in the normal posterior ureterovesical angle as a result of pelvic floor muscle laxity. Pelvic floor weakness is a common result of aging and multiparity. Treatment may involve the use of Kegel exercises (multiple contractions of the pelvic floor muscles as if the patient were shutting off the flow of urine) and α-adrenergic medications (e.g., pseudoephedrine). Estrogens may also be effective in treating women with stress incontinence. The presence of estrogen receptors in high concentrations throughout the lower urinary tract makes it possible to treat women with stress incontinence by localized estrogen replacement therapy. Estrogen replacement therapy causes engorgement of the periurethral blood supply and subsequent thickening of the urethral mucosa. Localized estrogen replacement therapy can be given in the form of estrogen cream or an estradiol-impregnated vaginal ring (Estring). Surgery (Marshall–Marchetti procedure) may be considered if the condition is severe and refractive to medication. In some cases, the use of a pessary may be beneficial. The U.S. Food and Drug Administration recently approved extracorporeal magnetic innervation, a noninvasive procedure for the treatment of incontinence caused by pelvic floor weakness. The patient sits fully clothed in a pulsating magnetic chair that stimulates the pelvic floor. A typical treatment session lasts approximately 20 minutes and includes high- and low-frequency stimulation. Preliminary results from one uncontrolled trial suggest that extracorporeal magnetic innervation may have a place in the treatment of women with stress and urge incontinence. Another minimally invasive procedure for the treatment of stress incontinence is periurethral injection. This procedure involves injection of material at the bladder neck just under the urothelium and is performed in an office setting under local anesthesia. Pharmacologic agents may be given empirically to women with symptoms of overactive bladder. Two new medications, tolterodine (Detrol) and extended-release oxybutynin chloride (Ditropan XL), have largely replaced generic oxybutynin as a first-line treatment option for overactive bladder because of favorable side effect profiles.
Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management. Am Fam Physician. 2000;62:2433–2444, 2447, 2452.
50. An 85-year-old man complains of chronic insomnia. Based on study results, you know that
A) insomnia is relatively rare in the elderly
B) insomnia is a natural progression of aging and has little effect on the well-being of elderly patients
C) chronic insomnia is an independent risk factor for cognitive decline in elderly men
D) insomnia has no impact on the risk of falls
E) insomnia does not lead to nursing home placement
View Answer
Answer and Discussion
The answer is C. Chronic insomnia is an independent risk factor for cognitive decline in patients 65 years and older, especially in men. Insomnia is often associated with dependence on sleep medications, chronic fatigue, and increased risk of falls. Chronic sleep disturbances may lead to nursing home placement.
Cricco M, Simonsick EM, Foley DJ. The impact of insomnia on cognitive functioning in older adults. J Am Geriatr Soc. 2001;49:1185–1189.
51. Which of the following tests may help identify elders who are at increased risk for falling?
A) Straight line test
B) One foot hop test
C) Two hand one foot test
D) Sit down and stop test
E) Get up and go test
View Answer
Answer and Discussion
The answer is E. Approximately one third of noninstitutionalized elders fall each year. The annual incidence of falls approaches 50% in patients over 80 years of age. Factors contributing to falls include age-related postural changes, decreased vision, certain medications (particularly anticholinergic, sedative, and diuretic medications), and diseases affecting muscle strength and coordination. A straightforward physical examination maneuver called the “get up and go” test can help identify those at risk for falls. In this test, the patient is instructed to arise from a sitting position, walk 10 feet, turn, and return to the chair to sit. A requirement of >16 seconds to complete the process or observation of postural instability or gait impairment suggests an increased risk of falling. A number of effective interventions are available for people with a history of falls or who are at risk for falling.
Mathias, S, Nayak, US, Isaacs, B. Balance in elderly patients: the “get up and go” test. Arch Phys Med Rehabil. 1986;67:387.
52. A 70-year-old man is recently diagnosed with early Alzheimer's disease. His family is very concerned with his ability to drive. You explain to them
A) in the first year after the diagnosis is made, patients with Alzheimer's disease have a similar rate of accidents as registered drivers of all ages
B) the risk of accidents rarely changes as Alzheimer's patients grow older
C) the department of transportation is the only group that has a role in the determination of driving skills
D) roadside testing should not be used to determine the ability to drive
E) accident rates may be overestimated because of the number of miles elderly people drive
View Answer
Answer and Discussion
The answer is A. In many situations one of the first safety issues to be confronted with elderly patients affected with dementia is their driving. In the first year after diagnosis, patients affected with Alzheimer's disease (AD) have a similar rate of accidents as registered drivers of all ages, although higher than age-matched controls. The risk of motor vehicle accidents increases dramatically in the following years. This increase is likely underrepresented in that the risk per mile driven is much greater because patients substantially reduce their driving. Discussions of driving cessation are often difficult. Patients are generally unaware of their deficits (particularly their deficits in judgment), and surrendering a license often represents a severe loss of independence. With early diagnosis, many patients will still be able to drive safely for a period of time, but all will eventually progress to the point where it is no longer safe to drive. Discussions with patients in the intermediate stages of dementia pose the greatest difficulty. Only the state of California currently has a requirement that physicians notify authorities when a patient is diagnosed with dementia. Although a number of driving safety tests have been suggested, no general guidelines have been broadly instituted. Local programs may exist to evaluate these patients with neuropsychological and roadside tests. In the absence of these programs, the department of motor vehicles often performs roadside testing, but patients must be informed that even if they pass they must be retested at regular intervals as their disease progresses. Families must be warned about potential liability for accidents. They may need to take possession of car keys, or even the cars, and restrict all driving. The American Academy of Neurology has issued guidelines for driving in patients with AD based on the clinical dementia rating scale.
Dubinsky RM, Stein AC, Lyons K. Practice parameter: risk of driving and Alzheimer's disease (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology. Neurology. 2000;54:2205.
53. Which of the following statements about rehabilitation after a stroke is true?
A) Physical therapy should be instituted for stretching and strengthening once supporting muscles are strong enough to support appropriate loads.
B) Tennis ball exercises can be used to strengthen the hand muscles.
C) Most motor function improvement occurs more than 6 months after a cerebral vascular accident.
D) A walking cane used on the affected side can help with ambulation and balance.
E) Bladder or bowel incontinence has no effect on prognosis after stroke.
View Answer
Answer and Discussion
The answer is A. Rehabilitation after a stroke is often a difficult and lengthy process. Most improvement in motor function occurs in the first 6 to 12 weeks after a stroke; speech may continue to improve significantly after this period. Stretching and strengthening exercises should be instituted when the supporting muscles are capable of supporting the appropriate loads. Gait training should take place as soon as the hip musculature is capable of supporting the patient's weight. In many cases, the patient can use a cane in the hand opposite to the side the stroke affected to help support the weaker side. Squeezing a tennis ball as a hand exercise should be discouraged, because it favors finger flexors over extensors and can lead to contractures. Using a team approach with a physical therapist, occupational therapist, speech therapist, and social workers is often beneficial. The outcome after a stroke is most likely to be positive when patients have bladder and bowel continence, are able to feed themselves, and have a healthy and caring spouse. Stroke rehabilitation must include the prevention or early diagnosis of medical complications, as well as patient and family education concerning the prevention of recurrent stroke.
Landefeld CS, et al. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:381–382.
Most improvement in motor function occurs in the first 6 to 12 weeks after a stroke; speech may continue to improve significantly after this period.
54. Pernicious anemia is associated with
A) vitamin B12 malabsorption
B) chronic blood loss
C) myelofibrosis
D) iron deficiency
E) malignancy
View Answer
Answer and Discussion
The answer is A. Anemia should not be accepted as an unavoidable consequence of aging. A cause is found in approximately 80% of elderly patients. The most common causes of anemia in the elderly are chronic disease and iron deficiency. Vitamin B12 deficiency, folate deficiency, gastrointestinal bleeding, and myelodysplastic syndrome are among other causes of anemia in the elderly. Serum ferritin is the most useful test to differentiate iron deficiency anemia from anemia of chronic disease. The condition of pernicious anemia is the result of malabsorption or lack of ingestion of vitamin B12. The lack of absorption is usually the result of atrophic gastric mucosa, which fails to produce the intrinsic factor that is required for the absorption of vitamin B12. With pernicious anemia, the lack of intrinsic factor results from destruction of the gastric parietal cells by autoimmune antibodies. Previous gastrectomy, blind-loop syndrome, fish tapeworm infections, or thyroid abnormalities may also decrease intrinsic factor secretion. The anemia usually develops over time and is associated with macrocytic features, basophilic stippling of red blood cells, and an increased red blood cell distribution width index. Achlorhydria (lack of acid production) is usually associated with pernicious anemia. Symptoms of pernicious anemia include anorexia, constipation, diarrhea, and abdominal pain; glossitis; loss of sensation involving the distal extremities; weight loss; and generalized fatigue. Previously, the Schilling test would have been used to identify the cause of inadequate vitamin B12 absorption. Recent studies, however, show that high-dose oral vitamin B12 effectively treats the deficiency regardless of the cause. Vitamin B12 deficiency is effectively treated with high-dose oral or parenteral vitamin B12 supplementation.
Smith DL. Anemia in the elderly. Am Fam Physician. 2000;62:1565–1572.
55. Which one of the following statements about Alzheimer's disease is true?
A) It is associated with microscopic senile plaques, neurofibrillary tangles, and granulovacuolar degeneration of neurons in the brain.
B) It is associated with birth trauma.
C) It is usually reversible.
D) It is associated with tremor, ataxia, and muscle rigidity.
E) It is not familial.
View Answer
Answer and Discussion
The answer is A. Alzheimer's disease is a progressive, irreversible cause of dementia. It is the most common type of dementia. Symptoms include memory difficulties, disorientation, impaired judgment, aphasia, and apraxia. Histopathologic changes seen in the brain with Alzheimer's include microscopic senile plaques, neurofibrillary tangles, and granulovacuolar degeneration of neurons. A CT scan usually shows cerebral cortical atrophy and ventricular dilation. There is no identifiable cause, and other causes for dementia must be ruled out before a diagnosis of Alzheimer's disease is made. It is important to remember that 5% to 15% of dementias are reversible and may be caused by factors such as meningiomas, subdural hematomas, systemic illnesses, deficiency states and endocrinopathies, heavy metal and drug poisonings, and infections. Alzheimer's disease is familial, and no specific cause has been identified. Treatment is supportive. Efforts should be made to provide regular routines that the patient becomes accustomed to. The mainstay of treatment options is acetylcholinesterase inhibitors, which increase the duration of acetylcholine action in synapses. Tacrine (Cognex), the earliest drug in this group, has only limited benefit and a poor side effect profile, including hepatotoxicity. Donepezil (Aricept) is a highly selective acetylcholinesterase inhibitor that significantly improved cognitive scores (during phases 2 and 3 clinical trials) with a better side effect profile. A newer acetylcholinesterase inhibitor, rivastigmine (Exelon), has a good side effect profile but requires more time for dosage titration than donepezil. Estrogen therapy increases acetylcholine concentrations and has antioxidant activity, but proof of its ability to reduce the risk of Alzheimer's disease has not been shown. Anti-inflammatory drugs are under investigation. Antioxidants, including selegiline and ginkgo biloba, have demonstrated some benefits in improving cognition and delaying progression of the disease, but the outcome measures used have been variable, making treatment recommendations difficult.
O'Hara R, Mumenthaler MS, Yesavage JA. Update on Alzheimer's disease: recent findings and treatments. West J Med. 2000;172:115–120.
56. Which one of the following is most likely to cause hypoglycemia in the elderly treated for diabetes mellitus?
A) Metformin (Glucophage)
B) Glyburide (Micronase, DiaBeta)
C) Glipizide (Glucotrol)
D) None of the above
View Answer
Answer and Discussion
The answer is C. Diabetes in the elderly poses some additional concern. The elderly develop microvascular complications such as diabetic retinopathy and peripheral neuropathy more quickly than younger patients. Diabetes also represents a major risk factor for the development of atherosclerosis. The renal threshold for glucose is also increased in the elderly, allowing higher levels of blood glucose before glycosuria is seen. The use of glyburide has shown a twofold relative risk of hypoglycemia when compared with glipizide. Metformin does not cause hypoglycemia with monotherapy.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:343–345.
57. An 85-year-old Alzheimer's patient is reported missing from a local nursing home. You are contacted about directions for a search. You make all of following statements except
A) Most people found alive are found within 24 hours.
B) Of those who die, >90% are found in natural areas.
C) Night searches should be avoided, because individuals are unlikely to wander when it is dark.
D) The first areas searched should be concentrated on open, populated areas.
E) The hottest and coldest times of the year are associated with the highest risk of death.
View Answer
Answer and Discussion
The answer is C. The issue of wandering and becoming lost, with the possibility for physical harm or death, is one of the concerns that often leads families and caregivers to place demented patients in nursing homes. A review of this issue that analyzed data from several available studies produced the following observations. All persons with dementia are at risk of becoming lost. The risk may be higher for demented men than for women. Individuals residing in professional care settings are at risk as well as those at home. Wandering is only a risk factor; individuals who had never wandered have become lost. The risk of becoming lost is increased when demented persons are unattended, even in their own residences. However, about 65% of people with dementia are in the presence of a caregiver at the time they become lost. Becoming lost appears to be a highly unpredictable event and can occur even when individuals with dementia are in their own homes or are participating in activities they had routinely performed many times in the past without incident. Most individuals who are found alive remain out in the open in populated areas of the community. The risk of death is increased if the demented person ends up secluded in natural or sparsely populated areas. About 91% of persons with dementia who died were found in natural areas such as woods, fields, ditches, bodies of water (approximately 20% drowned), or abandoned vehicles. The risk of death also appears to be associated with the hottest and coldest times of the year. The time it took to search for and locate a missing person with dementia also correlated with the risk of death, as most individuals found alive were located within 24 hours, and all were found within 4 days. Locating a person with dementia who becomes lost can be difficult, and this problem is complicated by several factors related to the increased likelihood of abnormal behavior. People with dementia are often unpredictable when lost. The accuracy of the search is usually not enhanced by predictions from families and caregivers. The lost persons rarely call for help or respond to searcher's calls. Search strategies should not be based on the individual characteristics of the missing person, because the unpredictable and abnormal behavior is likely to negate any prior individual patterns. Caregivers should report the person missing immediately to local authorities. An exhaustive search should begin immediately, so that the individual has less time to find a secluded hiding place and has reduced exposure to the environment. Searches should continue through the night, as individuals often continue to wander. The initial 6 to 12 hours of the search should cover a 5-mile radius around the location where the lost person was last seen, concentrating on open, populated areas, including the inside of easily accessible buildings. If initial search efforts fail, the subsequent efforts should be devoted to an intensive foot search of natural and sparsely populated areas beginning within a 1-mile radius of the last known location and extending from there. If the person with dementia traveled by car, initial search efforts should focus on locating the vehicle. Caregivers, both formal and informal, must be informed that all persons with dementia are at risk of becoming lost, even if the individual has never wandered or exhibited “risky” behavior in the past. Because the risk is highest when persons with dementia are left unattended, every effort should be made to ensure continuous supervision. Community resources, adult day care and respite care facilities, and caregiver support groups may be utilized, if available, to reduce the burden on families and caregivers.
Rowe MA, Feinglass NG, Wiss ME. Persons with dementia who become lost in the community: a case study, current research, and recommendations. Mayo Clin Proc. 2004; 79:1417.
58. Which of the following supplements has been shown to decrease the risk of falls?
A) Glucosamine/chrondroitin
B) Vitamin C
C) Ginkgo biloba
D) Vitamin D
E) Vitamin B12
View Answer
Answer and Discussion
The answer is D. Vitamin D supplementation, with or without calcium, has been shown to decrease the risk of falls in elderly patients. A subsequent meta-analysis focused specifically on vitamin D supplementation and concluded that such supplementation reduces the risk of falls (odds ratio 0.78, 95% CI 0.64–0.92); the proposed mechanism is through improvements in muscle strength with supplementation.
Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, et al. Effect of vitamin D on falls: a meta-analysis. JAMA. 2004;291:1999.
59. When performing an evaluation of urinary incontinence in elderly patients which of the following tests is not initially indicated?
A) Urinalysis
B) Urine culture
C) Serum glucose
D) Serum calcium
E) Urodynamic testing
View Answer
Answer and Discussion
The answer is E. Physicians must initiate a discussion of voiding symptoms because at least one half of incontinent individuals do not report the problem to their providers. A physical examination for incontinence should be comprehensive and extend “above the waistline.” In persons with symptoms of stress incontinence a clinical stress test may be performed by having the patient (who should not have recently voided) give a single vigorous cough while standing and maintaining a relaxed perineum. Instantaneous leakage suggests stress incontinence, whereas a delay of several seconds before leakage suggests stress-induced detrusor overactivity. If urinary retention is suspected, it is important to consider post-void residual testing, either by catheterization or ultrasound. A post-void residual >200 mL suggests detrusor weakness or obstruction, and in men should prompt a renal ultrasound examination to exclude hydronephrosis. If not recorded recently, it is necessary to measure renal function, glucose, calcium, and, in older people, vitamin B12 levels. A urinalysis should be obtained in all patients and a urine culture if infection is suspected. Routine urodynamic testing is not recommended, and is mainly of value to provide an accurate diagnosis when surgery is being considered.
Dubeau CE. Clinical presentation and diagnosis of urinary incontinence. Up to Date Online 14.1. http://uptodateonline. com. Accessed 4/10/06.
60. A 79-year-old woman with a history of atherosclerosis and hypertension is seen in the emergency room. The patient reports she suddenly lost her vision in her left eye on awakening this morning. She reports no pain associated with the eye and has no other symptoms. Funduscopic examination shows disk swelling, extensive retinal hemorrhages, and cotton-wool spots. The most likely diagnosis is
A) cerebrovascular accident
B) central retinal vein occlusion
C) closed-angle glaucoma
D) macular degeneration
E) transient ischemic attack
View Answer
Answer and Discussion
The answer is B. Central vein occlusion usually affects elderly patients with atherosclerosis. The severity is variable; older individuals are usually affected more severely. Predisposing factors include hypertension, diabetes mellitus, glaucoma, increased blood viscosity, and elevated hematocrit. Symptoms include a sudden, dramatic, painless loss of vision usually first noticed on awakening in the morning. Physical findings include disk swelling, venous dilation, retinal hemorrhages, and cotton-wool spots. Those with poor visual acuity at the onset have the worst prognosis. These patients usually have extensive hemorrhages and cotton-wool spots, indicating retinal ischemia, and they may develop neovascular (rubeotic) glaucoma within 3 months after the initial occlusion. Should this occur, laser photocoagulation should be performed; otherwise, there is no medical therapy available. Underlying predisposing factors should be ruled out and treated appropriately if present. Branch vein occlusions may show varying degrees of visual loss and have a better prognosis than central vein occlusion.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:917–918.
Symptoms of central vein occlusion include a sudden, dramatic, painless loss of vision usually first noticed on awakening in the morning.
61. Which of the following statements about hip fractures associated with osteoporosis is true?
A) African Americans have a higher incidence of osteoporosis and associated fractures.
B) The affected leg is usually shortened, abducted, and externally rotated.
C) Most fractures result from compression-type injuries rather than from falls laterally.
D) Bisphosphonates have not been found to be beneficial in preventing hip fractures.
E) The risk is highest for elderly men who have vision problems.
View Answer
Answer and Discussion
The answer is B. Hip fractures as a result of osteoporosis represent a major morbidity for the elderly. The cost for treatment is excessive. Elderly persons are rightfully concerned about the loss of independence associated with fractures. Six months after a hip fracture, many older persons still require assistance with the activities of daily living. Furthermore, >10% of persons with hip fractures die. In the United States alone, hip fractures are responsible for 31,000 deaths each year. The risk is greatest for postmenopausal women who suffer from osteoporosis. Whites have a higher incidence of osteoporosis and associated fractures than African Americans. Most hip fractures occur as a result of falling sideways and not from compression. This mechanism of injury has a direct impact on the greater trochanter at the proximal femur. Most hip fractures present with the affected leg shortened, abducted, and externally rotated. Other fracture sites, including the spine (compression type), wrist, humerus, and tibia, are also affected. The use of estrogen replacement therapy and calcium supplementation with vitamin D in postmenopausal women has a protective effect; however, because of controversy over estrogen risk, many avoid this treatment. The use of bisphosphonates, such as alendronate (Fosamax), risidronate (Actonel), etidronate (Didronel), or once monthly ibandronate (Boniva); calcitonin (Miacalcin); or raloxifene (Evista), a selective estrogen receptor modulator, can be beneficial in preventing further bone loss. Hip protectors may also help prevent hip fractures, although recent evidence is controversial.
Kannus P, Parkkari J, Niemi S, et al. Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med. 2000;343:1506–1513.
62. The solid tumor malignancy most frequently diagnosed in elderly men is
A) lung cancer
B) colon cancer
C) prostate cancer
D) lymphoma
E) esophageal cancer
View Answer
Answer and Discussion
The answer is C. In the United States, prostate cancer is the most common solid tumor malignancy in men and, second to lung cancer, is the leading cause of cancer deaths in this group. African Americans are at higher risk than Whites. The risk increases with age, and 70% of men older than 80 years are affected. Diagnosis is usually made by the detection of a palpable prostate nodule on physical examination followed by a PSA determination, which is elevated. The combination of a digital rectal examination and PSA test is more accurate in diagnosing early prostate cancer than either alone. The main problem with prostate cancer screening is that, although this malignancy is extremely common, it is the actual cause of death in only a small proportion of patients who have histologic evidence of prostate cancer. Prostate cancer screening programs may result in the detection and treatment of many asymptomatic cancers that have no impact on length of life. The decision to offer prostate cancer screening must be made on an individual basis, depending on the patient's age, health status, family history, risk of prostate cancer, and personal beliefs. The patient must be informed about the risks and potential benefits of screening. The patient also must be helped to realize that, although prostate cancer can grow quickly, it generally grows quite slowly.
Ultrasound examination with possible biopsy should be performed if the physical exam or PSA determination is abnormal. Metastasis is usually local extension or to bone and may manifest itself in low-back pain as the presenting complaint in an elderly man. Treatment consists of surgery, radiation, and hormonal manipulation, depending on the stage and type of tumor identified. In radical prostatectomy, the entire prostate is excised from the urethra and bladder, which are then reconnected. Severe complications from radical prostatectomy are relatively uncommon. However, damage to the urinary sphincter and penile nerves during surgery can result in postoperative urinary incontinence and impotence. External-beam radiotherapy appears to be as effective as surgery in curing prostate cancer, at least for the first 10 years after treatment. Radiotherapy is well tolerated, and it is associated with no hemorrhagic or anesthetic risks. Furthermore, this treatment option does not require hospitalization or a significant recovery period. Normal activity can usually be maintained during radiotherapy. However, treatment is administered daily for 4 to 6 weeks, and many patients report feeling fatigued at the end of this period. It is associated with severe bladder irritation (urgency, pain, and frequency) in as much as 5% of patients. Rectal irritations (diarrhea, urgency, tenesmus, and bleeding) occur in 3% to 10% of patients who receive radiotherapy for prostate cancer, and impotence is a problem in 40% to 50% of patients receiving this treatment. The two types of radiotherapy are external-beam irradiation and implantation of radioactive pellets (seeds). Although neither approach has been shown to be superior in terms of long-term outcome, seed implant therapy has been gaining in popularity since its introduction. Because of controversy surrounding outcomes and the potential for complications, the patient should be informed of the risks and benefits and participate in the decision making process.
Bhatnagar V, Kaplan RM. Treatment options for prostate cancer: evaluating the evidence. Am Fam Physician. 2005;71:1915–1922, 1929–1930.
63. Which one of the following statements about herpes zoster is true?
A) The virus remains dormant in the muscle fibers and can be reactivated by stress.
B) The rash is usually maculopapular, bilateral, and typically affects the lower abdomen.
C) The virus can lead to chronic, debilitating pain for an extended period after resolution of the rash.
D) Steroids should not be used for treatment in patients older than 50 years because of their immunosuppressant properties.
E) Exposure to patients with varicella (chickenpox) can cause herpes zoster.
View Answer
Answer and Discussion
The answer is C. Herpes zoster, also known as shingles, is caused by a reactivation of the virus that causes varicella (chickenpox). The virus remains dormant in the nerve endings and reactivates itself, in some cases, as a result of stress or infection. In most cases, a vesicular, painful rash develops in a single, unilateral, dermatomal pattern. Herpes zoster typically presents with a prodrome consisting of hyperesthesia, paresthesias, burning dysesthesias, or pruritus along the affected dermatome(s). The prodrome generally lasts 1 to 2 days but may precede the appearance of skin lesions by up to 3 weeks.
The elderly are most frequently affected. Areas of involvement usually include the trunk; however, it may occur on the face (in the distribution of the trigeminal nerve). Other symptoms include fatigue, fever, and headache. After the resolution of the rash, many patients develop postherpetic neuralgia, which can be chronic and debilitating. For acute herpes zoster, the antivirals acyclovir (Zovirax), valacyclovir (Valtrex), and famciclovir (Famvir) are useful for treatment, particularly if administered early in the course of the disease. If the use of orally administered prednisone is not contraindicated, adjunctive treatment with this agent is justified on the basis of its effects in reducing pain, despite questionable evidence for its benefits in decreasing the incidence of postherpetic neuralgia. Given the theoretic risk of immunosuppression with corticosteroids, some investigators believe that these agents should be used only in patients older than 50 years, because they are at greater risk of developing postherpetic neuralgia and prednisone may be beneficial. Treatment of postherpetic neuralgia consists of topical capsaicin (Zostrix) and amitriptyline. Pregabalin (Lyrica) is a new medication recently approved for the treatment of post herpetic neuralgia. Additionally a new immunization (Zostavax) has been approved for the prevention of herpes zoster in patients over the age of 60. Those not immune to varicella can develop varicella after exposure to herpes zoster.
Stankus SJ, Dlugopolski M, Packer D. Management of herpes zoster (shingles) and postherpetic neuralgia. Am Fam Physician. 2000;61:2437–2444, 2447–2448.
64. The misuse and overprescribing of psychotropics leads to adverse effects and deteriorating medical and cognitive status. To combat the problem in the United States, nursing home reform legislation, the Omnibus Budget Reconciliation Act of 1987 (OBRA–87), mandated freedom for every resident from medically unnecessary “physical or chemical restraints imposed for purposes of discipline or convenience.” After institution of this legislated action, which of the following occurred?
A) The use of SSRIs increased.
B) The use of long-acting benzodiazepines (e.g., diazepam) increased.
C) The use of neuroleptics increased.
D) Antipsychotic medication use increased.
E) There was no effect noted on physician's prescribing practices.
View Answer
Answer and Discussion
The answer is A. Several multi-year, multi-facility reviews have examined the impact of OBRA regulations on psychotropic prescribing in nursing homes. These confirm an encouraging trend, including increased awareness of neuroleptic indications and side effects. Post-OBRA, overall antipsychotic use declined by nearly one-third. Antidepressant prescribing increased (by almost 85% in one study), with significant increases in the use of selective serotonin reuptake inhibitors (SSRIs), nortriptyline, and trazodone, and decreases in amitriptyline and doxepin. Anxiolytic/hypnotic prescribing patterns are less consistent. A large study documented a 12% increase in anxiolytics but decreases in particular agents (e.g., diazepam, diphenhydramine). Two studies identified the implementation of OBRA regulations alone as responsible for decreased neuroleptic dosing.
Borson S, Doane K. The impact of OBRA-87 on psychotropic drug prescribing in skilled nursing facilities. Psychiatr Serv. 1997;48:1289.
65. When considering treatment of hyperlipidemia in elderly patients, which of the following is true?
A) Elderly patients should not receive lipid-lowering medication over age 85 because of the risk involved with the use of the medications.
B) In the presence of a terminal illness, the use of lipid lowering medication should not be withheld.
C) The decision to use lipid-lowering medications should be individualized to the patient.
D) All patients with a history of coronary artery disease should be treated with lipid lowering medications regardless of their comorbid conditions.
E) None of the above.
View Answer
Answer and Discussion
The answer is C. The decision whether to treat high or high-normal serum cholesterol in an elderly individual must be individualized, being based on both chronologic and physiologic age. As an example, a patient with a limited life span from a concomitant illness is probably not a candidate for drug therapy. However, an otherwise healthy elderly individual should not be denied drug therapy simply on the basis of age alone.
Grundy SM, Cleeman JI, Rifkind BM, et al. Cholesterol lowering in the elderly population. Coordinating Committee of the National Cholesterol Education Program. Arch Intern Med. 1999;159:1670.
66. Which of the following increases as men age?
A) Sex hormone-binding globulin (SHBG)
B) Serum free testosterone
C) Bone mineral density
D) Muscle mass
E) Muscle strength
View Answer
Answer and Discussion
The answer is A. Serum sex hormone-binding globulin (SHBG) concentrations increase gradually as a function of age. The clinical implication, because SHBG binds testosterone with high affinity, is that with increasing age, less of the total testosterone is free (i.e., biologically active). Because of the increase in SHBG with age, it is not surprising that the serum free testosterone concentration decreases with increasing age to a greater degree than the total testosterone. No consequences of the decline in serum testosterone with age are known with certainty, but several parallels between the effects of aging and those of hypogonadism suggest that the decline in serum testosterone might be related to decreased frequency of orgasm or intercourse. Men with hypogonadism due to known disease also have a decline in sexual function, as illustrated by an improvement after testosterone treatment. As men age, their bone mineral density also declines. In a study of healthy men who had never had any fractures, the bone mineral density of the femur and, to a lesser extent, the spine declined from age 20 to age 90. Men who are hypogonadal due to disease or whose testosterone has been lowered surgically or medically also have a decline in bone mineral density. As men age, their muscle mass declines and fat mass increases. Hypogonadal men also have less muscle mass and more fat mass than normal men; testosterone treatment in men with hypogonadism tends to reverse these changes. Men ages 60 to 79 years have less muscle strength than those ages 20 to 39 years. The decrease in serum testosterone concentrations that occurs with aging in men may be associated with a decline in neuropsychological function.
Snyder PJ. Decline in testicular function with aging. Up to Date Online 14.1. http://uptodateonline.com. Accessed 4/10/06.
67. Which one of the following is typically associated with normal-pressure hydrocephalus?
A) Tremor
B) Small ventricles
C) Short stature
D) Urinary incontinence
E) Macrocephaly
View Answer
Answer and Discussion
The answer is D. Normal pressure hydrocephalus is a relatively rare disorder characterized by the following triad: dementia, gait ataxia, and urinary incontinence. Lumbar cerebrospinal fluid (CSF) pressure must be normal, and there is usually ventricular dilation noted on the computed tomography (CT) or magnetic resonance image (MRI) examination that is disproportionate to cortical atrophy. The etiology is unknown, but there appears to be inadequate absorption of CSF, which leads to hydrocephalus. It may follow head injury, subarachnoid hemorrhage, or meningoencephalitis; however, in many cases there are no preceding conditions. The patient shows no weakness, but has a stuttering gait in which the initiation of gait is hesitant but gives way to walking. In addition, the patient may show lower-extremity spasticity and up-going toes. Treatment has included shunting of CSF fluid from the dilated ventricles, which has shown some clinical benefit but little effect with long-standing hydrocephalus. Brief improvement after removing approximately 50 mL of CSF indicates a better prognosis with shunting. Radiographic or pressure measurements alone do not seem to predict the response to shunting. Shunting CSF from the dilated ventricles sometimes results in clinical improvement, but, the longer the disease has been present, the less likely shunting will be curative.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1811, 1814.
Normal-pressure hydrocephalus is a relatively rare disorder characterized by the following triad: dementia, gait ataxia, and urinary incontinence.
68. A 65-year-old otherwise healthy woman presents to your office complaining of dyspareunia. The examination shows a pale-pink vaginal mucosa, loss of rugae, and a friable cervix. The most appropriate treatment is
A) trichloroacetic acid application
B) cryotherapy
C) estrogen vaginal cream
D) psychotherapy
E) vaginal dilation
View Answer
Answer and Discussion
The answer is C. Atrophic vaginitis is the result of a lack of estrogen on the vaginal tissue. Up to 40% of postmenopausal women have symptoms of atrophic vaginitis. Related to estrogen deficiency, the condition may occur in premenopausal women who take antiestrogenic medications [medroxyprogesterone (Provera), tamoxifen (Nolvadex), danazol (Danocrine), leuprolide (Lupron), and nafarelin (Synarel)] or who have medical or surgical conditions that result in decreased levels of estrogen. The thinned endometrium and increased vaginal pH level induced by estrogen deficiency predispose the vagina and urinary tract to infection and mechanical weakness. The earliest symptoms are decreased vaginal lubrication, followed by other vaginal and urinary symptoms that may be exacerbated by superimposed infection. Patients often report vaginal pruritus, burning, discharge, and excessive dryness with dyspareunia. Urethritis with urinary incontinence, dysuria, and frequency may also occur. Physical findings include a pale-pink vaginal mucosa with friable or atrophic cervix. Once other causes of symptoms have been eliminated, treatment usually depends on estrogen administration. Estrogen replacement therapy may be provided systemically or locally (preferred), but the dosage and delivery method must be individualized. Vaginal moisturizers and lubricants and participation in coitus may also be beneficial in the treatment of women with atrophic vaginitis.
Bachman GA, Nevadunsky NS. Diagnosis and treatment of atrophic vaginitis. Am Fam Physician. 2000;61:3090–3096.
69. Which of the following statements is true regarding insomnia in the elderly?
A) Men are more commonly affected.
B) The condition is associated with inadequate tryptophan ingestion.
C) Exercise before bedtime can help relieve symptoms of insomnia.
D) Low-dose trazodone (Desyrel) may be helpful for treating insomnia.
E) Small doses of alcohol given at bedtime can be used to treat insomnia.
View Answer
Answer and Discussion
The answer is D. Elderly patients often sleep more than younger patients; however, some elderly patients suffer great difficulty with sleep patterns. The number of those patients receiving <5 hours per night dramatically increases as patients grow older. Women are more commonly affected. Patients with insomnia may experience one or more of the following problems: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning, and nonrefreshing sleep. In addition, daytime consequences such as fatigue, lack of energy, difficulty concentrating, and irritability are often present. Behavior and pharmacologic therapies are used in treating insomnia. Behavior approaches take a few weeks to improve sleep but continue to provide relief even after training sessions have ended. Patients should be encouraged to keep a sleep diary for several weeks. Sleep diaries usually record bedtime, total sleep time, time until sleep onset, number of awakenings, use of sleep medications, time out of bed in the morning, and a rating of quality of sleep and daytime symptoms. The sleep diary provides a nightly record of the patient's sleep schedule and perception of sleep. Moreover, it may serve as a baseline for assessment of treatment effects. Treatment involves attention to contributing factors for insomnia, including depression, caffeine use, tobacco or alcohol use, and lack of exercise or exercise before bedtime. Medications include tricyclic antidepressants or trazodone (Desyrel) given in low doses 1 hour before bed. Zolpidem (Ambien) has less tendency for rebound and habituation and may be a suitable alternative to other medications. Other medications that are used include eszpiclone (Lunesta) and zaleplon (Sonata) and the melatonin receptor agonist ramelteon (Rozerem).
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:114–118.
70. Which of the following is a risk factor for fecal incontinence?
A) Running
B) Prolonged sitting
C) Childbirth
D) High-fiber diet
View Answer
Answer and Discussion
The answer is C. Fecal incontinence is a serious and embarrassing problem that affects up to 5% of the general population and up to 39% of nursing home residents. Providing effective treatment is challenging because of the difficulties in identifying the underlying etiology. Risk factors include female gender, older age, physical limitations, and poor health. Previous studies in women have shown that obstetric or iatrogenic surgical injuries damage the internal or external sphincters, and straining or childbirth can injure the pudendal nerves. Anal ultrasound detects defects in the sphincter complex in up to 87% of incontinent women. Anorectal physiologic studies can identify pudendal nerve injuries in many of the remaining patients. Fecal incontinence may be associated with other causes, including spinal cord injuries, diabetes, dementia, fecal impaction, tumors, trauma, chronic constipation, or previous rectal surgery. All of these conditions result in a low anal sphincter resting tone. Physical examination should include a rectal examination to check for adequate anal sphincter tone and sensation. Further tests include electromyogram studies of the pelvic floor and anal manometry. Treatment involves a strict bowel program to develop predictable bowel movements. Adequate diet with fiber and bulk, proper positioning when defecating, and occasional bowel stimulants can be used to help regulate bowel movements into a regular pattern. For resistant cases, loperamide (Imodium) or diphenoxylate with atropine (Lomotil) may be used to control bowel movements. Other methods to help with rectal incontinence include Kegel exercises to strengthen the pelvic floor muscles and biofeedback; surgery can be considered for resistant cases.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:229–230.
71. A 66-year-old otherwise healthy man presents to your office for a general examination. He had a pneumococcal vaccine 7 years ago and inquires whether he needs another one. You correctly answer
A) further immunizations are not needed
B) he should receive only one booster at 10 years
C) he should receive one more booster and no further immunizations are needed
D) he should receive boosters every 7 years indefinitely
E) he should receive boosters every 10 years indefinitely
View Answer
Answer and Discussion
The answer is C. The 23-valent pneumococcal vaccine provides protection from 85% to 90% of the serotypes that cause invasive disease in the United States. The vaccine is 56% to 81% effective in preventing invasive bacteremia. Current guidelines from the Advisory Committee on Immunization Practices (ACIP) recommend that persons ages 65 or older who were vaccinated before age 65 should receive one revaccination 5 years after the initial vaccination, and previously unvaccinated individuals should receive one dose at age 65.
Center for Disease Control. Pneumococcal polysaccharide vaccine: What you need to know. Online at http://www.cdc.gov/nip/publications/VIS/vis-ppv.pdf#search=‘pneumococcal%20vaccine’. Accessed on 4/3/06.
72. Based on the results of the Women's Health Initiative Study, which of the following is a correct statement?
A) Those taking conjugated estrogen combined with medroxyprogesterone had an increased risk of breast cancer, coronary artery disease, stroke, and pulmonary embolism than the control group.
B) Those taking conjugated estrogen combined with medroxyprogesterone had an increased risk of breast cancer alone.
C) Those taking conjugated estrogen combined with medroxyprogesterone had an increased risk of coronary artery disease alone.
D) Those taking conjugated estrogen combined with medroxyprogesterone had an increased risk only of stroke and pulmonary embolism than controls.
E) Those taking conjugated estrogen alone had an increased risk of breast cancer, coronary artery disease, stroke, and pulmonary embolism than the control group.
View Answer
Answer and Discussion
The answer is A. The conjugated estrogen/medroxyprogesterone acetate arm of the Women's Health Initiative Study was terminated early because of excess risk of breast cancer and overall risks exceeded benefits (rates of coronary artery disease, stroke, and pulmonary embolism were also higher in the control group).
Writing Group for the Women's Health Initiative Investigators: Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002; 288:321.
73. Which of the following is true regarding hospice services?
A) Patients that use hospice must be eligible for Medicare Part A.
B) Patients enrolled in hospice must be terminally ill.
C) Patients enrolled are expected to die within 6 months.
D) Patients must sign a statement choosing Hospice care instead of routine Medicare benefits for the specified illness.
E) All of the above.
View Answer
Answer and Discussion
The answer is E. Medicare patients may choose to use the Medicare hospice benefit in situations of terminal illness. Terminal illness is defined as a life expectancy of 6 months or less if the condition progresses as expected. Patients who decide to use the hospice benefit must be eligible for Medicare Part A, be certified by their physician and hospice medical director as terminally ill, sign a statement choosing hospice care instead of routine Medicare benefits for the specified illness, and receive care of their terminal illness through a Medicare–approved hospice program.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:30.
74. A 60-year-old multiparous woman presents to your office complaining of the sudden need to urinate followed by the loss of urine. The most likely diagnosis is
A) urge incontinence
B) stress incontinence
C) overflow incontinence
D) interstitial cystitis
E) multiple sclerosis
View Answer
Answer and Discussion
The answer is A. There are three basic types of urinary incontinence:
· Urge incontinence. Also known as detrusor hyperactivity, the patient suddenly feels the urge to urinate, and involuntary loss of urine follows. It is the most common form of incontinence in elderly patients. Causes include multiple sclerosis, neurogenic bladder dysfunction, interstitial cystitis, urinary obstruction, urinary stones, urinary neoplasm, and urinary infections. In most cases, the cause is idiopathic with no clear etiologic reason. Urge incontinence may occur alone or together with stress incontinence. Treatment involves determining and correcting the underlying cause. If the cause is idiopathic, a trial of anticholinergic medication such as oxybutynin (Ditropan), imipramine (Tofranil), or propantheline (Pro-Banthine) can be used. Routine voiding schedules may also be helpful. Tolterodine (Detrol) and extended-release oxybutynin chloride (Ditropan XL) have largely replaced generic oxybutynin as a first-line treatment option for overactive bladder that contributes to incontinence because of favorable side effect profiles.
· Stress incontinence occurs when there is incompetence in the urinary sphincter. The symptoms include an involuntary loss of urine with sudden and forceful Valsalva-type maneuvers such as sneezing, coughing, laughing, or lifting heavy objects. In women, pelvic floor muscle relaxation (seen with the development of cystoceles as a result of increasing age or multiparity) contributes to the symptoms. In men, who are less commonly affected, the symptoms are usually the result of previous prostate surgery that may have damaged the nerves responsible for urinary continence. Diagnosis is usually made by the observation of involuntary urinary loss with coughing while performing a pelvic examination or the loss of urine when a patient is standing and performs a Valsalva maneuver with a full bladder. Treatment involves the use of Kegel exercises (repeated tightening of the pelvic floor muscles as if one were shutting off the flow of urine), estrogen replacement, and α-adrenergic agonists (pseudoephedrine), which help improve the urinary sphincter tone. In some cases, the use of a pessary or surgical correction may be needed.
· Overflow incontinence results when the bladder becomes overdistended and the pressure within the bladder increases and exceeds the pressure of the urinary sphincter, leading to involuntary incontinence. Causes include outlet obstruction as a result of severe constipation with fecal impaction, urethral strictures, or prostatic hypertrophy or carcinoma; in children, causes include urethral meatal stenosis, urethral valves, or urethral strictures. Patients often report hesitancy and incomplete voiding. Post-void residuals usually exceed 100 mL. Treatment includes the use of α-blockers such as terazosin (Hytrin), doxazosin (Cardura), and tamsulosin (Flomax). Other treatments include relieving outlet obstruction with medication such as finasteride (Proscar) and dutasteride (Avodart) or surgery.
Culligan PJ, Heit M. Urinary incontinence in women: evaluation and management. Am Fam Physician. 2000;62:2433–2444, 2447, 2452.
75. Which one of the following statements associated with Parkinson's disease is true?
A) The condition is associated with neurofibrillary tangles found in the substantia nigra.
B) The carbidopa component of Sinemet blocks peripheral dopa decarboxylase.
C) Amantadine (Symmetrel) is an antagonist of levodopa.
D) Benztropine (Cogentin) is helpful for the bradykinesia late in the course of Parkinson's disease.
E) Surgery for Parkinson's disease has not been shown to be beneficial.
View Answer
Answer and Discussion
The answer is B. Parkinson's disease is a progressive neurologic disorder that is associated with the loss of dopamine-containing neurons in the substantia nigra. It usually affects older patients, and there is usually no family history. The diagnosis is usually made clinically. Symptoms include a resting, pill-rolling tremor, bradykinesia (the most common complaint), and cogwheel or lead-pipe rigidity. Other manifestations include infrequent blinking, a distinguishing blank stare, festinating gait (shuffling gait with a rapid initiation and the inability to stop once started), and increased salivation. The patient may also show signs of depression or dementia. Dopamine replacement is still considered the most efficacious treatment for Parkinson's disease. Because dopamine itself does not cross the blood–brain barrier, it is administered as the precursor levodopa in combination with carbidopa (Sinemet). Carbidopa blocks peripheral dopa decarboxylase, the enzyme that converts levodopa to dopamine within the blood–brain barrier. With the levodopa–carbidopa combination, more levodopa reaches the brain and is converted to dopamine. Amantadine (Symmetrel), which has a longer half-life than levodopa, appears to act synergistically with levodopa and thus has been considered useful in the treatment of early Parkinson's disease. Dopamine receptor agonists were introduced as adjuncts to levodopa therapy to help control the motor fluctuations that occur in patients with Parkinson's disease. The dopamine agonists available for the treatment of Parkinson's disease in the United States are bromocriptine (Parlodel), pergolide (Permax), pramipexole (Mirapex), and ropinirole (Requip). Dopamine enhancement through the inhibition of dopamine breakdown in the central nervous system was the mechanism behind the development of selegiline (Eldepryl), a monoamine oxidase B inhibitor. This agent is used as an adjunct to levodopa therapy. Theoretically, it allows levodopa to be administered less often, but this has not been observed in practice. Although selegiline has antioxidant properties, no evidence supports the earlier notion that the drug is neuroprotective and delays the natural progression of Parkinson's disease. Dopamine and its precursor, levodopa, are metabolized by the enzyme catechol O-methyltransferase in the liver, gastrointestinal tract, and other organs. By preventing this breakdown, catechol O-methyltransferase inhibitors [e.g., entacapone; tolcapone (Tasmar) has been associated with liver failure] enhance the amount of levodopa that reaches the central nervous system, thereby allowing more of the drug to be converted to dopamine. Although this mechanism parallels that of carbidopa, catechol O-methyltransferase inhibitors can be taken concurrently with the levodopa–carbidopa combination because a different enzyme is involved. Trihexyphenidyl (Artane) or benztropine (Cogentin) may be prescribed as adjunctive therapy to levodopa. Either of these anticholinergic drugs may be helpful in managing significant tremor early in the course of Parkinson's disease. Anticholinergic agents have been used with mixed results in patients with essential tremor, dystonias, and certain dyskinesias. Elderly patients are often unable to tolerate the side effects of these drugs, which include cognitive impairment, dry mouth, and urinary retention. Levodopa–carbidopa (Sinemet) should be taken with a low protein meal. Surgery is considered an option even in elderly patients as long as they meet medical screening criteria, including failure to respond to available medications and absence of cardiopulmonary risk factors for surgery. Thalamotomy effectively reduces tremor and sometimes rigidity on the contralateral side. Bilateral thalamotomy may result in speech, swallowing, and visual deficits. Thalamic stimulation can reproduce the benefits of thalamotomy without the risk of irreversible tissue loss, because no physical lesion is created. Pallidotomy is a procedure in which a portion of the globus pallidus is treated permanently. The procedure has significant associated risks, including visual field deficits and hemiparesis (because of the proximity of the medial pallidum to the optic tracts and internal capsule). Bilateral procedures have a >15% complication rate and are associated with postoperative neuropsychiatric deficits in some patients. Compared with thalamic procedures, pallidotomy is less beneficial for tremors and more beneficial for dyskinesias. Pallidal and subthalamic nucleus stimulation procedures are being accepted as less invasive, more reversible alternatives to pallidotomy. Tissue transplantation procedures are also being evaluated for the treatment of Parkinson's disease. Additional adjunctive therapies include physical therapy, nutritional counseling, and techniques to help patients manage emotional and cognitive changes related to the disease.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:88–98.
Parkinson's disease is a progressive neurologic disorder associated with the loss of dopamine-containing neurons in the substantia nigra.
76. Which of the following statements concerning macular degeneration is true?
A) Peripheral vision is spared.
B) Drusen is a sign of late disease.
C) The exudative form is the most commonly seen.
D) Vision loss is usually sudden and irreversible.
E) Vision rehabilitation is not beneficial.
View Answer
Answer and Discussion
The answer is A. Age-related macular degeneration is the leading cause of severe vision loss among the elderly. In this condition, central vision is lost, but peripheral vision almost always remains intact. Affected persons rarely require canes or guide dogs. However, the loss of central visual acuity can lead to a reduction of daily activities and mobility in the elderly and increases the risks of falls, fractures, and depression in this population. Patients with age-related macular degeneration may complain of acute loss of vision, blurred vision, scotomas (areas of lost vision), or chronic distortion of vision. All patients with vision loss should be referred to an ophthalmologist; those with acute loss of vision should be referred immediately. The diagnosis of age-related macular degeneration is based on symptoms and ophthalmoscopic findings. The disease is usually classified as early or late. Late disease can be divided into atrophic (dry) and exudative (wet) forms. In early disease, the macula shows yellowish-colored subretinal deposits called drusen and/or increased pigment. Drusen are thought to be byproducts of retinal pigment epithelium dysfunction. In most eyes with early disease, visual acuity remains stable for many years, and loss of vision is usually gradual. Late disease (atrophic and exudative) can lead to significant loss of vision. Exudative disease occurs in only 10% of patients with age-related macular degeneration, but it is responsible for the majority of cases of severe vision loss related to the disease. In atrophic disease, the macula usually shows areas of depigmentation. In the exudative form, fluid can accumulate underneath the retina, as in pigment epithelial detachments or subretinal neovascularization, and loss of vision is usually sudden. Fluorescein angiography can be used to help determine whether a patient has the atrophic or exudative form of the disease. The two currently proven treatments are laser photocoagulation and photodynamic therapy, but these measures are effective in only a small fraction of eyes with the exudative form of macular degeneration. Diet therapy and vitamin supplementation is still being investigated. Vision rehabilitation can help patients maximize their remaining vision and adapt so that they can perform activities of daily living. Families need encouragement in providing support and helping patients adjust to being partially sighted.
Fong DS. Age-related macular degeneration: update for primary care. Am Fam Physician. 2000;61:3035–3042.
77. Amyotrophic lateral sclerosis is associated with
A) sensory dysfunction
B) cerebellar dysfunction
C) atrophy of the muscles and fasciculations
D) extraocular muscle dysfunction
E) improved prognosis in elderly patients (older than 70 years)
View Answer
Answer and Discussion
The answer is C. Amyotrophic lateral sclerosis (ALS, or Lou Gehrig disease) affects upper and lower motor neurons. Two-thirds of patients present with symptoms associated with the limbs, and 25% have bulbar symptoms (usually in patients older than 70 years). ALS does not affect sensory, cerebellar, or extraocular muscle function. Men are more commonly affected. Most cases occur between the ages of 40 and 70 years. Rapidly fatal disease is associated with increasing age and bulbar symptoms. Electromyogram studies show muscle denervation with preserved nerve conduction velocities. Treatment is primarily symptomatic. Attention should be focused on emotional support and “end-of-life” issues.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1897.
78. The Minimum Data Set (MDS) is
A) a document that provides a comprehensive assessment of a nursing home resident and develops a plan of care
B) a list of vital signs for the nursing home resident
C) a document that describes the activities available to a nursing home resident
D) a set of minimum requirements that a nursing home has to abide by to receive state certification
E) a group of indicators that rank nursing homes based on safety and quality
View Answer
Answer and Discussion
The answer is A. A Minimum Data Set (MDS) is a federally mandated document that is based on a comprehensive resident assessment. Information from the physician's history and physical and progress notes is used to complete an MDS. The MDS is then used to develop a plan of care and also is used to determine Medicare reimbursement for the patient.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:40.
79. Physicians are required to see nursing home patients
A) daily
B) weekly
C) monthly as long as they reside there
D) monthly for 3 months and then every 2 months thereafter
E) every 3 months
View Answer
Answer and Discussion
The answer is D. Medicare regulations require that a physician make monthly visits for the first 3 months of a resident's nursing home stay and then every 2 months thereafter.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:40.
80. Which of the following is the major feature that distinguishes delirium from dementia?
A) Cognitive changes
B) Inattention
C) Disorganized thinking
D) Altered level of consciousness
E) Acute onset and fluctuating course
View Answer
Answer and Discussion
The answer is E. The distinguishing historical features of delirium are acute onset and fluctuating course, in which symptoms tend to come and go or increase and decrease in severity over a 24-hour period. This is the major feature that distinguishes delirium from dementia, which typically develops gradually and progressively over months to years. To satisfy the criteria of delirium, the change must occur in the context of a medical illness, metabolic disturbance, drug toxicity, or withdrawal.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:55.
81. Pick's disease is
A) a hematologic disorder that causes bleeding complications
B) a malignancy associated with exposure to mining dust
C) dementia associated with the frontal lobe
D) an infection related to prior tuberculosis exposure
E) a benign condition related to underlying panic disorder
View Answer
Answer and Discussion
The answer is C. Pick's disease is a less common form of dementia affecting predominantly the frontal and temporal lobes of the cortex. Symptoms include apathy, memory disturbances, increased carelessness, poor personal hygiene, and decreased attention span. Pick's disease has spongiform changes and ballooned neurons, some of which contain argyrophilic deposits known as Pick's bodies, which are composed of cytoskeletal proteins, neurofilament, tubulin, and tau. Frontal lobe dementias, including Pick's disease, are transmitted as an autosomal-dominant–inherited disease.
Beers MH, Porter RS, eds. The Merck manual of diagnosis and therapy, Merck Research Laboratories, 18th ed. Whitehouse Station, NJ: Merck & Co.; 2006:1820–1821.
82. Which of the following statements concerning advanced directives is true?
A) Once recorded, they cannot be changed.
B) Living wills are often easier for patients to complete than designating a health-care power of attorney.
C) Advanced directives should be discussed only when life-threatening illnesses are present.
D) Physicians are not automatically required to comply with patients’ requests for treatment when they believe such requests are ill advised, harmful, or futile.
E) There is no need to update advance directives.
View Answer
Answer and Discussion
The answer is D. An advance directive consists of a person's oral and written instructions about his or her future medical care in the event that he or she becomes unable to communicate, becomes incompetent to make health-care decisions (during a terminal illness), or is in a persistent vegetative state. There are two types of advance directives: a health-care power of attorney and a living will. The health-care (“durable”) power of attorney, or health-care proxy, is a document by which the patient appoints a trusted person to make decisions about his or her medical care if he or she cannot make those decisions. A living will is a written form of advance directive in which the patient's wishes regarding the administration of medical treatment are delineated in case the patient becomes unable to communicate his or her wishes.
Discussion of advanced directives should take place early on in the care of patients to discuss the patient's wishes should they become debilitated and cannot answer for themselves. The durable power of attorney allows the patient to designate a surrogate to make medical decisions if the patient loses decision-making capacity. The durable power of attorney is often less emotionally laden than outlining specific treatments to give or withhold. The five steps identified in the ideal process of advanced care planning are as follows: (1) Raise the topic and give information regarding the advance directive and health care proxy; (2) facilitate a structured discussion; (3) complete a statement, date and record it, and have the patient supply copies to the proxy and anyone else deemed appropriate (e.g., clergy); (4) periodically review and update the directive, and initial and date all changes; and (5) implement the plan by following the patient's wishes when the appropriate time comes. Finally, physicians are not automatically obliged to comply with patients’ requests for treatment when they believe such requests are ill advised, harmful, or futile. Strict adherence to such requests may interfere with the physician's autonomy and ability to provide sound medical care.
Aitken PV. Incorporating advance care planning into family practice. Am Fam Physician. 1999;59:605.
Silveira MJ, DiPiero A, Gerrity MS, et al. Patients’ knowledge of options at the end of life: ignorance in the face of death. JAMA. 2000;284:2483–2488.
83. A 70-year-old man with a history of atrial fibrillation now on warfarin therapy presents with a left-sided hemiparesis and a change in personality noted by his family. The nursing home reports a fall 2 weeks ago. A CT scan from the emergency room shows a small illuminated crescentic collection of fluid that is located adjacent to the convexity of the hemisphere. The most likely diagnosis is
A) subdural hematoma
B) epidural hematoma
C) subarachnoid hemorrhage
D) subdural abscess
E) brain tumor
View Answer
Answer and Discussion
The answer is A. Subdural hematomas are associated with rupturing of the bridging veins beneath the dura. The elderly and those taking anticoagulants are at increased risk. Acute subdural hematomas become symptomatic within minutes to hours after the injury. Patients may report a unilateral headache, and the examination shows a slightly enlarged pupil on the side affected. Stupor, coma, hemiparesis, and unilateral papillary enlargement are typical signs of larger hematomas. Pupillary dilation is contralateral in 5% to 10%. For the patient with a rapidly declining course, burr holes or emergency craniotomy is indicated to reduce intracerebral pressure from an expanding lesion. Most subdural hematomas appear as crescentic collections over the convexity of the hemisphere and are located in the frontotemporal region. Chronic subdural hematomas may develop as a result of mild trauma and manifest as chronic headaches, slowed thinking, change in personality, seizures, or a mild hemiparesis that develops weeks to months after the injury. Many are bilateral. Symptoms may resemble a cerebrovascular accident or transient ischemic attack. Epidural hematomas develop more quickly than subdural hematomas and are more dangerous. They occur as a result of arterial bleeding between the dura mater and skull and are less common in the elderly. Most patients are comatose when first seen. The epidural hematoma forms a lenticular-shaped clot on CT. Treatment is surgical evacuation.
Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison's principles of internal medicine, 16th ed. New York: McGraw Hill; 2005:2449.
84. Which of the following statements regarding home visits is true?
A) They are increasing in frequency.
B) Reimbursement has increased their use.
C) Physicians who perform home visits have increased job satisfaction.
D) Home visits are not effective at managing patients because of a lack of resources.
E) Home visits rarely identify new medical problems, but are better suited to manage chronic medical problems.
View Answer
Answer and Discussion
The answer is C. Years ago, the home visit was an essential part of primary care practice. More recently, the home visit has been used less frequently. The low frequency of home visits by physicians is the result of many coincident factors, including deficits in physician compensation for these visits, time constraints, perceived limitations of technologic support, concerns about the risk of litigation, lack of physician training and exposure, and corporate and individual attitudinal biases. Physicians most likely to perform home visits are older generalists in solo practices. Health-care providers who have long-established relationships with their patients are also more likely to use house calls. Rural practice setting, older patient age, and need for terminal care correlate with an increased frequency of home visits. Studies suggest that home visits can lead to improved medical care through the discovery of undetected health-care needs. Home assessment of elderly patients with relatively good health status and function can increase the detection of new medical problems and new intervention recommendations. There is also improved effectiveness of home visits in assessing unexpected problems in patient compliance with therapeutic regimens. Additionally, specific home-based interventions such as adjusting the elderly patient's home environment to prevent falls have also yielded health benefits. Beyond the potential benefit of improved patient care, family physicians who conduct home visits report a higher level of practice satisfaction than those who do not offer this service.
Unwin BK, Jerant AF. The home visit. Am Fam Physician. 1999;60:1481.
85. Which of the following should be adjusted for when performing a Mini-Mental State Examination (MMSE)?
A) Location and sex of individual
B) Age and education
C) Support and living arrangement
D) Height and weight
E) Eyesight and hearing
View Answer
Answer and Discussion
The answer is B. The MMSE is a 30-point tool that tests orientation, immediate recall, delayed recall, concentration/calculation, and language and visuospatial domains. Adjustments should be made for age and level of education. As a general guideline scores >26 are normal, scores of 24 to 26 may indicate mild cognitive impairment, and a score of <24 is consistent with dementia.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:64.
The Mini-Mental State Examination (MMSE) is a 30-point tool that tests orientation, immediate recall, delayed recall, concentration/calculation, and language and visuospatial domains. Adjustments should be made for age and level of education.
86. Which of the following blood test has been correlated with an increased risk of late onset Alzheimer's disease?
A) Apolipoprotein E–E4
B) Apolipoprotein E–E2
C) Homocystine
D) Sedimentation rate
E) C-reactive protein
View Answer
Answer and Discussion
The answer is A. The association between apolipoprotein E (APOE) and Alzheimer's disease is well established. The presence of one E4 allele increases the risk of Alzheimer's disease (AD) about two to three times, whereas the E2 allele may be protective. The absence of an E4 allele does not rule out the diagnosis, nor does the presence of homozygous E4/E4 rule it in. The test is considered experimental.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:66.
87. When treating nursing home patients, it is important to remember that any antipsychotic medications must be reviewed and an attempt to withdraw or taper them made every
A) 30 days
B) 3 months
C) 6 months
D) year
E) There is no need to withdraw or taper antipsychotic medications because of the risk to patient's safety.
View Answer
Answer and Discussion
The answer is C. Federal regulations require an attempt to withdraw (or decrease the dose) of medications to manage agitation or psychosis in nursing homes every 6 months.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:68.
88. Which of the following is less likely to occur in elderly patients with influenza?
A) Headache
B) Muscle aches
C) Fatigue
D) Sore throat
E) Fever
View Answer
Answer and Discussion
The answer is E. Influenza is a common respiratory infection that causes significant morbidity and mortality in older adults. Influenza is responsible for more than $1 billion in annual Medicare expenditures. Of deaths resulting from influenza, the vast majority occur in adults 65 years and older. Older adults are susceptible to severe and potentially fatal complications from this common illness because of coexisting chronic disease and weakened immunity. Older adults can benefit most from vaccination, early detection, and aggressive therapy. The signs and symptoms of influenza infection in older adults are similar to those occurring in younger patients, although a febrile response may be absent. Influenza is typically associated with rapid onset of headache, fever, chills, muscle aches, malaise, cough, and sore throat. Most people recover fully within 1 week, but older adults may develop a persistent weakness that can last for many weeks, and are also at higher risk for developing complications such as pneumonia. Diagnosis is usually made clinically. Several commercially produced rapid diagnostic tests intended for use in outpatient settings can detect influenza viruses within 30 minutes. In selected patients, obtaining a viral culture may be warranted to acquire specific information on influenza subtypes and strains. Four antiviral agents—amantadine (Symmetrel), rimantadine (Flumadine), zanamivir (Relenza), and oseltamivir (Tamiflu)—are approved for prevention or treatment of influenza. Zanamivir and oseltamivir are not approved for prophylactic use. It is unknown whether therapy with amantadine or rimantadine can prevent complications of influenza A among persons at high risk, including older adults. Rimantadine costs more than amantadine, but has fewer adverse effects on the central nervous system (e.g., confusion, nervousness, anxiety) and is less dependent on renal excretion. Zanamivir and oseltamivir are equally effective neuroaminidase inhibitors, but their place in therapy is yet to be determined. It has not yet been determined whether early initiation of treatment reduces hospital admission and mortality, particularly in elderly and high-risk patients.
Mouton CP, Bazaldua OV. Common infections in older adults. Am Fam Physician. 2001;63:257–268.
89. Which of the following statements regarding the treatment of prostate cancer is true?
A) Radical prostatectomy appears to have a better cure rate than radiation therapy.
B) Radiation therapy has a better cure rate than surgery.
C) Surgery is better suited for younger patients.
D) Younger patients are typically observed to prevent risks associated with surgery or radiation.
E) Metastatic disease is not treatable.
View Answer
Answer and Discussion
The answer is C. Young, healthy patients are most often encouraged to undergo radical prostatectomy, and older patients are steered toward observation or radiotherapy. However, the treatment choice must be based on the patient's preference, given his understanding of the benefits and side effects of each option. Overall, cure rates for radical prostatectomy generally fall between 60% and 70%. External-beam radiotherapy appears to be as effective as surgery in curing prostate cancer, at least for the first 10 years after treatment. Radiotherapy is well tolerated, and it is associated with no hemorrhagic or anesthetic risks. Furthermore, this treatment option does not require hospitalization or a significant recovery period. Normal activity can usually be maintained during radiotherapy. However, treatment is administered daily for 4 to 6 weeks, and many patients report fatigue at the end of this period. Compared with surgery, radiotherapy has several potential disadvantages. Radical prostatectomy provides more definitive information about long-term prognosis, because the size of the tumor, the presence of cancer spread, and the presence of cancer in the lymph nodes can be determined from the surgical specimen. With radiotherapy, the post-treatment status of the tumor is unknown; serial PSA levels serve as surrogate markers to determine whether the treatment was curative. Radiotherapy can also have significant side effects. It is associated with severe bladder irritation (urgency, pain, and frequency) in as many as 5% of patients. Rectal irritations (diarrhea, urgency, tenesmus, and bleeding) occur in up to 10% of patients who receive radiotherapy for prostate cancer, and impotence is a problem in almost one-half of patients receiving this treatment. Thus, surgery is generally preferred for younger patients, whereas radiation treatment may be better suited for older patients who may not be good surgical candidates. Metastatic disease can be treated with hormonal manipulation, including surgical castration or medical castration using a luteinizing hormone releasing agonist.
Bhatnagar V, Kaplan RM. Treatment options for prostate cancer: evaluating the evidence. Am Fam Physician. 2005;71:1915–1922, 1929–1930.
90. The Medicare Hospice Benefit covers all of the following expenses for patients in nursing homes EXCEPT
A) all visits by hospice team members
B) the rental or purchase of durable medical equipment
C) cost of supplies that are ordered by the hospice team
D) the costs of medication (except for a small copay)
E) payment of room and board
View Answer
Answer and Discussion
The answer is E. When a nursing home patient is identified as having a life-threatening illness or condition, it is appropriate to plan for end-of-life care. The Medicare Hospice Benefit can help greatly with the many tasks involved in providing palliative management of the dying patient's symptoms, attending to increased hygienic needs, and supplying bereavement services. For eligible terminally ill patients, the Medicare Hospice Benefit supplies an interdisciplinary team with skills in pain management, symptom control, and bereavement assistance. The services of the hospice team supplement the usual nursing home care at a time when staff, family members, and the patient are facing the increased and urgent needs associated with the dying process. The Medicare Hospice Benefit can make it much easier for physicians and nursing home staff to provide comprehensive palliative care for terminally ill patients. When a nursing home resident is referred for care under the Medicare Hospice Benefit, the hospice assumes responsibility for the professional management of many interdisciplinary services that supplement the usual care provided by nursing home staff. All medical treatments should have the goal of
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symptom control, and they should be consistent with the hospice plan of treatment. The Medicare Hospice Benefit covers all visits by hospice team members, the rental or purchase of durable medical equipment, and the cost of supplies that are ordered by the hospice team. The hospice also supplies drugs for the palliation and management of the terminal illness, a benefit that normally is not available under the regular Medicare program. For each of these drugs, the beneficiary is only responsible for a small co-payment. Thus, hospice care is not an additional expense for many nursing home residents. Payment of room and board remains the responsibility of the patient and/or the family, or government assistance programs cover it for eligible residents (e.g., under Medicaid). The Medicare Hospice Benefit cannot be provided for nursing home residents who are receiving skilled Medicare coverage if their diagnoses for hospice and nursing home skilled care are the same. Before the Medicare Hospice Benefit can be initiated, these patients may choose to use all their skilled-care days, or they may elect to waive their skilled coverage.
Keay TJ, Schonwetter RS. Hospice care in the nursing home. Am Fam Physician. 1998;57:491.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:44.
91. The drug of choice for the treatment of a serious methicillin-resistant Staphylococcus aureus (MRSA) infection is
A) penicillin
B) ceftazidime
C) metronidazole
D) imipenem
E) vancomycin
View Answer
Answer and Discussion
The answer is E. Methicillin-resistant Staphylococcus aureus (MRSA) is a major problem for elderly patients, especially those in institutional settings. People colonized with MRSA are at increased risk of MRSA infection. They also have a higher risk of death as a result of resistance to typical antibiotics. Poor functional status is associated with being an MRSA carrier. Therefore, nursing homes and other institutional settings must be especially careful to prevent the spread of infection caused by this organism. Hand washing, isolation of infected patients, and proper handling of body secretions are essential to prevent the spread of MRSA. The most common reservoirs for MRSA colonization are the nasal mucosa and oropharynx. Skin contamination from persons already colonized in these areas may also be a source for MRSA infection. Although colonization by MRSA does not require systemic treatment, an active serious infection with MRSA is treated with vancomycin as the preferred antibiotic. Older adults may require dosage adjustment based on renal function. Other regimens include vancomycin plus gentamicin (Garamycin) or rifampin (Rifadin), sulfamethoxazole–trimethroprim (Sulfa), doxycycline, minocyclcine, and clindamycin. Attempts to identify the original infected person (source case) should be made by swabbing the nasopharynx of patients and staff near to the outbreak and treating those found to have MRSA infection. Staff and patients who are MRSA carriers should be isolated, and some authorities recommend treatment with topical mupirocin (Bactroban), which is applied twice daily for 2 weeks to the nares or other areas of skin carriage (e.g., wounds) to reduce the shedding of MRSA. Colonization recurs in approximately one-half of treated subjects.
Mouton CP, Bazaldua OV. Common infections in older adults. Am Fam Physician. 2001;63:257–268.
92. The most common reason for discontinuing acetylcholinesterase inhibitors is
A) headache
B) hepatotoxicity
C) rash
D) cataracts
E) gastrointestinal side effects
View Answer
Answer and Discussion
The answer is E. Gastrointestinal side effects, including nausea, vomiting, and diarrhea, are a class effect and are the most common reason for discontinuation of acetylcholinesterase inhibitors (tacrine, donepezil, rivastigmine, and galantamine). These can usually be minimized by slow titration over an 8 to 12 week period. Reversible hepatotoxicity is seen with tacrine—therefore, this drug is not generally recommended as first-line therapy.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:69.
Gastrointestinal side effects, including nausea, vomiting, and diarrhea, are a class effect and are the most common reason for discontinuation of acetylcholinesterase inhibitors (i.e., tacrine, donepezil, rivastigmine, and galantamine).
93. Which of the following is considered a risk factor for falls?
A) Hypothyroidism
B) Anemia
C) Addison's disease
D) Vitamin D deficiency
E) All are risk factors for falls
View Answer
Answer and Discussion
The answer is E. Many conditions that affect the elderly can increase the risk for falls. Hypothyroidism, anemia, Addison's disease, vitamin B12 deficiency, and vitamin D deficiency are some notable causes that should be ruled out when assessing an elderly patient after a fall.
Landefeld CS, Palmer R, Johnson MA. Current Geriatric Diagnosis and Treatment. New York: Lange Medical Books/McGraw Hill; 2004:84.
94. An 87-year-old man is seen by you for a general examination. He has no history of coronary artery disease and remains active, playing golf three times per week. His only other medical problem is mild hypertension for which he takes hydrochlorothiazide. Which of the following statements is true regarding treatment of his elevated cholesterol, which was discovered on a recent blood test?
A) Based on his advanced age, he does not qualify for treatment of his hyperlipidemia.
B) Only lifestyle measures should be used to treat his cholesterol because of the risk of medication use.
C) The decision to treat this man should be based on national guidelines regardless of his underlying medical condition.
D) Treatment of hyperlipidemia should be individualized based on the patient's chronological and physiologic age and life expectancy.
E) The decision treat hyperlipidemia in the elderly should not be influenced by a patient's terminal diagnosis.
View Answer
Answer and Discussion
The answer is D. The decision whether to treat high or high–normal serum cholesterol in an elderly individual must be individualized and based on both chronological and physiologic age of the patient. As an example, a patient with a limited life span from a concomitant illness (e.g., metastatic cancer, dementia) is probably not a candidate for drug therapy. However, an otherwise healthy elderly individual should not be denied drug therapy simply on the basis of age alone.
Grundy SM, Cleeman JI, Rifkind BM, et al. Cholesterol lowering in the elderly population. Coordinating Committee of the National Cholesterol Education Program. Arch Intern Med. 1999;159:1670.