Geriatrics Board Review: October 9,2009

Board Review Geriatrics 1
Geriatrics Board
Review
October 9,2009
Question 1
A 74-year-old man has Parkinsons disease
that is well controlled. However, his gait is
unstable, with mild retropulsion and
bradykinesia. The patient has had one minor
fall and has reduced his activities because he
fears falling again. He has no other
neurologic or musculoskeletal problems.
Which of the following adaptive mobility aides
is most appropriate to facilitate safer
ambulation for this patient?
A. Straight cane
B. Four-prong cane
C. Standard walker
D. Wheeled walker
E. Wheelchair
The Correct Answer is D
Critiques Q1
In a patient who curtails activity because of a fear of falling, it is
important to respond quickly to avoid rapid deconditioning. This
patient has mild retropulsion and would be able to advance a
two-wheeled walker easily. If he began walking forward too
quickly, applying weight on the walker would slow his speed.
Patients with Parkinsons disease, particularly those with
significant bradykinesia, often have difficulty initiating movement.
Thus, the process of lifting and placing a cane or standard walker
can be difficult.
The continuous movement of advancing a wheeled walker
obviates initiation of multiple movements. Some Parkinsons
patients do even better with a four-wheeled walker than a two-
wheeled walker because of this. A physical therapist can help
determine whether a two- or four-wheeled walker would be better
for a specific patient with parkinsonism.
Canes offer less stability than walkers, which provide a wide
base of stability, particularly when the patient turnsen bloc
turning is a common finding in Parkinsons disease. A wheelchair
would be appropriate if this patient were no longer able to walk at
a speed consistent with effective ambulation and if ambulation
were unsafe even with a walker.
References:
1. Iansek RT, Morris M. Rehabilitation of gait in Parkinsons
disease. J Neurol Neurosurg Psychiatry. 1997;63(4):556557.
2. Morris ME. Movement disorders in people with Parkinsons
disease: a model for physical therapy. Phys Ther.
2000;80(6):578597.
3. Wright JC. Nonpharmacologic management strategies for
Parkinsons disease. Med Clin North Am. 1999;83(2):499508.
Critiques Q1
Question 2
An 82-year-old female nursing-home resident
has end-stage Alzheimers dementia. She is
mute, incontinent of urine and feces, and
bedbound. Daily skin inspection reveals
nonblanching erythema of the heels.
Which of the following will best prevent a
pressure ulcer in this patient?
A. Bladder catheterization
B. Massaging the sacral skin daily
C. Elevating the head of the bed to 45 degrees
D. Elevating the heels off the bed surface
E. Repositioning the patient every 4 hours
The Correct Answer is D
The heels of a bedbound patient require extra
protection, but it is difficult to redistribute pressure at
the heels because of their small surface area. No
pressure-relieving mattress surface adequately
reduces pressure at the heels. The greater the
weight and height of a patient, the greater the
tissue-interface pressure at the heels and the
greater the risk of skin breakdown.
This patients heels should be elevated off the bed
surface. A readily available way to do this is to place
plump pillows under the length of the lower legs.
Critiques Q2
Critiques Q2
Urinary or fecal incontinence can cause skin
maceration, which reduces the frictional coefficient
of the skin and lowers the pressureduration
threshold for breakdown. However, bladder
catheterization should be used only for urologic
problems, such as urinary retention. A variety of
absorbent pads and briefs will draw moisture away
from the skin surface. Topical moisture-barrier
creams also may be helpful. Massaging the skin
over at-risk bony prominences previously was
thought to stimulate blood and lymphatic flow and
improve circulation. However, it is of no proven
benefit and may damage dermal tissue.
Elevation of the head of the patients bed between 20 and 70
degrees puts additional pressure on the heels and ischial
tuberosities and promotes shearing-force injury at the sacrum.
Similar forces are produced when a patient is semi-recumbent in
a chair. Shearing force is the presence of tangential pressure on
the skin. It weakens the superficial fascial attachment of the skin
to deeper tissues, causing tissue cleavage. Blood vessels are
stretched and angulated in the area, leading to vessel thrombosis
and reduced circulation. High shearing force deceases the
amount of pressure required for vessel occlusion by one-half. All
patients at risk for pressure ulcers require frequent turning.
Optimal frequency depends on the patients risk status and the
pressure-relieving mattress surface used. Bedbound patients
should be turned at least every 2 hours, and appropriate
repositioning techniques should be used to avoid friction injuries.
Critiques Q2
References: Q2
1. Kanj LF, Wilking SV, Phillips TJ. Pressure ulcers. J Am Acad
Dermatol. 1998;38(4): 517536.
2. Klitzman B, Kalinowski C, Glasofer SL, et al. Pressure ulcer
and pressure relief surfaces. Clin Plast Surg. 1998;25(3):443
450.
3. Panel for the Prediction and Prevention of Pressure Ulcers in
Adults. Pressure Ulcers in Adults: Prediction and Prevention.
Clinical Practice Guideline No. 3. Rockville, MD: US Department
of Health and Human Services, Public Health Service, Agency
for Health Care Policy and Research. May 1992. AHCPR Pub.
No. 92-0047.
4. Ratliff CR, Rodeheaver GT. Pressure ulcer assessment and
management. Lippincotts Prim Care Pract. 1999;3(2):242258.
Question 3
A 79-year-old man comes to you for an initial
visit. He reports nocturia two to three times
per night. Further questioning elicits a pattern
of frequent daytime urination; for example, he
stops often during long car rides because of
the need to urinate. Medical history includes
a remote inferior wall myocardial infarction,
and his only current medication is one aspirin
tablet daily. Physical examination reveals an
enlarged, smooth prostate gland.
Which of the following is the best
management plan for this patient?
A. Begin therapy with finasteride.
B. Measure serum prostate-specific antigen (PSA)
C. Begin therapy with transrectal ultrasound.
D. Begin therapy with an -receptor blocking
agent.
E. Quantify the severity of symptoms.
The Correct Answer is E.
Critiques Q3
A quantitative assessment of the severity of urinary symptoms is
essential to the diagnosis, evaluation, treatment, and follow-up of
men with benign prostatic hyperplsia (BPH). Before initiating
therapy, the pattern and extent of symptoms, as well as the
degree of bother they cause, should be determined. A certain
level of symptoms may warrant intervention for a patient whose
quality of life is affected, but not for another who does not feel so
troubled or who fears the adverse effects of treatment. Formal
scales are available for quantifying BPH, including the American
Urological Association symptom index, adopted by the World
Health Organization and known as the International Prostate
Symptom Score (see the Appendix).
Critiques Q3
Although the pattern of symptoms cant be used to distinguish
prostate cancer from benign conditions, at age 79 a PSA test
would not be warranted for these mild symptoms. Serum PSA
has not been shown to be an effective or ineffective screening
test for prostate cancer, and its specificity declines in the
presence of BPH. Saw palmetto, a popular natural treatment for
BPH, shows evidence of some efficacy. -Blockers commonly
are prescribed for BPH, and some evidence suggests that
finasteride is most effective for men with large prostate glands.
None of these treatments should be started, however, until the
patients severity of symptoms and degree of bother are
determined. Transrectal ultrasound can quantify prostate volume
and identify suspicious lesions, but in the absence of prostate
cancer symptoms, knowing the prostate volume adds little. The
bother score would determine advisability of treatment regardless
of size.
Critiques Q3
References:
1. Holtgrewe HL. The medical management of lower urinary tract
symptoms and benign prostatic hyperplasia. Urol Clin North Am.
1998;25(4):555569.
2. Lane T, Shah J. Clinical features and management of benign
prostatic hyperplasia. Hosp Med. 1999;60(10):705709.
3. Medina JJ, Parra RO, Moore RG. Benign prostatic hyperplasia
(the aging prostate). Med Clin North Am. 1999;83(5):12131229.
4. Rhodes PR, Krogh RH, Bruskewitz RC. Impact of drug therapy
on benign prostatic hyperplasiaspecific quality of life. Urology.
1999;53(6):10901098.
Question 4
A healthy 75-year-old woman has a first
episode of major depression. Sertraline, 50
mg daily, is prescribed. Four weeks later, she
notes no improvement in mood, despite
adherence to the regimen. She has not had
any adverse effects but asks that you do
something more to help her.
Which of the following is the best treatment
option at this time?
A. Increase the dose of sertraline.
B. Substitute a different selective serotonin-
reuptake inhibitor.
C. Substitute an antidepressant of another class.
D. Add lithium carbonate.
E. Refer for electroconvulsive therapy.
The Correct Answer is A.
Critiques Q4
Increasing the dose of sertraline is the best option
for this patient. Older patients may require 6 to 12
weeks of antidepressant therapy before clinical
improvement is seen. The most common reasons
for lack of response are nonadherence and
inadequate dose or duration. If a patient has no
improvement after an adequate trial of the initial
drug, or is unable to tolerate adverse effects, it
would be appropriate to substitute a different
antidepressant, either from the same class or
another class. If a mild response occurs after
adequate treatment, augmenting the regimen would
be appropriate.
Critiques Q4
Lithium and thyroid supplementation have been
effective; methylphenidate also may be helpful.
Patients usually are referred for electroconvulsive
therapy (ECT) after two courses of drug therapy
have been ineffective; however, it should be
considered earlier for patients who are acutely
suicidal, severely delusional, or severely debilitated.
It also may be a first-line treatment for patients who
previously had a good response to ECT and a poor
response to medications.
Question 5
A 79-year-old man is brought to the emergency department because of
dense right hemiplegia and mental status changes that were present
when he awoke this morning. His wife states that he has been well
recently except for increasing headaches during the past few weeks;
acetaminophen has provided little relief. His chronic medical problems
include mild obesity; type 2 diabetes mellitus, controlled by diet
(hemoglobin A1C 7.2%); and essential hypertension, treated with
lisinopril. He has not smoked cigarettes in about 50 years, and he rarely
drinks alcohol.
Blood pressure is 200/100 mm. Temperature is 37.2C (99.0F). Pulse
rate is 64 per minute, and respirations are 16 per minute. Oxygen
saturation is 97%. The liver edge is palpable 2 cm below the right costal
margin, and the spleen tip is palpable 6 cm below the left costal margin.
The right side is flaccid.
Hematocrit is 58%. Leukocyte count is 10,000/L, and platelet count is
600,000/L. Other routine laboratory studies are normal. Computed
tomography (CT) of the head shows a large infarct in the left middle
cerebral artery, without hemorrhage.
Which of the following tests should you order
next?
A. Peripheral blood film and serum erythropoietin
B. Red cell mass and serum erythropoietin
C. Overnight oximetry and arterial blood gas
studies
D. Red cell mass and serum protein
electrophoresis
E. Serum protein electrophoresis and bone
marrow biopsy
The Correct Answer is B.
Critiques Q5
This patient most likely has polycythemia vera, which is a
myeloproliferative disorder characterized by autonomous,
unregulated erythrocytosis that results in increased red cell
mass. This is a disease of older adults, generally men, with a
mean age at diagnosis of 60 years. Extramedullary
hematopoiesis may occur in the liver, spleen, lymph nodes, or
other sites, resulting in organ enlargement. Complications
include ischemic vascular events, headache, mental status
changes, hemorrhage, rubor, plethora, pruritus, and gout.
Asymptomatic patients may be diagnosed when an elevated
hematocrit is noted incidentally. Leukocyte and platelet counts
also may be slightly elevated. The disease may progress to
myelofibrosis with bone marrow failure; mean survival without
treatment is approximately 18 months but can be several years
with treatment.
Critiques Q5
A hematocrit above 51% in men or 48% in women is suggestive
of the disease. Determination of red cell mass, usually by
radionuclide labeling, is necessary to eliminate pseudo-
erythrocytosis due to loss of plasma volume. Once erythrocytosis
is confirmed, secondary polycythemia can be excluded by
measuring serum erythropoietin. Levels usually are low since red
cell production is independent of erythropoietin in this condition.
An elevated erythropoietin level suggests polycythemia
secondary to hypoxia, hypercarbia, shunting, or exogenous
production by a tumor. Abdominal imaging, by ultrasound or CT,
is helpful to determine spleen size when the organ is not
palpable. When hepatosplenomegaly is detected, imaging rules
out other conditions. Visualization of the kidneys may be helpful
in evaluating secondary polycythemia.
Critiques Q5
Peripheral blood film and bone marrow biopsy frequently are nonspecific.
Usually the marrow is hypercellular with absent iron stores. Ultimately, marrow
fibrosis may develop with production failure. This is not a disease of humoral
function, so serum protein electrophoresis (SPEP) is not helpful. Funduscopy
may be indicated because of the stroke but would not be helpful in confirming
the diagnosis of polycythemia vera. Elements of this presentation are suggestive
of multiple myeloma or Waldenstrm macroglobulinemia, for which SPEP and
funduscopy would be helpful, but these conditions usually are not associated
with erythrocytosis. Arterial blood gas studies and overnight oximetry are useful
to exclude secondary polycythemia, but all secondary causes would elevate
serum erythropoietin level.
References:
1. Messinezy M, Pearson TC. ABC of clinical haematology: polycythaemia,
primary (essential) thrombocythaemia and myelofibrosis. BMJ.
1997:314(7080):587590.
2. Tefferi A. Diagnosing polycythemia vera: a paradigm shift. Mayo Clin Proc.
1999;74(2):159162.
Question 6
A 67-year-old woman asks you to prescribe
sleeping pills for her. She reports initial
insomnia and restless sleep with frequent
awakenings. The patient is retired and leads
a sedentary life style. She frequently reads or
watches television in bed and often naps,
despite caffeine intake throughout the day.
Physical examination is unremarkable.
Which of the following is most likely to
ameliorate this patients sleep disturbance?
A. Exposure to early morning daylight
B. Proper sleep habits
C. Sustained-release melatonin
D. Zolpidem
E. Referral for polysomnography
The correct answer is B.
Critiques Q6
Poor sleep habits may be the most common cause of sleep problems in
older adults. Irregular sleepwake patterns, related to the life style in
this patient, can undermine the ability of the circadian system to
effectively provide sleepiness and wakefulness at appropriate times.
Caffeine intake in the afternoon can have alerting effects for many
hours, thus impairing night-time sleep. Excessive wake time in bed may
cause increased arousal that is reinforced nightly. Other factors (eg,
medical illness, medications, psychiatric disorders, and primary sleep
disorders) also should be considered. However, proper sleep habits
should be implemented. These include regularity of sleep and wake
times; avoidance of excessive time in bed; relaxing bedtime routine;
daily activity and exercise; avoidance of caffeine, alcohol, and nicotine
in the afternoon and evening; and elimination of loud noise, excessive
light, and uncomfortable room temperature. Even if poor sleep habits
are not responsible for insomnia, their elimination minimizes any
perpetuating influence.
Critiques Q6
Use of a short-acting hypnotic agent is not an appropriate first
step in the management of simple insomnia. Hypnotics should be
used only in limited circumstances, following evaluation of the
patients symptoms and in the context of proper sleep habits.
Similarly, melatonin has not definitively been shown to benefit
age-related sleep-maintenance insomnia. Exposure to early
morning light can be useful for delayed or advanced sleep-phase
syndrome or jet lag.
Polysomnography can be useful for evaluating chronic insomnia
or for suspicion of primary sleep disorders such as sleep apnea,
periodic limb movement disorder, or rapid eye movement
(REM)behavior disorder, but referral to a sleep specialist is not
warranted for this patient.
Critiques Q6
References:
1. Chesson AL Jr, Wise M, Davila D, et al. Practice parameters
for the use of light therapy in the treatment of sleep disorders.
Sleep. 1999;22(7):961968.
2. Hughes RJ, Sack RL, Lewy AJ. The role of melatonin and
circadian phase in age related sleep-maintenance insomnia:
assessment in a clinical trial of melatonin replacement. Sleep.
1998;21(1):5268.
3. King AC, Oman RF, Brassington GS, et al. Moderate intensity
exercise and self-rated quality of sleep in older adults: a
randomized controlled trial. JAMA. 1997;277(1):3237.
4. Neubauer DN. Sleep problems in the elderly. Am Fam Phys.
1999;59(9):25512558.
Question 7
An 80-year-old woman comes to your office
for an initial evaluation. She is accompanied
by her daughter, who is concerned about the
patients memory. During the past year she
has been repeating questions and
statements; about 6 months ago she began
to have infrequent problems getting her
words out. Symptoms probably have
worsened. She is sometimes sad when
talking about deceased relatives.
Question 7
The patient lives alone and does most of her
own household chores. She completed the
10th grade. Her MiniMental State
Examination (MMSE) score is 26/30, with two
errors (near-misses) in orientation and two
in short-term recall. Physical examination is
normal. Laboratory studies are normal.
Which of the following is the most likely
diagnosis?
A. Normal aging
B. Minimal cognitive impairment
C. Major depression
D. Delirium
E. Alzheimer's disease
Critiques Q7
Minimal cognitive impairment is a syndrome of memory problems that
worsen within 1 year, with limited functional impairment and no definite
impairment in other cognitive domains. This patient has a 6- to 12-
month history of worsening memory complaints, supported by
screening assessment, with no evidence so far of other cognitive
impairment. The MMSE score probably is normal for her age and
education, but deficits may be more extensive on detailed evaluation.
(See the Appendix for the screen and interpretation.) There is no
evidence of any functional consequences. Treatment should include
discontinuation of any medications known to cause cognitive changes;
ensuring adequate nutrition; obtaining more information about her
functional status, including driving abilities; and working with the family
to enhance social stimulation. Her condition should be monitored
closely for several months. It also might be reasonable to obtain
neuropsychologic testing to help clarify the pattern of strengths and
weaknesses.
Critiques Q7
The kinds of cognitive changes that can be expected in normal
aging include some difficulty with recall of words and names,
without extension to other domains and not obviously increasing
in severity within the course of 1 year. The patient is not
depressed or delirious.
Alzheimers disease may precede the clinical dementia
syndrome by years, or even decades, and depressive features
often are associated. Although this patient may have early
dementia, most likely Alzheimers disease, she does not meet
the diagnostic criteria at this time. The research concept of
possible Alzheimers disease may be appropriate.
Critiques Q7
References:
1. Guttman R, Seleski M, eds. Diagnosis, Management and
Treatment of Dementia: A Practical Guide for Primary Care
Physicians. Chicago, IL: American Medical Association; 1999.
2. Petersen RC, Smith GE, Waring SC, et al. Mild cognitive
impairment: clinical characterization and outcome. Arch Neurol.
1999;56(3):303308.
3. Richards SS, Hendrie HC. Diagnosis, management, and
treatment of Alzheimer disease: a guide for the internist. Arch
Intern Med. 1999;159(8):789798.
4. Small GW, Rabins PV, Barry PP, et al. Diagnosis and
treatment of Alzheimers disease and related disorders:
consensus statement of the American Association of Geriatric
Psychiatry, the Alzheimers Association, and the American
Geriatrics Society. JAMA. 1997;278(16):13631371.
Question 8
After seeing a television commercial about
osteoporosis, a 72-year-old white woman asks you
whether she should be taking hormones. She is in
good health with occasional complaints of reflux and
takes no medications regularly.
Menopause occurred about 18 years ago; 5 years
ago she had a compression fracture of the lumbar
spine, which was treated with brief bed rest. Her
mother and sister had breast cancer. Bone
densitometry reveals a T score of 2.4.
In addition to adequate calcium and vitamin D
intake, which of the following is the most
appropriate treatment for this patient?
A. Estrogen, transdermally twice weekly
B. Conjugated estrogen orally daily
C. Cyclic estrogen and progesterone, orally daily
D. Raloxifene orally daily
E. Tamoxifen orally daily
The correct answer is D.
Critiques Q8
This patients bone mineral density (BMD) is consistent with
severe osteopenia, and the history of compression fracture is
consistent with osteoporosis. Treatment is indicated to reduce
her risk for additional fractures. Estrogen is appropriate therapy
for osteoporosis prevention, but it is contraindicated (in oral or
transdermal forms) in patients with a history of pelvic or breast
cancer and those with a family history of breast cancer. A cohort
study of follow-up data for 19801995 from the Breast Cancer
Detection Demonstration Project, which enrolled 46,355
postmenopausal women, showed an increased risk for breast
cancer in those taking estrogen or estrogen plus progesterone.
The increase was restricted to current use or use within 4 years;
combination therapy was associated with a higher risk than
estrogen alone.
Critiques Q8
Unopposed estrogen therapy is associated with an increased risk
for uterine bleeding and carcinoma. The addition of
progesterone, either in combination or sequentially, eliminates
the increased risk for uterine carcinoma but may reduce the
positive effects on serum lipids. Some older women also
experience periods with the combination regimen. A sequential
regimen often is recommended when the patient is immediately
postmenopausal; combination therapy may be substituted later.
However, many women discontinue treatment after 1 year
because of adverse effects such as breast tenderness and
bleeding. Physicians also may lack confidence in managing
these problems.
Critiques Q8
Transdermal estrogen does not undergo first-pass metabolism by the
liver, which is thought to be responsible for effects on coagulation
factors and lipid profile. Transdermal and systemic estrogen have
similar effects on BMD, but the effectiveness of the transdermal form in
reducing the risk for vertebral fracture has not been documented.
Tamoxifen also increases BMD and has been shown to be effective in
reducing the risk for recurrent breast cancer. However, it is associated
with a significant risk for uterine bleeding and carcinoma. Raloxifene,
another selective estrogen-receptor modulator, is not associated with
uterine bleeding or carcinoma and reduces the risk for new vertebral
fracture by 50% and recurrent vertebral fracture by 30%. The Multiple
Outcomes of Raloxifene Evaluation (MORE) found that older women
had a 2.1% increase in BMD at the femoral neck and 2.6% at the spine
after 36 months. However, raloxifene is indicated only for
postmenopausal use or in patients who are unable to take estrogen.
Raloxifene has also been shown to reduce the risk of invasive breast
cancer by 76% during 3 years of treatment.
Critiques Q8
References:
1. Cummings SR, Eckert S, Krueger KA, et al. The effect of
raloxifene on risk of breast cancer in postmenopausal women:
results from the MORE randomized trial. Multiple Outcomes of
Raloxifene Evaluation. JAMA. 1999; 281(23):21892197.
2. Ettinger B, Black DM, Mitlak BH, et al. Reduction of vertebral
fracture risk in postmenopausal women with osteoporosis treated
with raloxifene: results from a 3-year randomized clinical trial.
JAMA. 1999; 282(7):637645.
3. Kamel HK, Perry HM 3rd, Morley JE. Hormone replacement
therapy and fracture in older adults. J Am Geriatr Soc.
2001;49(2):179187.
4. Schairer C, Lubin J, Troisi R, et al. Menopausal estrogen and
estrogen-progestin replacement therapy and breast cancer risk.
JAMA. 2000; 283(4); 485491.
Question 9
An 80-year-old woman has fallen outside
her home twice. She fractured a wrist 3
months ago and has arm and facial
ecchymoses from a fall last week. She has
a distant history of a myocardial infarction
and is being treated with a diuretic for
hypertension. She reports occasional
difficulty with balance when walking.
Which of the following is the most
appropriate first step in evaluating the
falls?
A. Gather additional history and physical
examination.
B. Order laboratory studies, especially serum
electrolytes.
C. Perform electrocardiography.
D. Order computed tomography of the head.
E. Arrange for home-based assessment.
The correct answer is A.
Critiques Q9
The proper evaluation of a fall begins with the
history and physical examination. For this patient,
additional history is needed to assure that no
syncope or dizziness (related to cardiac dysfunction
or dehydration from the diuretic) occurred. Cardiac
auscultation and orthostatic blood-pressure
measurements are indicated. Since the patient has
difficulty with balance while walking, history and
physical examination should focus particularly on
the neurologic and musculoskeletal system.
CritiquesQ9
Some practitioners advocate obtaining laboratory tests for all patients
who fall, because occult metabolic disturbances may be revealed. Few
data justify an extensive laboratory and radiologic work-up; however,
these may be warranted, depending on findings of the history and
examination. For example, symptoms of weakness or confusion might
suggest screening for the metabolic effects of the diuretic by measuring
serum electrolytes. A history of syncope may support the need for
electrocardiography, and computed tomography would be appropriate
for a patient with facial trauma and neurologic findings. Home-based
assessment may be considered later, after a careful history and
examination, if targeted interventions do not decrease the patients
falling.
References:
1. Lipsitz LA. An 85-year-old woman with a history of falls. JAMA.
1996;276(1):5966.
2. Mahoney JE. Falls in the elderly: office-based evaluation, prevention
and treatment. Cleveland Clin J Med. 1999;66(3):181189.
Question 10
An 82-year-old woman with a history of
hypertension, diabetes mellitus, and osteoporosis
goes to the emergency department for evaluation of
the acute onset of severe upper back pain.
Evaluation demonstrates a new thoracic vertebral
compression fracture. In addition to prescribing
analgesia, the physician requests a consultation to
assist with discharge because the patient lives at
home alone and has difficulty getting out of bed
because of the pain.
What factor is most likely to predict the
admission of this patient to the hospital in the
next month?
A. Depressed mood
B. Urinary incontinence
C. Living alone
D. Advanced age
E. Functional impairment
The correct answer is E.
Critiques Q10
The promotion of functional independence is a primary goal of
clinicians providing care to older persons. This goal may be
achieved when older adults at high risk for functional decline are
identified by the use of a screening instrument. Those found to
be at high risk undergo a thorough assessment that identifies
problems for which interventions can be prescribed to prevent
functional impairment. One group of patients who may benefit
from such screening is older adults discharged to home following
an emergency department visit. One fifth of older patients
discharged to home from the emergency department will return
within the next 30 days, and a significant percentage of these will
be admitted to the hospital.
Critiques Q10
The presence of impairments in activities of daily living (ADLs) or
instrumental activities of daily living (IADLs) in this patient is most
likely to predict hospitalization in the next 30 days. (See the
Appendix, for ADL and IADL screens.) Valid questions used in
trials that were predictive of subsequent hospital admission
included requiring the assistance of another person to care for
oneself, an increase in the amount of help needed to care for
oneself, requiring assistance in transportation, and requiring the
assistance of a visiting nurse.
Cognitive factors associated with adverse outcomes in patients
seen in the emergency department include memory impairment
but not depressed mood. The presence of urinary incontinence,
dependency in bladder function, fecal incontinence, or
dependency in bowel functioning was not associated with
hospital admission.
Critiques Q10
Advanced age without comorbidity in this patient population was not predictive
of hospital admission following a visit to the emergency department.
Community-dwelling older adults who live alone were not found to be at risk for
hospital admission; either they are independent in their ADLs and IADLs, or they
have identified the community resources needed to allow them to live alone
successfully.
Additional variables that have been shown to be useful in identifying high-risk
older patients in the emergency department include poor vision and the use of
more than three medications.
References:
1. Caplan GA, Brown A, Croker WD, et al. Risk of admission within 4 weeks of
discharge of elderly patients from the emergency departmentthe DEED study:
discharge of elderly from emergency department. Age Ageing. 1998;27(6):697702.
2. McCusker J, Bellavance F, Cardin S, et al. Detection of older people at increased
risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J
Am Geriatr Soc. 1999;47(10):12291237.
3. McCusker J, Cardin S, Bellavance F, et al. Return to the emergency department
among elders: patterns and predictors. Acad Emerg Med. 2000;7(3):249259.
Question 11
A 72-year-old woman comes to your office for routine monitoring
of hypertension. She takes extended-release diltiazem, 240 mg
every morning, and has no complaints of side effects. Other
current medications are enteric-coated aspirin, 325 mg daily;
ranitidine, 150 mg daily; calcium citrate with vitamin D, 500 mg
three times daily; and a magnesium supplement, daily. She takes
acetaminophen for occasional headaches and echinacea and
zinc lozenges for cold symptoms. The patient had been feeling
sad recently because of the death of a friend, but her mood has
improved since she started taking St. Johns wort, 450 mg twice
daily.
Blood pressure today is 152/106 mm Hg (4 months ago, 130/82
mm Hg). Results of laboratory studies are within normal limits.
Which of the following is the most likely
explanation for the increased blood-pressure
reading?
A. Inaccurate blood pressure
B. Interaction between diltiazem and St. John's
wort
C. Interaction between diltiazem and the calcium
supplement
D. Development of serotonin syndrome
E. Echinacea
Critiques Q11
St. Johns wort is used routinely in Germany to treat
mild to moderate depression, and it has been
embraced as a self-treatment in the United States.
Studies suggest that it induces the cytochrome P-
450 isoenzyme 3A4. This patients blood pressure
was controlled on diltiazem, which is a substrate for
the 3A4 isoenzyme and can inhibit its activity.
However, the inhibitory effects stabilize after several
months. The recent addition of St. Johns wort
decreased blood levels of diltiazem, thereby causing
recurrent hypertension.
Critiques Q11
Inaccurate blood-pressure measurements can occur for a variety
of reasons. Two of the most common are white coat
phenomenon and age-related alterations in vasculature. Repeat
measurements may be necessary to determine the true reading.
However, if this patient is seen regularly, any such problems
should be known and taken into consideration. Calcium products
bind many medications, but there is no evidence of interference
with the absorption of diltiazem. Also, any interaction would have
stabilized over time.
In serotonin syndrome, excessive serotonin levels can increase
blood pressure. This patient, however, does not display the
characteristic symptoms of agitation, diaphoresis, hyperthermia,
confusion, and tremor. The only serotonergic medication she is
taking is St. Johns wort. The dosage is appropriate for the
treatment of mild to moderate depression, and serotonin
syndrome is very unlikely to occur with this drug alone.
Echinacea is not known to cause or worsen hypertension. Individuals sensitive
to the Asteraceae or Compositae plant family (ragweed, chrysanthemums,
marigolds, and daisies) are at increased risk of allergic reactions to echinacea.
References:
1. Chavez M, Chavez P. Echinacea. Hospital Pharmacy. 1998;33:180188.
2. Hawkins DW, Bussey HI, Prisant LM. Hypertension. In: DiPiro JT, Talbert RL,
Yee GC, et al., eds. Pharmacotherapy: A Pathophysiologic Approach. Stamford,
CT: Appleton and Lange; 1999:131152.
3. Pepping J. St. Johns wort: Hypericum perforatum. Am J Health Syst Pharm.
1999;56(4):329330.
4. Phillip M, Kohnen R, Hiller KO. Hypericum extract versus imipramine or
placebo in patients with moderate depression: randomised multicentre study of
treatment for eight weeks. BMJ. 1999;319(7224):15341539.
5. Roby CA, Anderson GD, Kantor E, et al. St Johns wort: effect on CYP3A4
activity. Clin Pharmacol Ther. 2000;67(5):451457.
Critiques Q11
Question 12
An 80-year-old man comes to you for advice regarding a serum
prostate-specific antigen (PSA) level of 0.8 ng/mL. He underwent
radical prostatectomy 10 years ago for prostate cancer; PSA was
7.1 ng/mL at that time. The tumor was Gleason grade 4, and
regional lymph nodes were negative. Postoperatively, PSA was
undetectable; 2 years ago during hospitalization for angina
pectoris, it was 0.06 ng/mL. He has not had bone pain, poor
appetite, or weight loss. Medical history also includes
hypertension, diabetes mellitus, and coronary artery disease. He
was deemed a poor risk for coronary artery bypass surgery.
Physical examination reveals diabetic retinopathy, a barrel chest
with poor air movement, distant heart sounds, and peripheral
neuropathy. Bone scan and abdominopelvic computed tomogram
show no evidence of metastases. Radiolabeled anti-prostatic
membrane antigen (PSM) antibody scan is negative.
Which of the following should you
recommend?
A. Antiandrogen therapy
B. Bilateral orchiectomy
C. Treatment with a luteinizing hormone-releasing
hormone (LHRH) agonist
D. Combination of (A) and (B)
E. Observation only
The correct answer is E
Critiques Q12
The degree of tumor differentiation and PSA level at diagnosis
are important prognostic factors in prostate cancer. Owing to
widespread monitoring of PSA, a rising level is commonly the
only evidence of recurrence. In one study of 304 patients,
metastases developed in 34% during a 15-year follow-up period;
the median time to development of detectable metastases was 8
years. Time to PSA recurrence (less than versus greater than 2
years), PSA doubling time (less than versus greater than 10
months), and Gleason grade (5 to 7 versus 8 or higher) were
predictors of adverse outcome. This patient had an 8-year
interval to PSA recurrence, a doubling time substantially greater
than 10 months, and a Gleason grade of 4. Also, imaging studies
did not detect any metastases. Thus, he is more likely to die of a
comorbid condition than of prostate cancer. The best option for
him is observation.
Critiques Q12
Androgen ablative therapy would be appropriate for a healthier patient with a
greater life expectancy. The efficacy of bilateral orchiectomy and LHRH agonists
is comparable. In a large prospectively randomized trial, no benefit to adding an
antiandrogen to orchiectomy was found.
References:
1. Coley CM, Barry MJ, Fleming C, et al. Early detection of prostate cancer: part I: prior
probability and effectiveness of tests. The American College of Physicians. Ann Intern
Med. 1997; 126(5):394406.
2. Coley CM, Barry MJ, Fleming C, et al. Early detection of prostate cancer: part II:
estimating the risks, benefits, and costs. The American College of Physicians. Ann
Intern Med. 1997; 126(6):468479.
3. Eisenberger MA, Blumenstein BA, Crawford ED, et al. A randomized double blind
comparison of bilateral orchiectomy for the treatment of patients with stage D2 prostate
cancer: results of NCI Intergroup Study 0105. N Engl J Med. 1998;339:10361042.
4. Pound CR, Partin AW, Eisenberger MA, et al. Natural history of progression after
PSA elevation following radical prostatectomy. JAMA. 1999;281:15911597.
Question 13
An 85-year-old woman has a 3-year history of increasing
lightheadedness upon standing. This first occurred only when
she rose from the toilet following a bowel movement. About 1
year ago, she noticed lightheadedness when preparing meals,
and she began sitting in a chair because she was afraid of
passing out. She now rarely cooks and is afraid to go outside.
The patient has no history of heart disease; her only current
medication is furosemide, 20 mg three times weekly, for chronic
bilateral leg edema. She has not had palpitations (pulse rate has
been 60 to 90 per minute during episodes), syncope, or dyspnea.
When the patient is recumbent, pulse rate is 64 per minute and
blood pressure is 140/88 mm Hg. Immediately after she stands,
her pulse rate is 68 per minute and blood pressure is 126/82 mm
Hg. After she had been standing for 3 minutes, her pulse rate is
68 per minute and blood pressure is 132/84 mm Hg.
Which of the following statements is correct
regarding this patients condition?
A. The drop in systolic pressure meets criteria for
orthostatic hypotension.
B. The drop in diastolic pressure meets criteria for
orthostatic hypotension
C. The most likely cause of dizziness is volume
contraction secondary to furosemide.
D. The most likely cause of dizziness is cardioinhibitory
carotid sinus syndrome.
E. The dizziness most likely is multifactorial.
Critiques Q13
Postural lightheadedness ( presyncope) usually results from reduced
blood flow to the cerebral cortex and is caused by cardiovascular and
orthostatic disorders. These include decreased cardiac output
secondary to arrhythmia or severe congestive heart failure, decreased
local blood flow because of multiple stenotic cerebral arteries, and
pooling of blood in the lower extremities. The latter is the most common
cause. In older patients, this often occurs even when the criteria for
orthostatic hypotension (a reduction of 20 mm Hg systolic or 10 mm
Hg diastolic, measured 2 to 3 minutes after standing) are not met. In a
study of 52 consecutive patients aged 60 and over with chronic
dizziness and a high prevalence of presyncope, 28% had
cardiovascular causes, often multifactorial. Accumulating evidence
suggests that many cases of dizziness in older persons are associated
with an accumulation of cardiovascular, neurosensory, and psychiatric
conditions, as well as medication use.
Critiques Q13
In this patient, multiple factors could contribute to venous pooling in the lower
extremities. These include vasovagal phenomena, decreased intravascular
volume secondary to furosemide, impaired venous return (manifested by chronic
leg edema without cardiac failure or pulmonary disease), and physical inactivity.
Vasodepressor carotid sinus syndrome can increase venous pooling, but the
absence of palpitations or decreased pulse rate during episodes argues against
this explanation. Treatment should be multifaceted, including discontinuation of
furosemide, pressure-gradient support stockings, increased walking, and
perhaps a medication to stabilize venous tone (eg, a -adrenergic blocking
agent) or to increase intravascular volume (eg, fludrocortisone).
References:
1. Drachman DA. A 69-year-old man with chronic dizziness. JAMA.
1998;280(24):21112118.
2. Lawson J, Fitzgerald J, Birchall J, et al. Diagnosis of geriatric patients with severe
dizziness. J Am Geriatr Soc. 1999; 47(1):1217.
3. Sloane PD. Evaluation and management of dizziness in the older patient. Clin
Geriatr Med. 1996;12(4):785801.
4. Tinetti ME, Williams CS, Gill TM. Dizziness among older adults: a possible geriatric
syndrome. Ann Intern Med. 2000;132(5):337344.
Question 14
A 79-year-old man comes to you for a routine
visit. He is accompanied by his daughter,
who reports that the patient is having difficulty
hearing. He denies this and explains that
people around him do not speak clearly. The
patients ears are free of cerumen impaction.
Which of the following is the most reliable
and valid screening test for hearing loss?
A. Tuning-fork test
B. Finger-rub test
C. Whisper test
D. Rinn and Weber tests
E. Audioscopy
Critiques Q14
Self-report is helpful in identifying hearing impairments that older adults
perceive as handicapping or disabling. The most common cause of
hearing impairment is presbycusis, which is a bilateral, symmetric, high-
frequency sensorineural hearing loss. Persons with mild to moderate
loss often complain that others mumble. This is because patients are
unable to hear consonants, which are high-frequency sounds.
The hand-held audioscope permits reliable and valid screening for
hearing loss. It is sensitive (87% to 90%) and specific (70% to 90%),
when compared with the gold standard of audiometry performed by an
audiologist. The audioscope, an otoscope with a built-in audiometer, is
set at 40 dB to assess hearing in older persons. A test tone of 60 dB is
delivered, then four tones (500, 100, 2000, and 4000 Hz) at 40 dB are
delivered. Testing takes approximately 3 minutes. Patients fail the
screen if they are unable to hear either the 1000- or 2000-Hz frequency
in both ears, or both the 1000- and 2000-Hz frequency in one ear. The
audioscope costs a little more than a standard otoscope and should be
recalibrated annually.
Critiques Q14
The tuning-fork test is performed by striking the tines of the fork against
the heel of the hand, then holding the vibrating fork 1 inch from the ear.
The fork then is moved away from the ear at a rate of 1 foot per second.
The patient indicates when the tone is no longer audible. Tuning forks
assess hearing in the range of 512 to 1024 Hz. This is not sufficient to
evaluate hearing loss in older persons, whose loss usually is in the
range of 2000 Hz or higher. Testing also depends on the force with
which the fork is struck, how quickly it is withdrawn, and assessment of
the distance at which the tone is no longer heard. The finger-rub test is
performed by rubbing the index finger and thumb together 1 inch from
the ear, then slowly withdrawing until the sound no longer is heard by
the patient. Its use has not been well studied in older patients. In the
whisper test, the examiner whispers at the side of the patient. This is
not reliable and correlates poorly with audiometry findings. Examiner
variability is a concern when using the tuning-fork, finger-rub, or
whisper tests.
Critiques Q14
The Rinn test compares conduction of sound in air and bone, to
distinguish conductive from sensorineural loss. The Weber test is used
to lateralize hearing loss, which is usually bilateral in older persons.
Neither of these is a screen for hearing loss.
References:
1. Lichtenstein MJ, Bess FH, Logan SA. Validation of screening tools for
identifying hearing-impaired elderly in primary care. JAMA.
1988;259(19):28752878.
2. Mansour-Shouser R, Mansour WN. Nonsurgical management of hearing
loss. Clin Geriatr Med. 1999;15(1):163177.
3. Mulrow CD, Lichtenstein MJ. Screening for hearing impairment in the
elderly: rationale and strategy. J Gen Intern Med. 1991;6:249258.
4. Weinstein B. Health promotion strategies for identifying older adults with
handicapping hearing impairment. In: Weinstein B. Geriatric Audiology. New
York: Thieme Medical Publishers, Inc.; 2000:267289.
QUESTION 15
A 66-year-old man asks you to prescribe sildenafil
for him. He has well-controlled type 2 diabetes
mellitus, hypertension, congestive heart failure, and
obesity. Current medications are digoxin, 0.25 mg
daily; furosemide, 40 mg daily; amlodipine, 5 mg
daily; and NPH insulin. Review of systems is
unremarkable except for sexual dysfunction, fatigue,
and frequent daytime sleepiness. The patient is 170
cm (70 in) tall and weighs 100 kg (220 lb). He is
poorly alert. Blood pressure is 160/90 mm Hg. The
patients wife tells you that he drinks one or two
bottles of beer each night, is sleepy during the day,
and snores loudly.
Which of the following treatments is most
likely to be beneficial?
A. Avoidance of alcohol
B. Nasal continuous positive airway pressure
(CPAP)
C. Methylphenidate
D. Oropharyngeal surgery
The correct answer is
Critiques Q15
This patient has multiple risk factors for, as well as
symptoms and signs of, sleep apnea. These include
obesity, cardiovascular disease, loud snoring, and
daytime sleepiness. Sexual dysfunction and
hypertension also may be partially caused by sleep
apnea. Information supplied by the patients wife
should prompt evaluation in a sleep laboratory;
electroencephalography is indicated, and arterial
blood oxygen saturation, airflow, and chest and
abdominal ventilatory effects should be assessed.
Erectile dysfunction also could be confirmed during
sleep studies.
Critiques Q15
This patient likely will demonstrate hundreds of apneic events
during the night, with episodes of brief arousal (sleep
interruptions) coupled with repeated decreases in oxygen
saturation. These events lead to a marked decline in daytime
alertness and may intrude on daytime activities such as driving,
with potentially dangerous consequences. Apneic episodes
usually result from complete or partial occlusion of the airway
(obstructive sleep apnea) or less commonly from a decrease in
the respiratory drive (central sleep apnea). Major risk factors for
sleep apnea include male sex and obesity (especially a heavy
neck); other associations include hypothyroidism,
neurodegenerative diseases, and cardiovascular disorders.
Critiques Q15
Primary therapy for obstructive sleep apnea is continuous positive
airway pressure (CPAP), delivered via a tight-fitting nasal mask during
sleep. Weight loss and avoidance of alcohol commonly are beneficial in
overweight patients; however, these measures do not correct the
underlying problem. Psychostimulants such as methylphenidate, which
may be useful in narcolepsy, are not beneficial. Use of sedative-
hypnotics at bedtime can worsen the condition. Surgical intervention
often eliminates the snoring but may not eliminate the apnea.
References:
1. Gentili A, Edinger JD. Sleep disorders in older people. Aging.
1999;11(3):137141.
2. Neubauer DN. Sleep problems in the elderly. Am Fam Physician.
1999;59(9):25512558.
3. Shapiro CM, Kayumov L. Sleepiness, fatigue and impaired alertness.
Semin Clin Neuropsychiatry. 2000;5(1):25.
4. Vitiello MV. Effective treatments for age-related sleep disturbances.
Geriatrics. 1999;54(11):4752.
Question 16
An 85-year-old woman has not urinated in 12 hours. Medical
history includes congestive heart failure and hypertension. Four
days ago, she was seen in the emergency department because
of a 1-week history of malaise, nausea, and vomiting. A
diagnosis of possible urinary tract infection was made, and
symptoms responded to the prescribed medication.
The patient reports some muscle aching today. She has lost 2.5
kg (5.5 lb) since her last visit 2 months ago. Pulse rate is 80 per
minute sitting and 100 per minute standing; blood pressure is
120/84 mm Hg sitting and 110/84 mm Hg standing. The patient is
a little dizzy when she stands. Mental status is at baseline.
Laboratory studies:
Blood urea nitrogen76 mg/dL
Serum creatinine3.0 mg/dL
Serum electrolytes:
Sodium140 mEq/L
Potassium5.8 mEq/L
Chloride90 mEq/L
Bicarbonate28 mEq/L
Urinalysis 03 red blood cells, 03 white blood cells
per high-power field; granular casts and needle-
shaped crystals
Of the following medications taken by this
patient, which is the most likely cause of
acute renal failure?
A. Digoxin
B. Diphenhydramine
C. Hydrochlorothiazide
D. Lisinopril
E. Trimethoprim-sulfamethizole
Critiques Q 16
This patient has crystal-induced acute renal failure
(ARF) secondary to sulfonamide use. Several other
medications, most notably methotrexate and
triamterene, also produce crystals that are insoluble
in urine. This patient is at increased risk for crystal
deposition because of renal insufficiency and
decreased intravascular volume. Renal failure often
is reversible with discontinuation of the drug and
volume expansion with high urinary rates; dialysis
may be required, however.
Critiques Q16
This patient is at risk for digoxin toxicity because of decreased
renal excretion, but this drug does not cause ARF. Standard
doses of diphenhydramine are unlikely to cause ARF. Thiazides
may impair the renal diluting systems to cause hyponatremia but
not ARF. Angiotensin-converting enzyme inhibitors have become
the standard of care in treatment of congestive heart failure and
diabetic nephropathy. They cause pre-renal ARF in patients with
renal artery stenosis, but the features are not consistent with this
patients presentation.
References:
1. Epstein M. Aging and the kidney. J Am Soc Nephrol.
1996;7(8):11061122.
2. Perazella M. Crystal-induced acute renal failure. Am J Med.
1999;106(4):459465.
3. Solomon DH. Toxicity of nonsteroidal anti-inflammatory drugs in
the elderly: is advanced age a risk factor? Am J Med.
1997;102(2):208215.

Geriatrics Board Review: October 9,2009

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