Geriatrics Board Review

October 9,2009

Board Review Geriatrics

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.

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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
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The Correct Answer is D

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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 twowheeled 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.
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Critiques Q1
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.
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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.

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Which of the following will best prevent a pressure ulcer in this patient?
A. B. C. D. E.

Bladder catheterization Massaging the sacral skin daily Elevating the head of the bed to 45 degrees Elevating the heels off the bed surface Repositioning the patient every 4 hours

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The Correct Answer is D

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Critiques Q2
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.
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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.
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Critiques Q2
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.
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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.
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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.
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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.
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The Correct Answer is E.

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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).

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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.
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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.

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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.

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Which of the following is the best treatment option at this time?

A. Increase the dose of sertraline. B. Substitute a different selective serotoninreuptake inhibitor. C. Substitute an antidepressant of another class. D. Add lithium carbonate. E. Refer for electroconvulsive therapy.
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The Correct Answer is A.

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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.
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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.
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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.
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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
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The Correct Answer is B.

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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.
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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 pseudoerythrocytosis 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.
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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.

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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.
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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

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The correct answer is B.

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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.

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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.

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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.
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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.
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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.

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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

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The correct answer is B.

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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 12month 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.

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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.

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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.
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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.
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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
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The correct answer is D.

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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.
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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.

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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.
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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.
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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.
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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.
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The correct answer is A.

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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.
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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.
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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.
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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
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The correct answer is E.

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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.

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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.
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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.

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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.

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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
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The correct answer is B.

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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 P450 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.
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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.
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Critiques Q11
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.

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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.
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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
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The correct answer is E

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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.
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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.

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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.
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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.
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The correct answer is E.

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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.

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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.
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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.

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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

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The correct answer is E.

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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, highfrequency 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.
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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.

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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.

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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.
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Which of the following treatments is most likely to be beneficial?

A. B.

C. D.

Avoidance of alcohol Nasal continuous positive airway pressure (CPAP) Methylphenidate Oropharyngeal surgery

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The correct answer is

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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.
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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.

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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 sedativehypnotics 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.
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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.

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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 needleshaped crystals
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A. B. C. D. E.

Of the following medications taken by this patient, which is the most likely cause of acute renal failure? Digoxin Diphenhydramine Hydrochlorothiazide Lisinopril Trimethoprim-sulfamethizole
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The correct answer is E.

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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.
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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.
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