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RIZZLE Pain Medicine Board Review > ASIPP Geriatrics Questions > Flashcards

ASIPP Geriatrics Questions Flashcards

1
Q

1738.A 67-year-old musician presents with a long history
of low back pain, Pain is worsened with prolonged
standing and with exercise, For the last several months,
the patient has noticed that the back pain comes on with
walking less than one block and radiates to the buttocks,
The pain is relieved by sitting for several minutes, On
physical examination, there are no neurologic defi cits
and bilateral straight-leg raising maneuvers are normal.
Peripheral pulses are strong and bilaterally equal. Which
of the following is the most likely diagnosis?
A. Lumbar spinal stenosis
B. Peripheral vascular disease
C. Lumbosacral sprain
D. Disk herniation
E. Diffuse idiopathic skeletal hyperostosis

A
  1. Answer: A
    Explanation:
    (Tierney, 42/e, p 796.)
    The patient is describing pseudoclaudication, which is
    characteristic of lumbar spinal stenosis. This arises from
    compression of the exiting nerve roots by a disk,
    osteophyte, or narrow canal. The leg pain is most
    pronounced when walking downhill or descending stairs
    and takes several minutes of sitting or fl exing f
    orward before resolution. Often patients who
    continue to walk with pain will stoop over to relieve the
    symptoms (stoop sign). Claudication is seen in peripheral
    vascular disease, but the pain that occurs with walking
    resolves immediately upon stopping or standing without
    sitting. Peripheral pulses may be compromised. Diffuse
    idiopathic skeletal hyperostosis (DISH) causes
    calcifi cation of the longitudinal ligaments of the spine and
    is usually found in patients with diabetes mellitus
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2
Q 
1739.The initial starting dose for a geriatric patient requiring
nortriptyline is:
A. 10 mg
B. 25 mg
C. 50 mg
D. 100 mg
E. 200 mg
A
  1. Answer: A

Source: Jackson KC. Board Review 2003

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3
Q 
1740. The leading cause of death in the elderly population is
A. Heart disease
B. Malignancies
C. Cerebrovascular disease
D. Pulmonary disease
E. Trauma (e.g., Harley accidents)
A
  1. Answer: A

Source: Day MR, Board Review 2003

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4
Q

1741.Which of the following is true regarding hepatic changes
in the elderly:
A. Conjugation changes little with age.
B. Demethylation increases with age.
C. Liver mass decrease starting at age 40.
D. Serum albumin levels remain the same.
E. Serum blood levels of drugs with high fi rst pass metabolism
remain the same.

A
  1. Answer: A

Source: Day MR, Board Review 2005

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5
Q 
1742. Exercise in the geriatric population has been found to
A. reduce falls.
B. increase strength
C. reduce depression
D. all of the above
E. none of the above
A
  1. Answer: D

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

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6
Q
  1. An elderly old woman presents with a new onset, severe
    right-sided headache for 1 day. She states that the vision
    in her right eye has diminished, and she complains of
    claudication of her jaw when she is chewing food. On
    physical examination, her right temple is tender to
    palpation. The most likely diagnosis is:
    A. Acute frontal sinusitis
    B. Giant cell arteritis
    C. Migraine headache
    D. Cluster headache
    E. Trigeminal neuralgia
A
  1. Answer: A
    Explanation:
    (Tierney, 42/e, pp 820-822.)
    Giant cell arteritis or temporal arteritis usually
    appears after the age of 55 and is more common
    in women than men. Patients typically present with
    severe headache, malaise, fever, and tenderness
    over the involved temporal artery. Patients may
    have ocular symptoms due to ischemic optic neuropathy
    (blindness is an irreversible complication) and complain
    of jaw pain when chewing (jaw claudication). Polymyalgia
    rheumatica (limb girdle stiffness and pain, weight loss,
    malaise) may be seen in up to 30% of patients with
    temporal arteritis. Patients suspected of having temporal arteritis require immediate corticosteroids; diagnosis is
    confi rmed by temporal artery biopsy. Trigeminal neuralgia
    (tic douloureux) causes severe unilateral facial pain but is
    not associated with vision changes or claudication. Cluster
    headaches occur mostly in men and are characterized by
    periorbital or temporal pain lasting up to 2 h and
    accompanied by lacrimation and ptosis. Patients complain
    of several attacks a day for several weeks followed by a
    period of remission.
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7
Q

1744.An elderly woman being treated for spinal stenosis,
presents with a new problem with the sudden onset of
severe left-sided chest pain that radiates in a bandlike
fashion to her left side and back. Pain is excruciating and
area is hyperesateric. Heart and lung examinations are
normal. No rash is visible. Electrocardiogram is normal.
The most likely diagnosis is:
A. Gastroesophageal refl ux disease
B. Myocardial infarction
C. Herpes zoster
D. Costochondritis
E. Dissecting aortic aneurysm

A
  1. Answer: C
    Explanation:
    (Tierney, 42/e, pp 105-106.)
    Herpes zoster is due to reactivation of latent
    varicella virus; patients typically present with a
    history of pain, tingling, or itching of the affected
    area followed by an eruption of vesicles overlying
    an erythematous base. Although the disease can
    disseminate and produce diffuse eruptions, it typically
    presents with involvement of a single dermatome. The
    disease is not limited to adults or immunocompromised
    patients and may be seen in children.
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8
Q

1745.A 66-year-old man has the chief complaint of pain and
numbness over the lateral aspect of the right thigh. He has
no back pain or diffi culty ambulating. The symptoms are
relieved by sitting. Physical examination is normal except
for impaired cutaneous sensation over the affected lateral
aspect of the right thigh. There is a negative straight-leg
raise maneuver; motor strength and deep tendon refl exes
are normal. Romberg test is negative. Which of the
following is the most likely diagnosis?
A. Peroneal nerve palsy
B. Meralgia paresthetica
C. Vitamin B12 defi ciency
D. Sciatic nerve palsy
E. Femoral neuropathy

A
  1. Answer: B
    Explanation:
    (Tierney, 42/e, p 997.)
    The patient describes symptoms due to compression of the
    lateral femoral cutaneous nerve arising from the L2 and L3
    roots (meralgia paresthetica). Entrapment of the nerve at
    any point from hyperextension of the hip may cause
    symptoms. Symptoms are usually mild, but patients may
    require hydrocortisone injections medial to the iliac spine.
    Patients with femoral neuropathy present with weakness
    and wasting of the quadriceps muscle, sensory
    impairment,and an absent patellar refl ex. The
    Romberg test is performed by having the patient
    stand with feet together, head erect, and eyes open.
    The patient is then examined for steadiness and
    then asked to close his or her eyes. A positive test
    occurs when the patient displays increased unsteadiness
    with the eyes closed but not with the eyes open.
    A positive Romberg test may be seen in diseases that
    affect the dorsal columns, such as tabes dorsalis and
    vitamin B12 defi ciency
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9
Q

1746.An elderly woman presents with paresthesias of the
feet and an unsteady gait for several months. Other
than a previous history of anemia, the patient has no
past medical history. She takes no medications and
does not smoke cigarettes or drink alcohol. On physical
examination, the patient is alert and oriented but cannot
recall three objects after 5 min. Her gait is unsteady and
broad-based, and she has increased muscle tone in the
lower extremities. Muscle strength is normal, but the
patient has diminished sensation to vibration from the
midcalf areas to the feet. Patellar and ankle refl exes are
absent bilaterally. The patient has bilateral extensor
Babinski refl exes and a positive Romberg test. Laboratory
data reveal a macrocytic anemia. Which of the following
is the most likely diagnosis?
A. Vitamin B12 defi ciency
B. Tabes dorsalis
C. Lead poisoning
D. Vitamin B6 defi ciency
E. Vitamin E defi ciency

A
  1. Answer: A
    Explanation:
    (Tierney, 42/e, pp 474-475.)
    The patient most likely has vitamin B12 defi ciency due to
    pernicious anemia (lack of intrinsic factor). Patients show
    loss of posterior column sensation (vibration and position
    sense), positive Romberg test, mild spasticity, and
    bilateral extensor plantar refl exes (upper motor neuron).
    Patients may also present with mild dementia or
    psychiatric symptoms. The polyneuropathy associated
    with B6 (pyridoxine) defi ciency is associated with
    isoniazid use. Lead poisoning causes a motor neuropathy (i.e., wristdrop, footdrop) and requires chronic exposure
    to lead as an adult. Tabes dorsalis due to tertiary syphilis
    causes progressive sensory loss, ataxia, and a positive
    Romberg test, but patients complain of severe lancinating
    leg pain. Patients are not spastic and do not have a positive
    Babinski sign. Vitamin E defi ciency is seen in liver disease,
    cystic fi brosis, and other malabsorption syndromes;
    patients present with ataxia and peripheral neuropathy.
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10
Q

1747.Compared with young adult patients undergoing stroke
rehabilitation, geriatric patients require
A. more medication to prevent recurrent stroke.
B. longer rehabilitation hospitalization.
C. more nasogastric tube feedings.
D. bladder catheterizations more frequently.
E. lesser rehabilitation hospitalization.

A
  1. Answer: B

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

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11
Q 
1748.A 70-year-old woman presents with poorly articulated
phrases but understands commands. Choose correct
diagnosis:
A. Upper motor neuron disease
B. Lower motor neuron disease
C. Myelopathy
D. Radiculopathy
E. Broca’s aphasia
A
  1. Answer: E
    Explanation:
    (Seidel, 5/e, p 798.)
    Upper motor neuron (UMN) disease (above the level of
    the corticospinal synapses in the gray matter) is
    characterized by spastic paralysis, hyperrefl exia,
    and a positive Babinski refl ex (everything is up in UMN
    disease). Lower motor neuron (LMN) disease (below the
    level of synapse) is characterized by fl accid paralysis,
    signifi cant atrophy, fasciculations, hyporefl exia, and a
    fl exor (normal) Babinski refl ex (everything is down in
    LMN disease). A radiculopathy occurs with root
    compression from a protruded disk that causes sensory
    loss, weakness, and hyporefl exia in the distribution of the
    nerve root. Myelopathy causes severe sensory loss 0
    posterior column sensation (position sense and vibration),
    spasticity, hyperrefl exia, and positive Babinski refl exes.
    Broca’s aphasia (left inferior frontal gyrus) is a nonfl uent
    expressive aphasia (Broca’s should remind you of broken
    speech); Wernicke’s aphasia (left posterior-superior
    temporal gyri) is a receptive aphasia because patients lack
    auditory comprehension (Wernicke’s should remind you
    of wordy speech that makes no sense).
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12
Q

1749.During evaluation of an elderly woman with severe
arthritic pain, it is noted that she has a poor appetite,
insomnia, and anxiety. A likely secondary consequence
of her pain in this setting that should also be treated
includes:
A. Acute delirium
B. Clinical depression
C. Dementia
D. Failure to thrive
E. Generalized anxiety diseases

A
  1. Answer: B
    Explanation:
    Clinical depression is a common consequence of untreated
    or undertreated pain. Signs and symptoms may include
    insomnia, amxiety, agitation, aggression, loss of appetite,
    and refusal of care.
    Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004
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13
Q 
1750.Independent of bone mineral density, in elderly women,
the factor contributing to an increased risk of fracture
secondary to a fall includes:
A. Obesity
B. Daily wine consumption
C. Poor visual acuity
D. Use of coumadin
E. Height
A
  1. Answer: C
    Explanation:
    (a) Kanis JA. Diagnosis of osteoporosis ad assessment of
    fracture risk. Lancet 2002;359:1929-36.
    (b) Dargent-Molina P, favier F, Grandjean H, et al. Fallrelated
    factors and risk of hip fracture: the EPIDOS
    prospective study [published erratum]
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14
Q 
1751.Which of the following abnormality is most common in
the disabled elderly population?
A. Epilepsy
B. Movement disorders
C. Transient ischemic attacks
D. Dementia
E. Stroke
A
  1. Answer: B
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15
Q 
1752.Which of the following agents would be best tolerated
in a medically debilitated patient for post-herpetic
neuralgia?
A. Amitriptyline
B. Desipramine
C. Maprotiline
D. Doxepin
E. Trazodone
A
  1. Answer: B
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16
Q 
1753.The major factor causing poor compliance with medical
advice by the elderly is
A. Drug costs
B. Race issues
C. Number of drugs
D. Communication
E. Insurance
A
  1. Answer: C
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17
Q

1754.In managing pain in the elderly patients, it is best to use
drugs in the following manner:
A. Start low and go slow for all medications.
B. Use high-dose, short-acting narcotics initially to get the
pain under control.
C. Avoid use of acetaminophen, due to liver toxicity.
D. Start with aspirin, which is safe and effective.
E. Start with transdermal fentanyl

A
  1. Answer: A
    Explanation:
    Physiologic changes with aging, including slowed
    absorption, metabolism, and elimination of medications,
    may lead to excess sedation, confusion, constipation, and
    urinary retention in geriatric patients. Thus, low initial
    doses are indicated, with slow upward titration.
    Acetaminophen is safe and effective for moderate pain.
    Aspirin in higher doses is associated with bleeding
    complications.
    Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004
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18
Q

1755.In general, patients who have chronic obstructive
pulmonary disease and are undergoing pulmonary
rehabilitation should maintain an arterial oxygenation
level no less than
A. 95%
B. 93%
C. 88%
D. 85%
E. 90%

A
  1. Answer: C

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

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19
Q

1756.The exercise program benefi cial for patients with
rheumatoid arthritis is:
A. High intensity progressive resistance exercises
B. Low-load, high-reception resistance exercise
C. Walking 3 to 4 times per week.
D. A program incorporating any of the above
E. None of the above programs

A
  1. Answer: D

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

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20
Q

1757.A 67-year-old man presents with an episode of right
face, arm, and leg weakness that resolved on arrival to the
emergency room. Choose appropriate diagnosis:
A. Basilar artery stroke
B. Middle cerebral stroke
C. Anterior cerebral stroke
D. Transient ischemic attack
E. Posterior cerebral stroke

A
  1. Answer: D
    Explanation:
    (Tierney, 42/e, pp 962-963.)
    Basilar artery stroke causes quadriplegia, sensory loss,
    and cranial nerve involvement; patients may present
    with coma or locked-in syndrome. Wallenberg
    syndrome or lateral medullary syndrome causes
    an ipsilateral weakness of the palate and vocal cords,
    ipsilateral ataxia, ipsilateral Horner syndrome, and
    ipsilateral loss of facial pain and temperature but
    contralateral loss of body pain and temperature sensation.
    There is no limb weakness in Wallenberg syndrome.
    Anterior cerebral stroke causes unilateral leg weakness and
    sensory loss. Posterior cerebral artery stroke causes an
    occipital stroke and a homonymous hemianopsia. Middle
    cerebral artery stroke causes hemiplegia or hemiparesis
    greater in the arm than the leg, aphasia, unilateral sensory
    loss, and eyes that deviate to the side of the hemispheric
    lesion. Patients with lacunar infarcts may present with
    different syndromes, such as dysarthria and mild
    hemiparesis (clumsy-hand dysarthria). Lacunar infarcts
    represent small artery occlusions; hypertension and
    diabetes are risk factors for these infarcts. Patients in a
    vegetative state from diffuse cortical damage have
    spontaneous eye opening and movement without evidence
    of awareness.
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21
Q
  1. In the elderly, scopolamine-induced delirium is
    A. Absent with doses less than 0.4 mg
    B. Decreased by physostigmine
    C. Reversible with diazepam
    D. Reversible with pyridostigmine
    E. Similar to that produced by glycopyrrolate
A
  1. Answer: B
    Source: American Board of Anesthesilogy, In-trainnig
    examination
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22
Q

1759.An elderly female has swelling and pain in several
of the interphalangeal (IP) joints of her hand. X-ray
examination reveals arthritic changes. Which agent
should not be prescribed?
A. Indomethacin
B. Acetaminophen
C. Tolmetin
D. Naproxen
E. Piroxicam

A
  1. Answer: B
    Explanation:
    Reference: Hardman, pp 631-633.
    All of the drugs listed, except acetaminophen, are usually considered NSAIDs, a large group of structurally
    dissimilar compounds. These drugs share the
    pharmacologic properties of the prototype compound,
    aspirin, in that all have analgesic, antipyretic, and antiinfl
    ammatory effects. The mechanism of action that is
    responsible for the effect of NSAIDs is reduction in the
    formation of eicosanoids (e.g., prostaglandins,
    thromboxanes) by inhibiting the enzyme cyclooxygenase.
    Acetaminophen differs from the other drugs in that it is a
    very weak anti-infl ammatory agent; however, it is an
    effective analgesic and antipyretic
    Source: Stern - 2004
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23
Q

1760.A 71-year-old woman presents with aphasia and severe
right-sided hemiparesis greater in the arm than the
leg. Her eyes deviate to the left. Choose appropriate
diagnosis:
A. Basilar artery stroke
B. Middle cerebral stroke
C. Anterior cerebral stroke
D. Transient ischemic attack
E. Posterior cerebral stroke

A
  1. Answer: B
    Explanation:
    (Tierney, 42/e, pp 962-963.)
    Basilar artery stroke causes quadriplegia, sensory
    loss, and cranial nerve involvement; patients may
    present with coma or locked-in syndrome.
    Wallenberg syndrome or lateral medullary syndrome
    causes an ipsilateral weakness of the palate and vocal
    cords, ipsilateral ataxia, ipsilateral Horner syndrome, and
    ipsilateral loss of facial pain and temperature but
    contralateral loss of body pain and temperature sensation.
    There is no limb weakness in Wallenberg syndrome.
    Anterior cerebral stroke causes unilateral leg weakness and
    sensory loss. Posterior cerebral artery stroke causes an
    occipital stroke and a homonymous hemianopsia. Middle
    cerebral artery stroke causes hemiplegia or hemiparesis
    greater in the arm than the leg, aphasia, unilateral sensory
    loss, and eyes that deviate to the side of the hemispheric
    lesion. Patients with lacunar infarcts may present with
    different syndromes, such as dysarthria and mild
    hemiparesis (clumsy-hand dysarthria). Lacunar infarcts
    represent small artery occlusions; hypertension and
    diabetes are risk factors for these infarcts. Patients in a
    vegetative state from diffuse cortical damage have
    spontaneous eye opening and movement without evidence
    of awareness.
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24
Q

1761.An eldery woman presents with back pain for several
months. She denies recent trauma. She has no weight
loss or loss of appetite. She has no fever, chills, or night
sweats. Physical examination reveals a dowager hump
and mild kyphotic bowing of the spine. Serum calcium,
phosphorus, alkaline phosphatase, and parathyroid hormone levels are normal. The following is the most
appropriate next step in diagnosis of this patient:
A. Lumbar spine radiographs
B. MRI of the spine
C. CT densitometry of the lumbar spine
D. Dual-energy x-ray absorptiometry
E. Bone scan

A
  1. Answer: D
    Explanation:
    (Tierney, 42/e, pp 1114-1115.)
    Risk factors for osteoporosis include white, Asian-Pacifi c
    Islander, and Native American race; Northwestern
    European descent; blonde or red hair; freckles;
    thin body frame; nulliparity; early menopause;
    family history of osteoporosis; postmenopause;
    constant dieting; calcium intake
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25
Q 
1762.What is the most common cause of dementia in the
elderly?
A. Parkinson’s disease
B. Neoplasm
C. Stroke
D. Depression
E. Alzheimer’s disease
A
  1. Answer: E

Source: Day MR, Board Review 2005

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26
Q

1763.An elderly man presents with the chief complaint of
leg pain, associated with headache and defi ciency with
walking. On physical examination, the patient has
bowing of the lower extremities and the right lower
extremity is longer than the left lower extremity. The
physical examination is normal, except for hearing loss
and war legs. Laboratory data reveal an isolated elevated
serum alkaline phosphatase level. The fo11owing is the
most likely diagnosis in this patient.
A. Vitamin D defi ciency
B. Paget’s disease
C. Cerebral vascular accident
D. Parkinson’s disease
E. Metastatic bone disease

A
  1. Answer: B
    Explanation:
    (Tierney, 42/e, pp 1119-1120.)
    Paget’s disease of bone
    (osteitis deformans) is a disorder in which normal bone is
    replaced by disorganized trabecular bone. Patients may be
    asymptomatic but may present with increased hat size
    (skull enlargement), hearing loss (involvement of the
    ossicles of the inner ear), facial pain, headache, backache,
    leg pain, growth of the lower extremities (one leg may be
    longer than the other), tibial bowing, and increased blood
    fl ow to the involved areas of bone growth. Alkaline
    phosphatase may be elevated, and a bone scan will detect
    the lytic lesions. A complication of paget’s disease is
    osteosarcoma (
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27
Q

1764.The most commonly prescribed analgesic in the elderly
chronic pain population is:
A. Tramadol
B. Acetaminophen
C. Non-steroidal anti-infl ammatory drugs
D. Opioids
E. Anti-epileptic drugs

A
  1. Answer: C

Source: Day MR, Board Review 2005

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28
Q

1765.Polymyalgia rheumatica is:
A. Twice as common in males as females
B. Responds only to high dose steroids
C. Affects distal muscle groups
D. More common in people of southern European decent
E. Almost exclusively found in Caucasians

A
  1. Answer: E

Source: Day MR, Board Review 2005

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29
Q

1766.In patients undergoing a rehabilitation program after a
hip fracture, benefi t from weight-bearing exercises can
A. improve walking velocity
B. decrease incidence of hip dislocation
C. decrease risk of prosthetic failure
D. improve pain control.
E. improve sleeping pattern

A
  1. Answer: A

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

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30
Q 
1767. Post-hepatic neuralgia is:
A. More common in women
B. Most often involves lumbar dermatomes
C. Incidence increases with age
D. Gradually worsens with time
E. Pain that persists for 12 month
A
  1. Answer: C

Source: Day MR, Board Review 2005

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31
Q

1768.Proportion of institutionalized elderly persons is
estimated to suffer from chronic pain is:
A. 20%
B. 50%
C. 80%
D. Less than 5%
E. 90%

A
  1. Answer: C
    Explanation:
    Chronic pain is estimated to affect 80% of institutionalized
    elderly people. Causes include skeletal pain related to
    osteoporosis, rheumatoid arthritis, cervical and lumbar
    spondylosis, osteoporosis, and fractures with resultant
    deformities. Neuropathic pain related to peripheral
    neuropathy from diabetes mellitus, previous stroke, and
    postherpetic neuralgia also occurs. Pain with peripheral
    vascular and cardiovascular diseases, skin ulcers, and
    cancer also occur with greater frequencies in this
    population.
    Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004
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32
Q
  1. Which of the following CNS changes are associated with
    aging?
  2. Absent or decreased ankle jerk refl exes
  3. High frequency hearing loss
  4. Reduced information retrieval
  5. Decreased muscle tone
A
  1. Answer: A (1, 2 & 3)

Source: Day MR, Board Review 2005

33
Q
  1. GI changes associated with the elderly include:
  2. Decreased gastric acid production
  3. Increased lower esophageal sphincter tone
  4. Decreased esophageal transit time
  5. Increased intestinal blook flow
A
  1. Answer: B (1 & 3)

Source: Day MR, Board Review 2005

34
Q
  1. True statement/s regarding temporal arteritis include/s:
  2. More common in men
  3. Vision changes is the leading symptom
  4. Sedimentation rate is normal
  5. Requires a biopsy to prove diagnosis
A
  1. Answer: D (4 only)

Source: Day MR, Board Review 2005

35
Q
  1. Hepatic changes associated with aging include:
  2. Decrease in conjugation
  3. Decrease in demethylation
  4. Increase in oxidation
  5. Decrease in liver mass
A
  1. Answer: C (2 & 4)

Source: Day MR, Board Review 2005

36
Q 
1773.The objective/s of physical therapy and rehabilitation
is/are:
1. Stabilize the primary disorder
2. Prevent secondary disabilities
3. Decrease pain perception
4. Treat functional defi cits
A
  1. Answer: E (All)

Source: Day MR, Board Review 2005

37
Q

1774.An elderly woman is being discharged from the acute
rehabilitation unit after a stroke that resulted in right
hemiparesis. When ordered by a physician and medically
justifi ed. Which service is covered under Medicare?
1. Transportation for medical appointments
2. Spasticity medications
3. Dressing assistance in the morning.
4. Front-wheeled walker

A
  1. Answer: D (4 Only)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

38
Q
  1. Characteristics of Azheimer’s disease include:
  2. Increase in acetyltransferase
  3. Affects aging populations equally
  4. A rapidly progressive disorder
  5. Mostly affects the Nucleus basalis of Meynert
A
  1. Answer: C

Source: Day MR, Board Review 2005

39
Q

1776.Pharmacodynamic change/s associated with aging is/
are:
1. Increased sensitivity to opiods
2. Decreased sensitivity to adrenergic specifi c drugs
3. Decreased sensitivity to cholinergic specifi c drugs
4. Decreased sensitivity to benzodiazepines

A
  1. Answer: A (1, 2 & 3)

Source: Day MR, Board Review 2005

40
Q

1777.Appropriate strategies to manage polypharmacy in
elderly persons include the following:
1. Person-to person patient and family education
2. Use of clinical decision support systems and protocols
3. Assessment of potential drug interactions when starting
a new medication
4. Maintenance of chronic medication regimens despite an
acute medical change

A
  1. Answer: A (1, 2, & 3)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

41
Q

1778.Ventilatory function is impaired in the elderly for which
of the following reasons?
1. Decreased intercostal and diaphragmatic muscle mass
and function
2. Loss of alveolar spaces and septa, which resembles emphysematous
changes
3. Decreased pulmonary parenchymal and chest wall
elasticity
4. Diminished hypoxic drive

A
  1. Answer: E (All)
    Explanation:
    (Miller, 4/e. 2151-2152.)
    Hypoxic and carbon dioxide drive is not lost in the elderly,
    but it may be diminished. Therefore, the elderly are at
    great risk for hypoxia and hypercarbia from anesthetic
    drugs that cause respiratory depression. Another factor
    adding to potential pulmonary failure in the elderly is
    complex mechanical changes that involve the chest wall,
    diaphragm, and pulmonary parenchyma.
    Source: Curry S.
42
Q

1779.Changes in cardiac physiology that occur in the elderly
include
1. a decrease in beta receptor responsiveness but no change
in receptor density
2. increased responsiveness of the geriatric heart to indirect-
acting beta mimetics such as ephedrine
3. degenerative changes of the SA node, AV node, and cardiac
conduction system
4. higher resting heart rates

A
  1. Answer: B (1 & 3)
    Explanation:
    (Miller, 4/e, pp 2150-2151.)
    There is no change in beta receptor density in the elderly;
    however, function is diminished, which affects inotropicity
    and chronotropicity. Also, as a result of diminished
    function, there is diminished responsiveness in both direct
    and indirect beta sympathomimetic drugs. There are
    degenerative fi brotic changes throughout the conduction
    system, which can lead to heart blocks. Resting heart rate is
    decreased
    Source: Curry S.
43
Q
  1. Age changes in the hepatic system include a reduction in
  2. First pass metabolism
  3. Microsomal oxidation
  4. Demethylation
  5. Glucuronidation
A
  1. Answer: B (1 & 3)
44
Q

1781.Which of the following regarding Polymyalgia
Rheumatic are true?
1. More common over the age 55 yrs
2. Elevated erythrocyte sedimentation rate
3. Associated with temporal arteritis
4. Elevated creatine kinase

A
  1. Answer: A (1, 2, & 3)
45
Q
  1. In the elderly, drug effects are infl uenced by:
  2. Decreased renal function
  3. Increased volume of distribution
  4. Reduced hepatic function
  5. Decreased relative body fat
A
  1. Answer: B (1 & 3)
46
Q
  1. Age changes in the renal system include a reduction in
  2. Creatinine clearance
  3. Renal blood fl ow
  4. Glomerular fi ltration
  5. Free water clearance
A
  1. Answer: A (1, 2, & 3)
47
Q 
1784.Grapefruit juice increases serum levels of all of the
following medications
1. warfarin.
2. thoephylline.
3. cyclosporine.
4. nonsteroidal anti-infl ammatory drugs
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    Grapefruit juice inhibits hepatic enzyme metabolism and
    increases the serum levels of certain medications, for
    example, warfarin, theophylline, and cyclosporine.
    Source: Source: Podrazik PM, Schwarts JB. Cardiovascular
    pharmacology of aging. Cardiol Clin 1999;17:17-34.
48
Q
  1. Changes in the central nervous system (CNS) that occur
    in the geriatric population include
  2. a progressive decline in CNS function with a loss of
    cerebral cortex neurons
  3. decreased cerebral metabolic rate and decreased cerebral
    blood fl ow
  4. a decrease in the synthesis of neurotransmitters and
    receptor sites for them
  5. a need for increased doses of local anesthetics when
    epidural anesthesia is performed
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    (Miller, 4/e. pp 2147-2148.)
    There is a generalized decline in the CNS with aging. MAC
    decreases as a result. Local anesthetic requirements
    decrease as well as for all nerve blocks.
    Source: Curry S.
49
Q

1786.Changes in cardiac output in the elderly are correctly
characterized by which of the following statements?
1. Cardiac output declines more with age in women than
in men
2. Increases in cardiac output that occur with stress decline
with aging
3. Coronary blood fl ow needs are decreased in the elderly
for a given cardiac output
4. Persons who maintain physical aerobic fi tness may have
unchanged cardiac output from the third to the sixth
decade

A
  1. Answer: C (2 & 4)
    Explanation:
    (Miller, 4/e. pp 2150-2151.)
    Cardiac output does not necessarily decline with aging.
    Persons who maintain aerobic fi tness may have unchanged
    cardiac output well into the seventh decade, at which point
    cardiac output will fall off. In the elderly there is a loss of
    an increase in cardiac output in response to stress, but this
    is attenuated somewhat in the elderly who are fi t.
    Source: Curry S
50
Q
  1. Considerations in elderly patients include that
  2. body fat decreases, as does the half-life of fat-soluble
    drugs
  3. impaired hypothalamic function, which mediates heat
    control, is the primary reason the elderly become hypothermic
    more easily than do the young
  4. right bundle branch blocks are common in healthy,
    asymptomatic elderly patients and in most cases should
    be considered a normal fi nding
  5. they have widened pulse pressure
A
  1. Answer: D (4 Only)
    Explanation:
    (Stoelting, Anesthesia and Co-Existing Disease, 3/e. pp
    631-633.)
    Body fat increases (in women more than in men) and fatsoluble
    drugs have a longer elimination half-life in the
    elderly. Hypothalamic dysfunction may be one factor that
    contributes to a greater degree of heat loss in elderly
    patients, but the primary reason for a propensity to
    hypothermia is impaired cutaneous vasoconstriction and
    reduced heat production (basal metabolic rate declines
    from 42 kcal/h in a 20-year-old to 32 kcal/h in an 80-yearold
    person). Healthy, asymptomatic elderly patients have a
    high incidence of supraventricular and ventricular ectopic
    beats. A right bundle branch block is not a normal
    fi ndings and should prompt a search for organic heart
    disease. Systolic blood pressure increases in the elderly as
    the aorta and large arteries lose distensibility. Diastolic
    pressure normally does not change much with age.
    Source: Curry S.
51
Q
  1. The type(s) of exercise training widely accepted as the
    optimal way to enhance and maintain function in older
    adults include:
  2. Endurance
  3. Flexibility
  4. Balance
  5. Resistance
A
  1. Answer: D (4 Only)
    Explanation:
    Endurance exercises have effects on cardiovascular
    impairment, leading to improvements in morbidity and
    mortality, but their effect on function is limited. Resistance
    training enhances function and is accepted as the optimal
    means to maintain function in older adults. Flexibility and
    balance probably also contribute to function but adequate
    studies designed for the purpose of evaluating disability
    are lacking.
    Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004
52
Q

1789.Regarding interdisciplinary assessment, the following
benefi ts apply to the geriatric population.
1. It allows the development of specifi c, targeted interventions.
2. It allows reliable testing of persons over time.
3. It allows better reimbursement and insurance coverage
for outpatient and home-based interventions.
4. It allows care providers to develop independent treatment
plans.

A
  1. Answer: A (1, 2, & 3)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

53
Q 
1790.Which physiologic factor in the elderly exacerbates
orthostasis?
1. Decreased creatinine clearance
2. Decreased peripheral resistance
3. Decrease in arterial stiffness
4. Decreased baroreceptor response
A
  1. Answer: D (4 Only)
    Explanation:
    As many as 20% of persons over the age of 65 years and
    30% of those over age 75 have orthostatic hypotension.
    Orthostasis is often exacerbated because of an increase in
    arterial stiffness, increased peripheral resistance, decreased
    baroreceptor response, and low plasma rennin activity.
    Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004
54
Q

1791.True statements regarding pain in the elderly persons
are as follows:
1. Elderly persons feel pain as much as younger people.
2. Pain can commonly be localized to a single site.
3. Approximately one third of elderly individuals have
chronic joint pain and arthritis.
4. Pain results in less functional impairment in the elderly
compared with the younger population.

A
  1. Answer: B (1 & 3)
55
Q

1792.True statements regarding falls in the geriatric
population include the following:
1. Most falls are considered accidental, rather than related
to underlying diseases or functional impairments.
2. The timed “Get up & Go” test is an appropriate way to
assess someone who presents with frequent falls.
3. Dynamic balance training activities such as Tai Chi have
no effect on fall risk or fear of falling.
4. Fall risk assessment should evaluate both intrinsic and
extrinsic risk factors.

A
  1. Answer: D (4 Only)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

56
Q 
1793.The factor(s) improving bowel transit time in persons
with chronic constipation include:
1. Bedrest
2. Bulking agents
3. Fluid restriction
4. High fiber diet
A
  1. Answer: C (2 & 4)
    Explanation:
    Schiller LR. Constipation and fecal incontinence in the
    elderly. Gastroenterol Clin North Am 2001; 30:497-515.
57
Q 
1794. Drugs used in the treatment of dementias include which
of the following?
1. Nonsteroidal antiinfl ammatory drugs
2. Anticholinesterase drugs
3. Antioxidant agents
4. Muscarinic antagonists
A
  1. Answer: A (1, 2, & 3)
58
Q

1795.Which of the following changes in renal function will
occur in the geriatric population?
1. An increase in renal cortical blood fl ow versus renal
medullary blood fl ow occurs
2. Decreased muscle mass in the elderly leads to decreased
creatinine levels
3. There are no changes in urine concentrating ability
4. Decreased renal blood fl ow occurs because of decreased
cardiac output and a decrease in size of the renal vascular
bed

A
  1. Answer: C (2 & 4)
    Explanation:
    (Miller, 4/e. pp 2146-2147.
    )
    Renal blood fl ow decreases in the elderly because of a
    decrease in cardiac output and a decrease in the size of the
    renal vasculature, particularly the cortex. This leads to
    reduced renal cortical blood fl ow and decreased
    glomerular fi ltration rate (GFR), concentrating ability, and
    creatinine clearance. With the decrease in creatinine
    clearance, there is also a decrease in muscle mass and
    production of creatinine. This explains why serum
    creatinine levels do not decrease in the elderly. Any
    increase in creatinine in the elderly signifi es a large
    decrease in an already diminished GFR.
    Source: Curry S.
59
Q

1796.Endocrinologic changes that occur in the elderly
include
1. a greater incidence of primary hyperparathyroidism
2. increased incidence of diabetes mellitus
3. increased incidence of Graves’ disease
4. increased incidence of hypothyroidism

A
  1. Answer: C (2 & 4)
    Explanation:
    ( Stoelting, Anesthesia and Co-Existing Disease, 3/e. pp
    633-636.)
    Primary hyperparathyroidism and Graves’ disease do not
    have an increased incidence in the elderly. Adult-onset
    diabetes occurs with greater frequency in the sixth and
    seventh decades. Circulating insulin levels are normal. It is
    believed that the cause of diabetes in this age group may
    be
    insulin receptor dysfunction. Thirteen percent of the
    elderly population have hypothyroidism; the vast majority
    are asymptomatic. The only abnormal measure of thyroid function may be an elevated level of thyroid stimulating
    hormone. The most common cause of hypothyroidism is
    Hashimoto’s thyroiditis.
    Source: Curry S.
60
Q

1797.Regarding foot care, compared with the general
population, diabetic patients
1. are 15 to 17 times more likely to require an amputation.
2. have a 10-year survival rate of 25% to 50% after an
amputation.
3. are less likely to be noncompliant with foot checks.
4. Have a 15% rate of amputation if a chronic ulcer is
present.

A
  1. Answer: B (1 & 3)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

61
Q 
1798.Activities associated with a reduced risk of dementia
include:
1. Playing musical instruments
2. Dancing
3. Playing board games
4. Bowling
A
  1. Answer: A (1, 2, & 3)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

62
Q
  1. True statements about the hepatobiliary system in the
    geriatric age group include
  2. hepatic blood fl ow decreases as a result of decreased
    cardiac output
  3. a decrease in activity of hepatic microsomal enzymes
    occurs
  4. production of albumin is decreased
  5. hepatic vein blood fl ow decreases
A
  1. Answer: E (All)
    Explanation:
    (Miller, 4/e. pp 2145-2146.)
    The reduction in hepatic blood fl ow is commensurate with
    the decrease in cardiac output that occurs in the elderly.
    Hepatic microsomal enzyme activity also decreases in the
    ages. Drug clearance and metabolism are reduced in the
    elderly, but the cause of this is probably the decrease in
    cardiac output rather than diminished enzyme activity.
    Hepatic vein blood fl ow and albumin levels are
    diminished in the elderly.
    Source: Curry S
63
Q

1800.The benefi ts of hiring older workers (compared with
younger colleagues) in medical industry include
1. fewer workers compensation claims.
2. less use of health care benefi ts.
3. decreased rate of burns.
4. lower absentee rates.

A
  1. Answer: D (4 Only)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

64
Q
  1. Dementias are characterized by
  2. Generalized limitation of cognitive function
  3. Cholinergic dysfunction
  4. Progressive decline in function
  5. Depression of consciousness
A
  1. Answer: A (1, 2, & 3)
65
Q 
1802.Elderly patients generally show increased sensitivity to
which of the following drugs?
1. Phenylephrine
2. Diazepam
3. Oxycodone
4. Morphine
A
  1. Answer: C (2 & 4)
66
Q

1803.In the general geriatric population, the factor(s)
associated with an increased risk of driving accidents
are as follows:
1. Hemodialysis
2. Chronic Pain
3. Myopia
4. Stroke

A
  1. Answer: D (4 Only)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

67
Q 
1804.In elderly patients, conditions contraindicating to
starting an exercise program are:
1. End-stage congestive heart failure
2. Recent ophthalmologic surgery
3. severe behavioral disturbance
4. Stable 3-cm abdominal aortic aneurysm
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    The condition that is not a contraindication to starting an
    exercise program in an elderly patient from the listed
    choices is a small or stable abdominal aortic aneurysm. All
    the other conditions warrant further investigation and
    stabilization before initiating an exercise program.
    Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004
68
Q

1805.Which statement concerning osteoarthritis (OA) is true?
1. Exercise in patients with OA contributes to pain reduction.
2. Group exercise programs are much more effective than
individual programs in reducing disability
3. High-intensity progressive resistance exercises in patients
with OA causes the disease to progress.
4. Exercise in patients with OA contributes to pain reduction.

A
  1. Answer: D (4 Only)
    Explanation:
    Exercises for patients with osteoarthritis (OA) is
    considered to be safe and to contribute to the reduction of
    pain. Exercise programs have not been associated with
    disease progression. No clear difference has been noticed
    in the reduction of disability when comparing group,
    individual, and home-based exercise programs. Aerobic
    exercise is effective in correcting reductions in aerobic
    capacity in patients with OA.
    Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004
69
Q

1806.Which physiologic changes related to aging is included
among factors that necessitate decreased loading doses
for water soluble medications?
1. Increased fat mass
2. Decreased muscle mass
3. Decreased total body water
4. Decreased cardiac output

A
  1. Answer: A (1, 2, & 3)
    Explanation:
    Increased fat mass, decreased muscle mass, and decreased
    total body water affect the distribution of medications.
    Normal pshsiologic changes of aging include decreased
    intestinal motility, decreased cardiac output, and decreased
    creatinine clearance.
    Source:Fulop T Jr, Worum I, Csongor J, Foris G, Leovey A.
    Body composition in elderly people. I.Determination of
    body composition by multiisotope method and the
    elimination kinetics of these isotopes in healthy elderly
    subjects. Gerontology 1985; 31:6-14.
70
Q
  1. Pharmacokinetic changes in the elderly include
  2. Increased volume of distribution
  3. Deceased lean body mass
  4. Increased lipid content
  5. Longer beta elimination
A
  1. Answer: E (All)
71
Q

1808.A 75-year-old sedentary man with a history of
hypertension, type II diabetes mellitus, and mild sensory
neuropathy who is currently a nonsmoker wishes to
begin an exercise program. The safest initial modality of
exercise includes the following:
1. Treadmill walking at 1.5mph on level surface
2. Stair stepper for 15 minutes without resistance
3. Machine-based quadriceps extensions at 80% maximum
weight
4. Lifting 1- to 3-pond weights overhead while seated

A
  1. Answer: D (4 Only)
    Explanation:
    Bean JF, Vora A, Frontera WR. The benefi ts of exercise for
    community-dwelling older adults. Arch Phys Med Rehabil
    2004;85(Suppl 3):S31-42.
72
Q 
1809.Risk factor(s) for erectile dysfunction in elderly men
include the following:
1. Recurrent inguinal hernia.
2. pharmacologic side effects.
3. hypothyroidism
4. Low testestrone levels
A
  1. Answer: C (2 & 4)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

73
Q

1810.Important pharmacologic considerations in the elderly
include that
1. the dose of thiopental in elderly patients should be decreased
primarily because of altered pharmacokinetics
2. the elimination half-life of diazepam in hours approximates
the patient’s age in years
3. the dose of atracurium need not be adjusted for age
4. the MAC for isofl urane in a 40-year-old is 1.15 and in an
80-year-old is 0.97

A
  1. Answer: E (All)
    Explanation:
    (Miller, 4/e. pp 2143-2146.)
    The initial volume of distribution for thiopental is
    decreased, which causes higher serum concentrations in
    older compared with younger patients. Elderly and
    younger patients respond to similar serum concentrations
    of thiopental. The clearance of diazepam is reduced in the
    elderly, which accounts for its longer duration of action.
    Cognitive impairment can continue for a very long time
    after administration of this drug in the elderly. Unlike all
    other nondepolarizing muscle relaxants, attacurium is
    independent of age-related changes. Decreases in MAC
    occur with age for isofl urane and the other potent
    inhalational agents.
    Source: Curry S.
74
Q

1811.True statements concerning the elderly include
1. there is a direct correlation between biologic age and
chronologic age
2. the fi ve most frequently performed surgical procedures
are cataract extraction, transurethral, prostatectomy,
herniorrhaphy, cholecystectomy, and reduction of a
hip fracture
3. geriatric patients are arbitrarily defi ned as those older
than 75 years of age
4. generalized osteoporosis may be an important factor in
the increased incidence of hip fractures in the elderly

A
  1. Answer: C (2 & 4)
    Explanation:
    (Stoelting, Anesthesia and Co-Existing Disease, 2/e, pp
    633 – 637.)
    There is no defi nite correlation between biologic age and
    chronologic age. In patients who maintain aerobic fi tness,
    there may be no changes in cardiac output until well into
    the seventh decade. Physical fi tness will even decrease
    osteoporosis and may cause a decrease in the incidence of
    hip fractures. Patients who do not maintain aerobic fi tness
    may show signs of osteroporosis and decreases in cardiac
    output that make them biologically older than those who
    do. Geriatric patients are arbitrarily defi ned as those over
    65 years of age.
    Source: Curry S.
75
Q

1812.Major anatomic changes seen in the cardiovascular
system in the elderly include
1. an increase in left ventricular wall thickness
2. myocardial fi brosis
3. valvular fi brocalcifi cations
4. loss of elasticity of the peripheral circulation

A
  1. Answer: E (All)
    Explanation:
    (Miller, 4/e. pp 2150 – 2151.)
    Explanation: All the listed changes are normal parts of the
    aging process. Atherosclerosis superimposed on these
    changes only exacerbates the decrease in cardiovascular
    function, particularly a decrease in cardiac output.
    Source: Curry S.
76
Q 
1813.Parkinson’s Disease is noted to include which of the
following clinical fi ndings?
1. Painful dystonias
2. On/Off phenomena (freezing)
3. Cognitive dysfunction
4. Tremors
A
  1. Answer: E (All)
77
Q
  1. An 85-year-old, 300-pound man underwent right upper
    lobectomy. Which of the following would be acceptable
    techniques to provide adequate postoperative pain relief?
  2. Cryoneurolysis of the right intercostal nerves at multiple
    levels
  3. Continuous segmental epidural analgesia with local
    anesthetic
  4. Intercostal blocks with long-acting local anesthetic on
    the right at multiple levels
  5. Intercostal blocks with long-acting local anesthetic bilaterally
    at multiple levels
A
  1. Answer: A (1, 2, & 3)
    Explanation:
    (Capan, p 691.)
    In elderly patients with high body mass
    indices, bilateral intercostal nerve blocks at T5-T11 were
    found to change the relationship between closing capacity
    and functional residual capacity, leading to hypoxemia and
    hypercarbia. This did not occur in younger patients with
    normal body mass indices. Cyroneurolysis, unilateral
    intercostal nerve blocks, and epidural analgesia are
    acceptable techniques for providing postoperative
    analgesia and decreasing pulmonary dysfunction.
    Source: Kahn and Desio
78
Q
  1. In the elderly population
  2. Cold pressor response is decreased
  3. Nociceptors demonstrate increased sensitivity
  4. Cutaneous electrical current threshold decreases
  5. Mechanical pressure threshold decreases
A
  1. Answer: E (All)
79
Q

1816.Your suspect that your elderly patient is being abused
by a family caregiver. To assess this risk, the element
evaluated include:
1. Stress
2. Alcoholism
3. Violence
4. Driving

A
  1. Answer: A (1, 2, & 3)

Source: Arch Phys Med Rehabil Vol 85, Suppl 3, July 2004

RIZZLE Pain Medicine Board Review (35 decks)

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