Chapter 20 - Older Adult

Question 1

Which of the following changes are expected in vision as part of the normal aging process?

A) Cataracts
B) Glaucoma
C) Macular degeneration
D) Blurring of near vision

Answer 1

Ans: D
Chapter: 20
Page and Header: 918, Techniques of Examination
Feedback: The lens loses its elasticity over time as part of the normal aging process, and the eye is less able to accommodate and focus on near objects; therefore, the patient will be expected to have blurring of near vision.

Question 2

A 72-year-old retired truck driver comes to the clinic with his wife for evaluation of hearing loss. He has noticed some decreased ability to hear what his wife and grandchildren are saying to him. He admits to lip-reading more. He has a history of noise exposure in his young adult years: He worked as a sound engineer at a local arena and had to attend a lot of concerts. Based on this information, what is the most likely finding regarding his hearing acuity?

A) Loss of acuity for middle-range sounds
B) Increase of acuity for low-range sounds
C) Loss of acuity for high-range sounds
D) Increase of acuity for high-range sounds

Answer 2

Ans: A
Chapter: 20
Page and Header: 896, Anatomy and Physiology
Feedback: Human speech is considered to be a middle-range sound. During the aging process there is a loss of acuity, starting with high-pitched sounds but extending to the middle range and then into the low range.

Question 3

A 79-year-old retired banker comes to your office for evaluation of difficulty with urination; he gets up five to six times per night to urinate and has to go at least that often in the daytime. He does not feel as if his bladder empties completely; the strength of the urinary stream is diminished. He denies dysuria or hematuria. This problem has been present for several years but has worsened over the last 8 months. You palpate his prostate. What is your expected physical examination finding, based on this description?

A) Normal size, smooth
B) Normal size, boggy
C) Enlarged size, smooth
D) Enlarged size, boggy

Answer 3

Ans: C
Chapter: 20
Page and Header: 899, Anatomy and Physiology
Feedback: This is the expected physical examination finding in benign prostatic hyperplasia (BPH).

Question 4

A 70-year-old retired auto mechanic comes to your office because his neighbor is concerned about his memory. The patient himself admits to misplacing his keys more often and forgets what he is supposed to buy from the grocery store and where he has parked the car. He denies getting lost in familiar places. Upon further questioning, he states that his wife of 40 years died 8 months ago; his three children live in three different states; and he has limited his activities because the people he interacted with were “his wife’s friends, not his.” He drinks a six-pack of beer daily; he does not smoke or use illicit drugs. You perform a mini-mental state examination and obtain a total score of 24 out of 28. Based on this information, what is your most likely diagnosis?

A) Benign forgetfulness
B) Dementia
C) Meningitis
D) Depression

Answer 4

Ans: D
Chapter: 20
Page and Header: 911, Health Promotion and Counseling
Feedback: The patient has symptoms of depression: His wife died, he has no real social support system, and he has isolated himself from his usual activities. He also drinks a considerable amount of alcohol on a daily basis, which can further depress his mood. Depression can masquerade as dementia in the elderly and must be considered in a patient with memory loss.

Question 5

An 85-year-old retired teacher comes to your office for evaluation of weakness. You obtain a complete history, perform a thorough physical examination, and order laboratory tests. You diagnose her with hyperthyroidism. Based on her age, which of the atypical symptoms of hyperthyroidism is more likely to be seen?

A) Fatigue
B) Weight loss
C) Tachycardia
D) Anorexia

Answer 5

Ans: D
Chapter: 20
Page and Header: 903, The Health History
Feedback: This is an atypical symptom of hyperthyroidism that is more likely to be seen in the older patient.

Question 6

A 78-year-old retired seamstress comes to the office for a routine check-up. You obtain an ECG (electrocardiogram) because of her history of hypertension. You diagnose a previous myocardial infarction and ask her if she had any symptoms related to this. Which of the following symptoms would be more common in this patient’s age group for an acute myocardial infarction?

A) Chest pain
B) Syncope
C) Pain radiating into the left arm
D) Pain radiating into the jaw

Answer 6

Ans: B
Chapter: 20
Page and Header: 903, The Health History
Feedback: This is an atypical symptom and more likely to be seen in this patient’s age group.

Question 7

An 88-year-old retired piano teacher comes for evaluation of fatigue. You notice that her clothes are hanging loosely off her frame and that she has lost 15 pounds. She is unaware of this. Her husband of 63 years died a few months ago. You ask the patient to complete a Rapid Screen for Dietary Intake. Which of the following statements is considered to be part of this rapid screen?

A) I eat more than two meals per day.
B) I drink one glass of alcohol every day.
C) Without wanting to, I have lost or gained 10 pounds in the last 6 months.
D) I eat with at least one other person most of the time.

Answer 7

Ans: C
Chapter: 20
Page and Header: 906, The Health History
Feedback: This is part of the Rapid Screen for Dietary Intake.

Question 8

An 89-year-old retired school principal comes for an annual check-up. She would like to know whether or not she should undergo a screening colonoscopy. She has never done this before. Which of the following factors should not be considered when discussing whether she should go for this screening test?

A) Life expectancy
B) Time interval until benefit from screening accrues
C) Patient preference
D) Current age of patient

Answer 8

Ans: D
Chapter: 20
Page and Header: 909, Health Promotion and Counseling
Feedback: The current age of the patient is not as important as her actual life expectancy and current health status.

Question 9

Which of the following booster immunizations is recommended in the older adult population?

A) Tetanus
B) Diphtheria
C) Measles
D) Mumps

Answer 9

Ans: A
Chapter: 20
Page and Header: 909, Health Promotion and Counseling
Feedback: Older adults who have received the primary series of three tetanus immunizations should receive the single booster dose of tetanus immunization every 10 years.

Question 10

You are asked to perform a home safety assessment for an 87-year-old retired farmer who lives by himself. Which of the following is not considered to be an increased risk for falls?

A) Loose electrical cords
B) Slippery or irregular surfaces
C) Chairs at awkward angles
D) Bright lighting

Answer 10

Ans: D
Chapter: 20
Page and Header: 911, Health Promotion and Counseling
Feedback: Bright lighting is a recommendation to improve an older person’s ability to see all possible things that could result in a fall.

Question 11

A 73-year-old retired accountant comes to your office for her annual examination. She has incontinence of urine when she coughs or sneezes. She takes several medications for control of hypertension and diabetes. You use the DIAPERS mnemonic to assess the cause of her incontinence. All of the following are items represented by the mnemonic except for:

A) Atrophic vaginitis
B) Depression
C) Pharmaceuticals
D) Restricted mobility

Answer 11

Ans: B
Chapter: 20
Page and Header: 913, Techniques of Examination
Feedback: Depression is not a risk factor for incontinence. The D in the mnemonic stands for delirium.

Question 12

Which of the following brief screening measures is useful in assessing memory?

A) Three-item recall
B) Serial 7s
C) Spelling “world” backward
D) Copying intersecting pentagrams

Answer 12

Ans: A
Chapter: 20
Page and Header: 913, Techniques of Examination
Feedback: If the patient is unable to remember three items after 1 minute has passed, then this is a positive screening test and indicates a need for further testing. This is part of the “10-Minute Geriatric Screener.”

Question 13

Which of the following questions is part of the screening for physical disability?

A) Are you able to go shopping for groceries or clothes?
B) Are you able to walk one block?
C) Are you able to pass the driver’s license test?
D) Are you able to perform light dusting and pick up after yourself around the house?

Answer 13

Ans: A
Chapter: 20
Page and Header: 914, Techniques of Examination
Feedback: This is part of the Physical Disability screening portion of the 10-Minute Geriatric Screener.

Question 14

It is summer and an 82-year-old woman is brought to you from her home after seeing her primary care doctor 2 days ago. She was started on an antibiotic at that time. Today, she comes to the emergency room not knowing where she is or what year it is. What could be a likely cause of this?

A) Alzheimer’s dementia
B) Stroke
C) Delirium
D) Meningitis

Answer 14

Ans: C
Chapter: 20
Page and Header: 931, Table 20-2
Feedback: These are not signs of normal aging and seem to be of acute onset. This makes Alzheimer’s less likely. Stroke and meningitis could cause these symptoms as well, but the combination of the heat and a recent infection make delirium much more likely. Though she was prescribed an antibiotic, she may not have improved because of bacterial resistance or because of noncompliance due to cost, depression, or even an underlying mild dementia. Dementia should not result in an acute mental status change, although illness may cause a worsening of dementia.

Question 15

Blood pressure abnormalities found more commonly in Western elderly include which of the following?

A) Isolated elevation of the diastolic BP
B) Narrow pulse pressure
C) Elevation of the systolic BP
D) Elevation of the BP with standing

Answer 15

Ans: C
Chapter: 20
Page and Header: 895, Anatomy and Physiology
Feedback: Isolated systolic hypertension is common in the elderly because of stiffening of the large arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP changes are often seen with postural changes and can account for falls as well.

Question 16

Which of the following represents age-related changes in the lungs?

A) Decrease in chest wall compliance
B) Speed of expiration increases
C) Increase in respiratory muscle strength
D) Increased elastic recoil of lung tissue

Answer 16

Ans: A
Chapter: 20
Page and Header: 897, Anatomy and Physiology
Feedback: The lungs age along with the rest of the body. These changes include decreased lung and chest wall compliance, increased expiratory time, decreased muscle strength and cough, and decreased elastic recoil.

Question 17

Mrs. Stanton is a 79-year-old widow who presents to your office for a routine BP visit. You note a new pulsatile mass in the right neck at the carotid artery. Which of the following is the most likely cause for this?

A) Anxiety
B) Carotid artery aneurysm
C) Kinking of the artery
D) Tortuous aorta

Answer 17

Ans: C
Chapter: 20
Page and Header: 897, Anatomy and Physiology
Feedback: While a carotid artery aneurysm is a possibility, it is more likely due to kinking of the carotid artery in this patient with HTN. A tortuous aorta will sometimes cause elevation of the left jugular vein by impairing drainage within the thorax.

Question 18

Mr. Chin is an 82-year-old man who comes to your office for a routine check. On examination, you notice a somewhat high-pitched murmur in the second right intercostal space during systole. It does not radiate and the rest of his examination is normal for his age. Which is true of the most likely cause of this murmur?

A) It often decreases carotid upstroke.
B) It carries with it increased risk for cardiovascular disease.
C) It is usually accompanied by an S3 gallop.
D) It is found in 10% of otherwise normal elderly patients.

Answer 18

Ans: B
Chapter: 20
Page and Header: 898, Anatomy and Physiology
Feedback: This murmur most likely represents aortic sclerosis, a common murmur affecting about one third of those near 60 years of age. It is caused by calcification of the valve and is associated with cardiovascular risk. Aortic sclerosis does not usually cause obstruction to normal flow, so carotid upstroke should be normal, and it is not associated with an S3 gallop.

Question 19

Mrs. Buckley is a 75-year-old widow who wants you to look at her teeth because over the past 2 weeks she has had right-sided jaw pain when eating. It does not occur otherwise. She also has had a headache. Which of the following should be considered?

A) Palpation of her temples
B) Dental referral
C) Ultrasound of the gallbladder
D) Inquiry about anosmia

Answer 19

Ans: A
Chapter: 20
Page and Header: 898, Anatomy and Physiology
Feedback: This story can be consistent with temporal arteritis, which can cause blindness in 15% of those affected. Early recognition is crucial. Most of these patients will have tenderness over one or both of the temporal arteries, and some have diminished temporal pulses as well. Early treatment with corticosteroids is indicated. It can also be associated with polymyalgia rheumatic, a condition which causes pain in the shoulder girdles and pelvis.

Question 20

Which of the following is commonly seen in aging men?

A) Erectile dysfunction in 20% of all men
B) Testicles ride higher within the scrotum
C) Strong response to visual erotic cues
D) Persistent sexual interest

Answer 20

Ans: D
Chapter: 20
Page and Header: 899, Anatomy and Physiology
Feedback: Erectile dysfunction affects about half of elderly men but sexual interest generally remains intact. A decrease in sexual interest may indicate other problems such as depression. Visual cues become less important and tactile stimulation more important. The testicles are positioned lower in the scrotum.

Question 21

Which of the following accompanies decreased ovarian function?

A) Increased sleep
B) Diminution of sexual interest
C) Enlargement of the clitoris
D) Decrease in vaginal secretions

Answer 21

Ans: D
Chapter: 20
Page and Header: 899, Anatomy and Physiology
Feedback: Menopause, or the cessation of menses for 1 year, commonly occurs in the late 40s to early 50s. Many experience hot flashes, sweating, chills, anxiety, decreased sleep, and urge incontinence. Dyspareunia is common secondary to decreased vaginal secretions. Sexual interest does not normally decrease. The clitoris and length of the vaginal vault decrease in response to decreased estrogen.

Question 22

You are examining an elderly man and notice the following: decreased vibration sense in the feet and ankles, diminished gag reflex, right patellar reflex less than the left, and diminished abdominal reflexes. Which of these is abnormal?

A) Decreased vibration sense
B) Diminished gag reflex
C) Diminished right patellar reflex compared to the left
D) Diminished abdominal reflexes

Answer 22

Ans: C
Chapter: 20
Page and Header: 901, Anatomy and Physiology
Feedback: Asymmetry on any examination is usually reason for concern. The other changes are commonly associated with aging. You may consider looking for other neurologic signs on the right, although occasionally you may mistake an abnormally brisk reflex to be normal when compared to the other side. It is usually a good idea to question whether the opposite side is actually the abnormal one when you find asymmetry on examination.

Question 23

Mrs. Glynn is 90 years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living?

A) Bathing
B) Dressing
C) Preparing food
D) Transferring from bed to chair

Answer 23

Ans: C
Chapter: 20
Page and Header: 906, The Health History
Feedback: Instrumental activities of daily living involve higher thought processes such as preparing food, whereas bathing, dressing, and transferring are considered physical activities of daily living.

Question 24

Mr. Kelly comes to you today for a burning pain in his lower abdomen. This has gone on for 2 months. He has received radiation for prostatic cancer for the past quarter. What assumptions could you draw from this?

A) This represents persistent pain.
B) His pain reporting is likely to be unreliable.
C) There are “red flags” present.
D) He is depressed.

Answer 24

Ans: C
Chapter: 20
Page and Header: 906, The Health History
Feedback: This scenario is consistent with acute pain, although this may become persistent if it lasts beyond 3 months. The burning quality to the pain should be a red flag, along with descriptions of pain as “discomfort” or “soreness.” Depressed affect or changes in posture or gait are also red flags. Studies have found that pain reporting in the elderly is accurate. Although depression may be present, we have no indications of it in this scenario.

Question 25

Mr. White’s son brings him in today because he notes that Mr. White has not been himself lately. He seems forgetful and has not taken care of himself as he normally does. He has reported falling twice at home to his son and has telephoned late at night because of insomnia. His blood pressure and diabetes have been difficult to control and his warfarin dosing has become more difficult. Which of the following should you suspect?

A) Alzheimer’s dementia
B) Alcohol use
C) Urinary tract infection
D) Stroke

Answer 25

Ans: B
Chapter: 20
Page and Header: 908, The Health History
Feedback: All of these answers are common diseases of the elderly and many have atypical presentations in this age group. The fact that his hypertension has become more difficult to control and his warfarin dosing is challenging to manage should lead you to consider that there is alcohol use. Further questioning, quantifying his use of alcohol, and application of the CAGE questionnaire may be useful.

Question 26

Claire’s daughter brings her in today after Claire fell at her home. Which assessments are indicated at this time?

A) Orthostatic vital signs
B) Review of her medications
C) Assessment of gait and balance
D) All of the above

Answer 26

Ans: D
Chapter: 20
Page and Header: 913, Techniques of Examination
Feedback: Falls are common in the elderly and can often result in serious injuries. When assessing the cause of falls, gait and balance should be checked first. Medication, particularly use of more than three, is associated with falls. Vision problems, lower-limb joint problems, and cardiovascular problems such as arrhythmias may be reasonable to search for. Orthostatic vital sign changes should be sought.

Question 27

Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar aspects of her forearms and on her abdomen. She otherwise has no complaints and her diabetes and hypertension are well managed. Her son from out of state accompanies her today and has recently moved in to help her. What should you suspect?

A) Overuse of aspirin
B) Frequent falls
C) Elder abuse
D) Depression

Answer 27

Ans: C
Chapter: 20
Page and Header: 912, Health Promotion and Counseling
Feedback: The different colors of the bruising indicate that they have occurred at different times and are unlikely to have resulted from a single fall. The location of the bruising on the ulnar aspects of the forearms potentially indicates that she was trying to defend herself and are not typical areas to be bruised by a fall. Depression may be evident, but this is more likely to be a result rather than a cause of her situation today. While nothing is proven, it would be wise to interview her without her son in the room. If in doubt, a social worker consult may be helpful to determine if elder abuse is occurring.

Question 28

A patient comes to you for the appearance of red patches on his forearms that have been present for several months. They remain for several weeks. He denies a history of trauma. Which of the following is likely?

A) Actinic keratoses
B) Pseudoscars
C) Actinic purpura
D) Cherry angiomas

Answer 28

Ans: C
Chapter: 20
Page and Header: 917, Techniques of Examination
Feedback: Actinic purpura is a common benign skin condition of the elderly, frequently involving the forearms. Pseudoscars are white patches and cherry angiomas are bright-red raised lesions usually found on the torso. Actinic keratoses are lesions resembling nevi, often with features which would be concerning if considering melanoma (review the ABCDEs of melanoma), but they produce a slightly greasy scale when scratched with a nail.

Question 29

On routine screening you notice that the cup-to-disc ratio of the patient’s right eye is 1:2. What ocular condition should you suspect?

A) Macular degeneration
B) Diabetic retinopathy
C) Hypertensive retinopathy
D) Glaucoma

Answer 29

Ans: D
Chapter: 20
Page and Header: 918, Techniques of Examination
Feedback: This cup-to-disc ratio means that the cup takes up 50% of the disc, which is abnormally large. This is usually an indication of glaucoma, which is a common cause of visual loss in the elderly. The cup-to-disc changes are not seen in diabetes, hypertension, or macular degeneration. Many elderly do not have regular eye examinations and are not screened for glaucoma.

Question 30

Which of the following is true of assessment of the vascular system in the elderly?

A) Fewer than one third of patients with peripheral vascular disease have symptoms of claudication.
B) An aortic width of 2.5 cm is abnormal.
C) Bruits are commonly benign findings.
D) Orthostatic blood pressure and pulse are not useful in this population.

Answer 30

Ans: A
Chapter: 20
Page and Header: 921, Techniques of Examination
Feedback: It is the minority of patients with peripheral vascular disease who experience claudication; therefore, ankle–brachial ratios should be performed more frequently. The aorta should be 3 cm or less. Bruits usually indicate pathology, and even when there is not a significant blockage, the risk of vascular disease throughout the body is increased. Orthostatic vital signs are very useful in this population. Remember to observe the pulse as well, as failure of the heart to increase its rate is a common cause of orthostatic hypotension. This can occur as a result of autonomic neuropathy or medications such as beta-blockers, among other causes.