Geriatric/Palliative Flashcards
In frail elderly patients, starvation can be distinguished from cachexia by which one of the following? (check one)
An inflammatory response seen in starvation
A normal appetite in the early stages of cachexia
A rapid decrease in albumin in the early stages of starvation
A reversal of changes with refeeding in starvation
A reversal of changes with refeeding in starvation
In the frail elderly, it may be difficult to distinguish relative starvation due to decreased or inadequate caloric intake from cachexia, which is due to an inflammatory response with elevated cytokines. Appetite is decreased early in cases of cachexia but remains normal in the early stages of starvation. Likewise, albumin decreases early in cases of cachexia and later in starvation. Due to the inflammatory changes, cachexia is resistant to refeeding.
A patient with advanced dementia is bed-bound and requires total assistance with all activities of daily living. She was treated recently for pneumonia, which has raised concerns that she is aspirating. Her oral intake has decreased and is not adequate for the patient’s nutritional requirements. She does not have an advance directive. You schedule a family conference.
Which one of the following is your recommended approach to this problem? (check one)
Clear liquids
Intravenous fluids
Hand feeding
Percutaneous endoscopic gastrostomy (PEG) tube feeding
Nasogastric tube feeding
Hand feeding
The American Geriatrics Society (AGS) position statement on feeding tubes states that percutaneous feeding tubes are not recommended for older adults with advanced dementia, and that careful hand feeding should be offered instead. This is the first recommendation by the AGS in the Choosing Wisely campaign.
Careful hand feeding for patients with severe dementia is at least as good as tube feeding with regard to the outcomes of death, aspiration pneumonia, functional status, and patient comfort. Regular food is preferred. Tube feeding is associated with agitation, increased use of physical and chemical restraints, and worsening pressure ulcers.
The preponderance of evidence does not support the use of tube feedings, based upon expert opinion and extensive observational data. Published empirical work using observational data is highly consistent regarding the lack of efficacy for tube feeding in this population.
An 85-year-old male is brought to your office by his family because they are concerned that he may be depressed.
Which one of the following is most likely in a depressed patient in this age group? (check one)
Suicidal ideation
Somatic symptoms
Depressed mood
Preoccupation with guilt
Somatic symptoms
Somatic complaints are seen in up to two-thirds of primary care patients with depression, and are more likely in certain groups, including pregnant women, children, the elderly, and low-income groups.
A 77-year-old female is admitted to the critical care unit for acute respiratory failure and is on a ventilator for more than 48 hours. Stress ulcer prophylaxis is ordered.
This prophylaxis should be continued until (check one)
venous thromboembolism prophylaxis is stopped
the patient is transferred out of the critical care unit
the patient is discharged from the hospital
the patient is discharged from a skilled care or rehabilitation care facility
30 days after discharge from the hospital
the patient is transferred out of the critical care unit
Not all hospitalized patients need stress ulcer prophylaxis. Routine acid-suppression therapy to prevent stress ulcers has no benefit in hospitalized patients outside of the critical care setting. Only critically ill patients who meet specific criteria should receive this therapy. One indication for stress ulcer prophylaxis is prolonged mechanical ventilation for more than 48 hours. Hemodynamically stable patients admitted to general care floors should not receive stress ulcer prophylaxis, as it only decreases the rate of gastrointestinal bleeding from 0.33% to 0.22%. Furthermore, long-term proton pump inhibitor therapy has been associated with complications such as Clostridium difficile diarrhea and community-acquired pneumonia. Discontinuation of stress ulcer prophylaxis should be considered for this patient when she moves out of the critical care unit. It could also be considered when the patient is removed from the ventilator.
A 75-year-old male reports that his handwriting seems more “cramped,” he has started shuffling more as he walks, and he has been experiencing some difficulty turning over in bed, rising from a chair, and opening jars. He also reports increasing body stiffness and a resting tremor in his hand.
Given the stage of his disease, which one of the following options for initial medical management is supported by the best evidence? (check one)
Amantadine
Bromocriptine (Parlodel)
Benztropine
Carbidopa/levodopa (Sinemet)
Entacapone (Comtan)
Carbidopa/levodopa (Sinemet)
All of the drugs listed are used to treat motor symptoms in patients with Parkinson’s disease. However, the best evidence supports the use of carbidopa/levodopa, non-ergot dopamine agonists such as pramipexole or ropinirole, or monoamine oxidase-B inhibitors such as selegiline or rasagiline for initial management of patients with early disease (SOR A).
A disheveled 89-year-old male with dementia who relies on a caregiver for bathing, dressing, shopping, and meal preparation is brought in for continued evaluation of weight loss. No medical cause has been found at this point. On examination a large purplish bruise is noted over his posterior leg and a more faded greenish-yellow bruise is noted over his abdomen, which his caregiver explains by saying that he has fallen several times recently. The patient is also noted to have a large sacral decubitus ulcer.
Which one of the following should you suspect as the cause of bruising in this patient? (check one)
Senile purpura
Thrombocytopenia
Leukemia
Elder abuse
Cushing syndrome
Elder abuse
This patient has numerous red flags for elder abuse, including unexplained weight loss, reliance on a caregiver, a disheveled appearance, a pressure ulcer, and bruising in locations that are not typically associated with unintentional trauma from falls. Although the other listed causes of bruising are possible, in this scenario the index of suspicion should be highest for elder abuse.
An elderly male who has an implanted cardioverter-defibrillator is admitted to long-term care. He has several chronic comorbidities, including hypertension, a previous stroke, coronary artery disease, osteoarthritis, advanced chronic systolic heart failure, chronic kidney disease with a calculated glomerular filtration rate of 20 mL/min/1.73 m2, diabetes mellitus, and hypercholesterolemia.
The patient’s quality of life has declined to the point that he wishes to receive only palliative care. He does not want aggressive treatments, including hospitalization, except for reasons of comfort. He has decided he does not wish to be resuscitated, including CPR or intubation.
When considering his goals, and after consultation with the patient and his spouse, which one of the following would be most appropriate for managing his defibrillator? (check one)
Adjust the defibrillator to deliver shocks only for ventricular fibrillation
Adjust the defibrillator to deliver shocks only for a heart rate >140 beats/min
Remove the defibrillator generator
Deactivate the defibrillator
Make no change to the defibrillator
Deactivate the defibrillator
It is recommended that an implanted cardioverter-defibrillator be deactivated when it is inconsistent with the care goals of the patient and family. In about one-quarter of patients with an implanted cardioverter-defibrillator, the defibrillator delivers shocks in the weeks preceding death. For patients with advanced irreversible disease, defibrillator shocks rarely prevent death, may be painful, and are distressing to caregivers and family members. Advance care planning discussions should include the option of deactivating the implanted cardioverter-defibrillator when it no longer supports the patient’s goals.
Mild cognitive impairment is characterized by which one of the following? (check one)
Localized motor dysfunction
Impairment in at least one activity of daily living
Impairment in at least one instrumental activity of daily living
The presence of the APO E4 allele
Objective evidence of memory decline
Objective evidence of memory decline
Mild cognitive impairment is an intermediate stage between normal cognitive function and dementia. Motor function remains normal. The presence of the APO E4 allele is a risk factor, but is not necessary for a diagnosis. Patients have essentially normal functional activities but there is objective evidence of memory impairment, and the patient may express concerns about cognitive decline.
The Timed Up and Go test consists of a patient rising from a chair, walking 3 meters (or about 10 feet), turning around, walking back, and sitting back down. The average healthy adult over the age of 60 can perform this in how many seconds? (check one)
5
10
20
30
45
10
For the average adult over the age of 60, the normal time required for the Timed Up and Go test is 10 seconds. A time longer than 10 seconds may indicate weakness, a balance or gait problem, and/or an increased fall risk.
Which one of the following is considered first-line therapy for mild to moderate Alzheimer’s disease?
(check one)
Donepezil (Aricept)
Memantine (Namenda)
Selegiline (Eldepryl)
Risperidone (Risperdal)
Ginkgo biloba
Donepezil (Aricept)
Anticholinesterase inhibitors such as donepezil are considered first-line therapy for patients with mild to moderate Alzheimer’s disease (SOR A). Memantine is an NMDA receptor antagonist and is often used in combination with anticholinesterase inhibitors for moderate to severe Alzheimer’s disease, but it has not been shown to be effective as a single agent for patients with mild to moderate disease. There is not enough evidence to support the use of selegiline, a monoamine oxidase type B inhibitor, in the treatment of Alzheimer’s disease. Risperidone and other antipsychotic medications are not approved by the Food and Drug Administration for treatment of Alzheimer’s disease, but can sometimes be helpful in controlling associated behavioral symptoms. Studies of ginkgo biloba extract have not shown a consistent, clinically significant benefit in persons with Alzheimer’s disease.
Which one of the following activities is most likely to be impaired in early dementia?
(check one) Dressing Eating Toileting Grooming Cooking
Cooking
Basic activities of daily living, such as dressing, eating, toileting, and grooming, are generally intact in early dementia. In contrast, instrumental activities of daily living, such as managing money and medications, shopping, cooking, housekeeping, and transportation, which often require calculation or planning, are frequently impaired in early dementia.
A 72-year-old female with a history of hypertension, previous stroke with no residual deficits, and mild cognitive impairment presents for an annual health maintenance examination. Her documented weight 6 months ago was 79 kg (174 lb) and her current weight is 73 kg (161 lb). She is sedentary and has not changed her diet.
Which one of the following is true about this patient’s condition? (check one)
It is associated with increased mortality
It is associated with a lower risk of cardiovascular disease
More than 50% of patients with this condition will be diagnosed with a malignancy
High-calorie dietary supplements are recommended as primary treatment
Medications do not contribute to her condition
It is associated with increased mortality
This patient has experienced a significant but unintentional weight loss of more than 5% in 6 months. Such weight loss has been associated with increased mortality in the elderly in several studies. An evaluation for etiology of the weight loss should be completed, including a history with a medication review and a physical examination, but many medical and psychiatric conditions are associated with unintentional weight loss. Unintentional weight loss is not associated with a lower risk of cardiovascular disease. About one-third of patients with unintentional weight loss will be diagnosed with a malignancy. In the Choosing Wisely campaign, the American Geriatrics Society recommended avoidance of high-calorie dietary supplements and appetite stimulants due to the lack of evidence that they improve quality of life or offer a survival benefit. A Cochrane review of supplements in elderly patients showed a small weight gain but no overall mortality benefit. Medications, including polypharmacy, can contribute to unintentional weight loss.
An 85-year-old male is admitted to a nursing home due to weakness, debility, and limitation of activities of daily living (ADLs) after being hospitalized for acute community-acquired pneumonia. He previously lived with his wife independently and his goal is to return home when he is strong enough. He has a history of coronary artery disease, type 2 diabetes mellitus controlled with diet, hypertension, and chronic diastolic heart failure, but he has no symptoms related to these chronic problems. His appetite is poor and he has lost a significant amount of weight. His admission diet order from the hospital was a cardiac diet.
Which one of the following would be the most appropriate diet for this patient?
(check one)
A regular diet
An American Heart Association diet
A diet with no added salt
An 1800-calorie/day American Diabetes Association diet
A diet with no concentrated sweets
A regular diet
This patient should be provided with a regular diet, which may promote weight gain in nursing-home residents with unintentional weight loss. Malnutrition and unintentional weight loss are significant problems in nursing-home residents and lead to multiple complications, including pressure ulcers and infections. The American Dietetic Association recommends liberalizing diets to improve nutritional status and quality of life in older adults. A small study demonstrated equivalent glycemic control in nursing-home residents who ate a regular diet compared to those who ate a restricted American Diabetes Association diet (SOR C). Low-salt and low-cholesterol diets are unpalatable and are often associated with protein-energy malnutrition and postural hypotension in older persons. Special diets should be avoided whenever possible in nursing-home patients.
You are the attending physician at a long-term care facility. A new resident, an 85-year-old female, presents for an initial evaluation. Upon reviewing her history, you find that she is on 18 different medications. Until you can obtain additional history and medical records, you decide to stop or decrease some of her medications and monitor her response.
Which one of the following would be most appropriate to stop or decrease initially?
(check one)
Sertraline (Zoloft), 25 mg daily
Acetaminophen/diphenhydramine (Tylenol PM), 500 mg/25 mg daily
Dipyridamole/aspirin (Aggrenox), 200 mg/25 mg daily
Digoxin, 0.125 mg every other day
Omeprazole (Prilosec), 20 mg daily
Acetaminophen/diphenhydramine (Tylenol PM), 500 mg/25 mg daily
Polypharmacy is common in the elderly population, but the use of numerous medications is necessary in some elderly patients. However, some medications have been identified as having a considerably higher potential to cause problems when prescribed to elderly patients.
In the case described, acetaminophen/diphenhydramine would be an appropriate medication to stop initially. The older antihistamines cause many adverse CNS effects such as cognitive slowing and delirium in older patients. These effects are more pronounced in elderly patients with some degree of preexisting cognitive impairment. The anticholinergic properties of older antihistamines produce effects such as dry mouth, constipation, blurred vision, and drowsiness. The sedative effect of older antihistamines also increases the risk of falls. Hip fracture and subsequent death have been reported in patients who use older antihistamines such as diphenhydramine.
Sertraline is an SSRI, a preferred class for the treatment of depression in the elderly compared to the tricyclic antidepressants, which are associated with several side effects. Dipyridamole is associated with hypotension in elderly patients, but it benefits some individuals by preventing strokes. It can be used in the elderly, but patients should be monitored for side effects. Therefore, until further information is obtained, it is appropriate to continue the dipyridamole/aspirin in this patient.
When used in elderly patients with heart failure, digoxin should be given in a dosage no greater than 0.125 mg daily; the low dosage used in this individual should not be considered inappropriate until the reason for its use is clarified. While omeprazole can cause problems in the elderly with long-term use, 20 mg/day is a relatively low dose and the decision to discontinue its use should be delayed until more history is available.
Total parenteral nutrition is most appropriate for patients: (check one)
With poorly functioning gastrointestinal tracts who cannot tolerate enteral feeding
Who cannot swallow because of an esophageal motility problem
Who refuse to eat
In whom maintenance nutrition is desired for a short period following recovery from surgery
With poorly functioning gastrointestinal tracts who cannot tolerate enteral feeding
Total parenteral nutrition (TPN) is indicated for patients with poorly functioning gastrointestinal tracts who cannot tolerate other means of nutritional support and for those with high caloric requirements that cannot otherwise be met. Patients who cannot swallow because of an esophageal motility problem and those who are resistant to feeding can be managed with tube feedings. Peripheral alimentation, which provides fewer calories than TPN or liquid tube feedings, would be more appropriate over the short term in patients recovering from surgery.
