GERIATRICS 2

Question 1

PATIENT CASE:
Date: February 17, 2022
Initials
LE
Age
88 years of age
Sex
F
Race/Ethnicity
Caucasian
Source
Electronic medical records
Chief Complaint/History of Present Illness (CC/HPI) (including symptom analysis for CC):
LE and her husband have transferred care to the skilled nursing facility (SNF) from home. Their two
daughters aided with care at home. LE can answer direct questions but is an unreliable historian due to
dementia. She reports that pain keeps her from moving very much.
Past Medical History (major illnesses and surgeries):
Dementia, breast cancer, osteoporosis, depression/anxiety, hypertension (HTN), orthostatic hypotension,
hyperlipidemia (HLD), deep vein thrombosis (DVT), osteoarthritis, Vitamin D deficiency, h/o femur fracture,
h/o falls, pressure ulcer of sacrum
Current Prescription/Over‐the‐counter Medications/Complementary and Alternative Medicine
Start Date Drug Name/Strength/Regimen Indication
Feb 17 Apixaban 5 mg orally twice daily DVT
Feb 17 Buspirone 5 mg orally twice daily Anxiety
Feb 17 Calcium‐vitamin D 600 g/200 orally three times daily Osteoporosis
Feb 17 Cholecalciferol 2000 IU orally once daily Vitamin D deficiency
Feb 17 Escitalopram 5 mg orally once daily Depression
Feb 17 Gabapentin 300 mg orally in morning and at noon, and 600 mg orally
daily at bedtime
Anxiety
Feb 17 Lorazepam 0.5 mg orally twice daily and every 6 hr as needed Anxiety
Feb 17 Tramadol 50 mg orally every 8 hr as needed Pain
Feb 17 PEG 3350 17 g orally once daily in 8 oz liquid Constipation
Feb 17 Simvastatin 20 mg orally daily at bedtime HLD
Feb 17 Turmeric 1000 mg orally once daily Antioxidant
Immunizations: Influenza Fall 2021; Pneumovax 2013; COVID 2021
RX Payment: Medicare Part D Meds Admin by: nursing staff
Drug Allergies/Adverse Effects: Sulfa
Family Medical History: Non‐contributory
Social History Occupation:
Homemaker
No alcohol, tobacco, or illicit drugs
Review of Systems Unable to obtain due to mentation
Objective Vital signs: Pulse 64 bpm and regular, BP 122/71 mm Hg, Temp 98.2 °F,
Ht 5’1”, Wt 109 lb
Physical Exam: Appropriate for age except for stiff lower extremities and a
round unstageable sacral ulcer with significant pain

Question 1:
Which characteristic or condition for LE is present in about 10% of adults over age 85?
A. Female
B. Dementia
C. Loss of mobility
D. Moving into a nursing home

Answer 1

1. Correct answer = D. Living in a nursing home
   According to the U.S. Census Bureau, of the population >85 years of age, 10.6% live in group settings like nursing
   homes. The ratio of men to women ranges from 53 to 79 men per 100 women for 2016 depending upon the age
   category. For 85 years of age and older, the ratio of men to women is 53, which means that women form 65% of
   this population. Only 23% of the population over 85 years of age identifies dementia as a significant limiting
   characteristic; 48% indicate ambulation as a disability.
   (BCGP Outline 1 A)

Question 2

Question 2:
Which problems in LE are most associated with normal aging?
A. Dementia and depression
B. Orthostatic hypotension and constipation
C. Vitamin D deficiency and falls
D. Osteoporosis and osteoarthritis

Answer 2

2. Correct answer = B. Orthostatic hypotension and constipation
   The other answers identify conditions that are common in older adults, occurring in 30‐50% of individuals in those
   over 80 years of age. However, stiffening of the arteries coupled with reduced baroreceptor response is a
   universal, normal change seen with aging that contributes to orthostatic hypotension. Likewise, diminished
   peristalsis is a normal change in aging which contributes to constipation.
   (BCGP Outline 1 A)

Question 3

Chemistry
Na 137 mEq/L
K 3.7 mEq/L
BUN 30 mg/dL
Creatinine 1.5 mg/dL

Lipid Panel
Total cholesterol 190 mg/dL
HDL 83 mg/dL
TG 58 mg/dL
LDL calculated 95 mg/dL

Other Vitamin D 22 ng/mL
Vitamin B12 1063 pg/mL
Thyroid‐stimulating hormone 5.49 milliunits/L

Question 3:
Which of LE’s medications should have a dose adjustment because of her renal function?
A. Buspirone, escitalopram
B. Gabapentin, simvastatin
C. Gabapentin, tramadol
D. Buspirone, lorazepam

Answer 3

3. Correct answer = C. Gabapentin, tramadol
   Gabapentin and tramadol are eliminated renally to some extent, which requires dose adjustment in patients with a
   lower creatinine clearance like LE. The other drug choices are not substantially eliminated renally.
   (BCGP Outline 1 A B.; 2 B. I)

Question 4

PATIENT CASE:
Date: February 17, 2022
Initials
LE
Age
88 years of age
Sex
F
Race/Ethnicity
Caucasian
Source
Electronic medical records
Chief Complaint/History of Present Illness (CC/HPI) (including symptom analysis for CC):
LE and her husband have transferred care to the skilled nursing facility (SNF) from home. Their two
daughters aided with care at home. LE can answer direct questions but is an unreliable historian due to
dementia. She reports that pain keeps her from moving very much.
Past Medical History (major illnesses and surgeries):
Dementia, breast cancer, osteoporosis, depression/anxiety, hypertension (HTN), orthostatic hypotension,
hyperlipidemia (HLD), deep vein thrombosis (DVT), osteoarthritis, Vitamin D deficiency, h/o femur fracture,
h/o falls, pressure ulcer of sacrum
Current Prescription/Over‐the‐counter Medications/Complementary and Alternative Medicine
Start Date Drug Name/Strength/Regimen Indication
Feb 17 Apixaban 5 mg orally twice daily DVT
Feb 17 Buspirone 5 mg orally twice daily Anxiety
Feb 17 Calcium‐vitamin D 600 g/200 orally three times daily Osteoporosis
Feb 17 Cholecalciferol 2000 IU orally once daily Vitamin D deficiency
Feb 17 Escitalopram 5 mg orally once daily Depression
Feb 17 Gabapentin 300 mg orally in morning and at noon, and 600 mg orally
daily at bedtime
Anxiety
Feb 17 Lorazepam 0.5 mg orally twice daily and every 6 hr as needed Anxiety
Feb 17 Tramadol 50 mg orally every 8 hr as needed Pain
Feb 17 PEG 3350 17 g orally once daily in 8 oz liquid Constipation
Feb 17 Simvastatin 20 mg orally daily at bedtime HLD
Feb 17 Turmeric 1000 mg orally once daily Antioxidant
Immunizations: Influenza Fall 2021; Pneumovax 2013; COVID 2021
RX Payment: Medicare Part D Meds Admin by: nursing staff
Drug Allergies/Adverse Effects: Sulfa
Family Medical History: Non‐contributory
Social History Occupation:
Homemaker
No alcohol, tobacco, or illicit drugs
Review of Systems Unable to obtain due to mentation
Objective Vital signs: Pulse 64 bpm and regular, BP 122/71 mm Hg, Temp 98.2 °F,
Ht 5’1”, Wt 109 lb
Physical Exam: Appropriate for age except for stiff lower extremities and a
round unstageable sacral ulcer with significant pain

Question 4:
Which of LE’s medications should have a dose adjustment because of increased pharmacodynamic sensitivity
associated with aging?
A. Buspirone, gabapentin
B. Buspirone, escitalopram
C. Apixaban, simvastatin
D. Lorazepam, tramadol

Answer 4

4. Correct answer = D. Lorazepam, tramadol
   Older adults are most sensitive to benzodiazepines and opioids such that they are listed as medications to avoid in
   older adults on the Beers Criteria. This increased sensitivity is despite dose adjustments that may be done to
   address pharmacokinetic changes seen with aging.
   (BCGP Outline 2 B. I)

Question 5

PATIENT CASE – 1 month later:
Vital Signs
 Pulse 68 bpm and regular; BP 132/76 mm Hg; Temp 98.4 °F
 Ht 5’1” ; Wt 98 lb
Physical exam is unchanged except that sacral ulcer is cleaned and dressed.
Current Medications (changes noted in bold)
Apixaban 5 mg orally twice daily
Ascorbic acid 500 mg orally twice daily
Buspirone 5 mg orally twice daily
Calcium‐vitamin D 600/200 orally three times daily
Cholecalciferol 2000 IU orally once daily
Escitalopram 5 mg orally once daily
Gabapentin 300 mg orally in morning and 600 mg orally daily at bedtime
Liquid protein 30 mL orally twice daily
Lorazepam 0.5 mg orally twice daily and every 6 hr as needed
Tramadol 50 mg orally every 12 hr as needed for pain
PEG 3350 17 g orally once daily in 8 oz liquid
Simvastatin 20 mg orally daily at bedtime
Turmeric 1000 mg orally once daily
Zinc 220 mg orally once daily

Question 5:
Which medication change is best to treat LE’s frailty?
A. Change simvastatin to pravastatin 20 mg orally daily at bedtime.
B. Increase cholecalciferol to 4000 IU once daily.
C. Add mirtazapine 7.5 mg orally daily at bedtime.
D. Discontinue simvastatin and tramadol.

Answer 5

5. Correct answer = D. Discontinue simvastatin and tramadol.
   The primary medication adjustments recommended in patients with frailty are to ensure that doses are adjusted
   correctly for reduced body weight and pharmacokinetics. In addition, discontinuing unnecessary medications
   which could impact function and increase risk of falls is recommended. Stopping simvastatin to reduce risk for
   muscle aches and stopping the as‐needed tramadol at a higher‐than‐recommended dose for her renal function and
   with the number of serotonin drugs on her list is indicated to reduce LE’s risk for adverse effects. While ACEIs have
   some evidence for benefit in frailty, the evidence is weak and it is likely that similar effects could be seen with
   angiotensin receptor blocking drugs. Since LE’s vitamin D level is >20, she would not benefit from increasing her
   oral intake. Adding mirtazapine may increase appetite, but it has not been shown to improve outcomes in older
   adults or frailty.
   (BCGP Outline 1 A A; 2 A A; 2 A M)

Question 6

PATIENT CASE (cont’d):
LE experiences a fall and is transferred to the hospital. After 1 week of hospitalization, she is ready for discharge
back to the SNF. Her discharge summary indicates she had 2 broken ribs and delirium for 4 days. Her family is
requesting she receive physical therapy.

Question 6:
Which venue of care is most appropriate for LE at this time?
A. Acute rehabilitation at hospital prior to transfer to nursing home
B. Weekly visit from nursing home to physical therapy clinic
C. Skilled nursing sub‐acute rehabilitation at nursing home
D. Long‐term care with full nursing assistance

Answer 6

6. Correct answer = C. Skilled nursing sub‐acute rehabilitation at nursing home
   If LE can recover function lost during her hospitalization, it is important to attempt physical therapy to help her get
   back to her baseline functioning. Because LE is unlikely to be able to tolerate 3 hours per day of therapy, an acute
   rehabilitation unit would not be appropriate for her. Skilled nursing sub‐acute rehabilitation is usually provided in a
   nursing home, so LE could have the support she needs while trying to regain her function.
   (BCG Outline 3 A A)

Question 7

PATIENT CASE (cont’d):
 Despite two weeks of subacute rehabilitation, LE was unable to regain her previous function and cannot walk without assistance.  Two weeks later, her husband was transferred to the hospital and died from heart failure.
 LE began to stay in her room and not socialize as she had previously. Multiple options to treat depression
were tried without success over the next three months.
 LE began to stay in bed all day and now is unable to assist with transfers.
 She no longer recognizes her family and repeats “Help me”; however, the staff are unable to identify
additional needs.
 She develops two additional pressure ulcers and refuses to eat.
 Her daughters come to discuss goals of care.
Current Medications (changes noted in bold)
Apixaban 5 mg orally twice daily
Ascorbic acid 500 mg orally twice daily
Buspirone 5 mg orally twice daily
Calcium‐vitamin D 600/200 orally three times daily
Cholecalciferol 2000 IU orally once daily
Escitalopram 10 mg orally once daily
Gabapentin 300 mg orally in morning and 600 mg orally daily at bedtime
Liquid protein 30 mL orally twice daily
Lorazepam 0.5 mg orally twice daily and every 6 hr as needed
Mirtazepine 15 mg orally daily at bedtime
PEG 3350 17 g orally once daily in 8 oz liquid
Turmeric 1000 mg orally once daily
Zinc 220 mg orally once daily

Question 7:
At a family conference, LE’s daughter asks what options are available for her mother’s care. What
recommendation is best to make?
A. Consult to hospice/palliative care.
B. Consult to geriatric psychiatry.
C. Return to the hospital for assessment.
D. Contact family members to come daily.

Answer 7

7. Correct answer = A. Consult to hospice/palliative care.
   Because LE has lost additional function and the social support of her husband, she is at a point where
   hospice/palliative care for symptom control is best for her. Geriatric psychiatry would not be able to provide for
   her ADLs and would unlikely be able to improve her mentation.
   (BCGP Outline 1 D A; 3 A A)

Question 8

PATIENT CASE (cont’d):
 Despite two weeks of subacute rehabilitation, LE was unable to regain her previous function and cannot walk without assistance.  Two weeks later, her husband was transferred to the hospital and died from heart failure.
 LE began to stay in her room and not socialize as she had previously. Multiple options to treat depression
were tried without success over the next three months.
 LE began to stay in bed all day and now is unable to assist with transfers.
 She no longer recognizes her family and repeats “Help me”; however, the staff are unable to identify
additional needs.
 She develops two additional pressure ulcers and refuses to eat.
 Her daughters come to discuss goals of care.
Current Medications (changes noted in bold)
Apixaban 5 mg orally twice daily
Ascorbic acid 500 mg orally twice daily
Buspirone 5 mg orally twice daily
Calcium‐vitamin D 600/200 orally three times daily
Cholecalciferol 2000 IU orally once daily
Escitalopram 10 mg orally once daily
Gabapentin 300 mg orally in morning and 600 mg orally daily at bedtime
Liquid protein 30 mL orally twice daily
Lorazepam 0.5 mg orally twice daily and every 6 hr as needed
Mirtazepine 15 mg orally daily at bedtime
PEG 3350 17 g orally once daily in 8 oz liquid
Turmeric 1000 mg orally once daily
Zinc 220 mg orally once daily

Question 7:
At a family conference, LE’s daughter asks what options are available for her mother’s care. What
recommendation is best to make?
A. Consult to hospice/palliative care.
B. Consult to geriatric psychiatry.
C. Return to the hospital for assessment.
D. Contact family members to come daily.