Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

*GERIATRICS > geriatrics final > Flashcards

geriatrics final Flashcards

1
Q

in 2000, our Life expectancy is ~__ years

A

75 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

main causes of death now

A

Heart disease, cancer, stroke, pneumonia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

main causes of death in 1900s

A

Trauma, infectious disease (TB, pneumonia), HD, stroke and cancer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

life expectancy in 1900s

A

55 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

currently does acute or chronic illness predominate?

A

chronic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

people lose ___% of renal mass by the age of 90

A

20-30%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

30-40% of geriatric patients fall in functioning glomeruli by age __

A

80

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Reduced blood flow is seen in up to___% of people by age 80

A

50%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

there is __% GFR loss with aging

A

50%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Geriatric Syndromes (5)

A

1.Sensory loss
o Hearing, vision

  1. Incontinence
  2. Balance and gait changes
4. Falls and fractures
o	Strength and balance
o	Vestibular function
o	Medication effects
o	Bone density
  1. Polypharmacy and drug interactions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Memory peaks in what age?

A

30s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Cognitive capacity is more than memory, it includes what three things?

A

o Visual-spatial perception
o Cognitive processing
o Sensory and motor dependent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Apparent Cognitive changes may reflect what three things?

A

3 D’S:

o Delirium: may be evidence of reduced cognitive reserves with fluctuations in level of consciousness
o Depression: bimodal distribution
o Dementia: final common pathway of many diseases but is not “normal”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Risk factors which increase vulnerability to infectious disease (14)

A
  1. Decreased PF and cough reflex
  2. Decreased gastric acidity and GI motility
  3. Atherosclerosis and reduced cap blood flow
  4. Thin, easily injured skin
  5. Reduced activity (motor and balance)
  6. Impaired host defense mechanisms
  7. Inadequate nutrition
  8. Lack of immunization
  9. Neuropsych disease and reduced MS
  10. Chronic medications
  11. Chronic diseases
  12. Previous exposures
  13. Hospitalizations and LTC facility
  14. Invasive devices (urinary and venous catheters)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Healthy aging occurs without ____ and _____.

A

functional impairment and disability

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Disability pathway results from the impact of what 4 things?

A

genetics, disease, lifestyle and behaviors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Risk factors for functional impairment

A

o Age, gender
o Obesity, exercise
o Chronic illnesses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what are Basic ADLs (6)

A 
o	Walking
o	Dressing
o	Eating
o	Bathing
o	Toilet
o	Transfer
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

what are Instrumental ADLs (6)

A 
o	Walking distances
o	Shopping
o	Cooking (food preparation)
o	Housekeeping
o	Using the phone
o	Managing finances
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

pt should get Tdap vaccination when/how often?

A

once at age 65

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

pt should get Td vaccination when/how often?

A

every 10 years

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

pt should get influenza vaccination when/how often?

A

yearly during flu season

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

pt should get Pneumococcal vaccination when/how often?

A

once after age 65

If <65 when received, and 5 years since shot, then give again at or after age 65

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

pt should get Prevnar 13 vaccination when/how often?

A

once at 65

At least 3 months after Polyvalent 23

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

pt should get Zostavax vaccination when/how often?

A

Once at 65 (or earlier)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Cancers for which we may screen older patients and how to screen for them (5)

A
  • Breast - mammogram
  • Cervical – pap test
  • Colon - colonoscopy
  • Prostate – PSA
  • Skin – physical exam
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Implementing Preventive Care and screening in older people- 4 questions to consider

A
  • Is the patient at risk for the disease?
  • Is it likely to have a proximate benefit?
    o Test performance
    o Post-test probability
  • What is the level of risk of the intervention?
    o Competing mortality
  • Is it consonant with patient values and preferences?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

what are 3 patient factors when considering CA screening in older patients

A

o Competing mortality and individual prognosis
o Patient beliefs, level of anxiety, preferences, ie. values
o Life expectancy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

4 Physiologic Changes in geriatric patients

A
  • Less body water more body fat
  • Less muscle mass
  • Decreased hepatic metabolism and renal excretion
  • Decreased responsiveness and sensitivity of the baroreceptor reflex
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Excretion changes in geriatric patients

A
  1. Reduced kidney clearance
    o 30-40% fall in functioning glomeruli by 80
    o 1% (at age 20) ->30% sclerotic glomeruli
  2. Serum creatinine not accurate predictor of renal function due to decreased muscle mass
    o Creatinine secretion reduced ~40%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Generally the elderly are more sensitive to drug effects, especially with what 2 drug classes?

A

o Anticholinergics

o Benzodiazepines

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Homeostasis is more effected by drugs because of what three things?

A

o Postural BP
o EPS
o Cognition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Risk Factors for Adverse Drug Events (6)

A
  • > 6 chronic disease states
  • > 12 doses/day
  • > 9 Medications
  • Low BMI (<22 kg/m2)
  • Creatinine clearance <50 mL/min
  • Female
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Adverse Drug Events are Linked to preventable problems in the elderly, such as? (6)

A 
o	Depression
o	Constipation
o	Falls
o	Immobility
o	Confusion
o	Hip fractures
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

what is Beers Criteria

A

o Medications that should generally be avoided because they are either ineffective or they pose a high risk
o Medications that should not be used in older persons known to have specific medical conditions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Beers Criteria: Anticholinergic Agents

what are the 3 drug Classes?

A

o Tricyclic antidepressants
o Antihistamines
o Antispasmodics and muscle relaxants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Beers Criteria: Anticholinergic Agents

what are adverse events with these medications?

A

o Urinary incontinence
o Constipation
o Confusion, delirium, behavior changes
o Exacerbation of dementia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Beers Criteria: Benzodiazepines

long acting and short acting adverse events

A

Long-acting
o Prolonged half-life in older adults (days)
o Sedation, cognitive impairment, depression
o Increased risk of falls and fractures (Haldol)

Short-acting
o Increased sensitivity in older adults
o If necessary, use lower doses

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

what are 2 Non-steroidal anti-inflammatory drugs (NSAIDS) that should be avoided completely?

A

o Indomethacin has significant CNS side effects

o Ketorolac (Toradol) can cause serious GI and renal effects

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Beers Criteria: Pain medications

Long-term use of NSAIDS can cause what adverse effects?

A

o Potential for GI bleed
o Renal failure
o Heart failure
o High blood pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Meperidine (Demerol) has low oral efficacy, active metabolites and __effects

A

CNS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Beers Criteria: Cardiovascular Agents

Digoxin Should not exceed 0.125 mg/day except when treating ________.

A

atrial arrhythmias

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Beers Criteria: Cardiovascular Agents

Digoxin causes Decreased______ which results increase in toxic effects

A

decreased renal clearance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Beers Criteria: Cardiovascular Agents

Amiodarone is Associated with ___ interval problems. It has a Lack of efficacy in older adults

A

QT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

according to beers criteria, you should avoid what meds in Parkinson’s disease?

A

metoclopromide and anti-psychotics (Haldol)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

according to beers criteria, you should avoid what meds in Stress incontinence

A

alpha-blockers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

according to beers criteria, you should avoid what meds in Hyponatremia

A

SSRIs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

according to beers criteria, you should avoid what meds in constipation

A

CCBs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

according to beers criteria, you should avoid what meds in cognitive impairment

A

Anticholinergics, antispasmodics, and muscle relaxants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Three medications caused 1/3 of ED visits in elderly patients, what were they?

A

o Insulin
o Warfarin
o Digoxin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

when taking NSAIDS, Several risk factors place the elderly population at increased risk for GI bleeds, what are they? (5)

A 
o	>75 years of age
o	History of PUD
o	History of GI bleed
o	Concomitant use of warfarin 
o	Long term glucocorticoid use
52
Q

if pt is at increased risk for GI bleed, what treatment should be used instead of NSAIDS?

A

misoprostol or PPI

53
Q

For medication safety with geriatric patients, we should prescribe how many medication at a time? and how should we dose it?

A
  • Prescribe one medication at a time
  • Start the dose low and titrate up slowly
  • Use once daily dosing if possible (Increases patient adherence)
54
Q

you should Avoid drug-drug interactions that are associated with hospitalizations. For benzodiazepines, you should avoid what meds?

A

Antidepressant and antipsychotics

55
Q

you should Avoid drug-drug interactions that are associated with hospitalizations. For ACE inhibitors, you should avoid what meds?

A

Potassium sparing diuretic or potassium supplement

56
Q

you should Avoid drug-drug interactions that are associated with hospitalizations. For Warfarin, you should avoid what meds?

A

New antibiotic, potent CYP inhibitors/inducers

57
Q

what are the Risk Factors for Adverse Drug Events (6)

A
  • > 6 chronic disease states
  • > 12 doses/day
  • > 9 Medications
  • Low BMI (<22 kg/m2)
  • Creatinine clearance <50 mL/min
  • Female
58
Q

People over the age of 65 consume 30% of all prescriptions in the US and___% of all over-the-counter medications, even though they only represent 15% of the US population

A

40%

59
Q

Elderly are frequently not included in clinical trials due to _________.

A

unpredictable drug metabolism and effects

60
Q

Elderly patients regularly take an average of ___ prescribed medications

A

4.5

61
Q 
76 year old man with falls and new resting tremor.
he has the following medical conditions: 
o	Heart failure
o	Hypertension
o	Diabetes 
o	CKD stage 3
o	Osteoarthritis
o	Dementia
and takes the following meds:
o	Furosimide 20 mg /D
o	Benazepril 10 mg/D
o	Metformin 1 gm BID
o	Glipizide 10 mg /D
o	Haldol 1.0 mg H

what med should be avoided?

A

Haldol 1.0 mg H

62
Q

For patients with no risk factors, fall risk is__%

A

8%

63
Q

For patients with 4 or more risk factors, fall risk is __%

A

78%

64
Q

Risk factors for Falls (12)

A
  • Age and Female gender
  • Past history of a fall
  • Lower extremity weakness
  • History of stroke
  • Balance problems
  • Arthritis
  • Cognitive impairment
  • Psychotropic drug use
  • Dizziness
  • Orthostatic hypotension
  • Vision problems
  • Anemia
65
Q

Immediate Consequences of Falls

A
  1. Physical – Fall-related injuries
    o 5 – 15% of falls result in fractures or serious soft tissue injuries
    o The majority of nonfatal injuries in adults aged 65 and older treated in ED in the US in 2001 were caused by falls
    o Account for ~ 10% of ED visits and 6% of urgent hospitalizations
    o Loss of function or immobility
    o Death
  2. Social – impacts quality of life
  3. Psychological – Fall-related fear & loss of self-efficacy
66
Q

what is the most common cause of traumatic brain injuries (TBI)?

A

falls

67
Q

Most fractures among older adults are caused by falls. The most common fractures are?

A

spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand.

68
Q

what medication would you need to reduce to improve postural hypotension?

A

Anticholinergic, alpha-blockers

69
Q

if patient has Postural Hypotension, how should they change positions?

A

change position slowly. Dangle feet before rising from bed

70
Q

in regards to diet, what should be counseled to patients that have postural hypotension

A
  • Consider liberalizing salt intake - carefully

- Encourage adequate hydration

71
Q

For Environmental Hazard Modification, what hazards are included?

A 
o	Clutter
o	Electric cords
o	Slippery throw rugs and loose carpet
o	Poor lighting
o	Lack of stair rails
o	Lack of shower rails / grab bars
o	Proper shoes
72
Q

Timed Up & Go Test (assess possibility of falling)

explain process once time starts and average results

A
  • Time starts when the patient initiates movement
  • The patient walks 10ft across the room and circles around a marker
  • Time stops when the patient returns and is seated in the chair
  • Average results are as follows
    o Age 60 – 69 7.24 seconds
    o Age 70 – 79 8.54 seconds
73
Q

what should be done with patient prior to timing a Timed Up & Go Test

A
  • Patient can use arms or assistive device – must document if either is used
  • Explain the test to the patient
  • Demonstrate the test
  • Do practice trial
  • Perform timed evaluation
  • Patient starts from a seated position
74
Q

what is continuity of care?

A

Continuity is ‘‘care over time by a single individual or team of healthcare professionals’’ including ‘‘effective and timely communication of healthcare information.’’

75
Q

what are Pupil Changes with Aging?

A
  • Pupil Decreases in Size

- Slower Light and Dark Adaptation

76
Q

what are lens Changes with Aging?

A
  • Yellowing of the Lens
  • Increased: Scatter and Fluorescence
  • Loss of Flexibility / Accommodation
77
Q

79 year old man in ED with nausea, vomiting and eye pain

you perform an Exam on his left eye and find:
o reduced vision, conjunctival injection, mild corneal edema
o Fixed, mid-dilated pupil

what is the diagnosis?

A

Closed-angle glaucoma

78
Q

Closed-angle glaucoma is the Mechanical obstruction of ___.

A

outflow

79
Q

in Closed-angle glaucoma, Rapid increase in intra-ocular pressure causes what symptoms?

A

Eye pain, nausea, halos around lights

80
Q

what would you see on a physical exam of Closed-angle glaucoma

A

Exam reduced vision, conjunctival hyperemia, corneal edema
o Fixed, mid-dilated pupil
o Increased intraocular pressure
o Narrow anterior chamber

81
Q

Closed-angle glaucoma treatment

A

topical pilocarpine or timolol, IV acetozolomide

82
Q

what is the Leading Cause of Blindness in the United States

A

macular degeneration

83
Q

what is presbyopia?

A

farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.

84
Q

what is Presbycusis?

A

is the most common type of Sensorineural Hearing Loss caused by the natural aging of the auditory system. It occurs gradually and initially affects the ability to hear higher pitched (higher frequency) sounds.

85
Q

______ Hearing loss is Due to damage to neurons or hair cells transmitting auditory signals to the brain for interpretation.

A

Sensorineural

86
Q

Sensorineural hearing loss due to aging is known as ___.

A

“presbycusis”

87
Q

Loud environments, neural tumors, viral insults (acoustic neuritis) can cause what kind of hearing loss?

A

Sensorineural

88
Q

_____ Hearing Loss is Due to mechanical damage or obstruction of the middle ear or external auditory canal

A

Conductive

89
Q

Examples of middle ear causes of conductive hearing loss

A

o effusions purulent serous otitis– Eustachian tube dysfunction
o trauma to the boney structures or tympanic membrane (scarring –tympanosclerosis)
o growths such as cholesteotomas or otosclerosis

90
Q

Examples of external auditory canal causes of conductive hearing loss

A 
o	foreign body (cerumen, insect, crayon)
o	inflammation (otitis externa), or growth (polyp, malignancy)
91
Q

what test helps differentiate between conductive and sensorineural hearing loss.

A

Weber Testing

92
Q

how do you perform the weber test?

A

Strike the tuning fork and place on the forehead, teeth, or nose.

93
Q

what are the results of a normal weber test?

A

No lateralization of sound at all

94
Q

results of weber test with unilateral conductive loss

A

Lateralizes to affected ear

95
Q

results of weber test with unilateral Sensorineural loss

A

Lateralizes to the normal ear or side you hear better in.

96
Q

what test helps test for conductive hearing loss?

A

rinne testing

97
Q

how do you perform the rinne test?

A

Strike the tuning fork and place on the mastoid. Have the patient tell you when they stop hearing the sound. Move the fork to beside the ear and check to see if they can hear the sound again.

98
Q

what are results of a normal rinne test?

A

Air conduction > Bone conduction – Patient hears the fork when placed BESIDE the ear

99
Q

what are results of an abnormal rinne test?

A

Bone conduction > Air Conduction – Patient does not hear the fork placed BESIDE ear. Signifies a conductive hearing loss on the affected side.

100
Q

describe deliriums onset, duration, attention, and consciousness

A

onset: abrupt
duration: hours to days
attention: impaired
consciousness: reduced, fluctuating

101
Q

describe dementia onset, duration, attention, and consciousness

A

onset: slow, insidious
duration: months to years
attention: normal, except in severe cases
consciousness: clear

102
Q

describe depression onset, duration, attention, and consciousness

A

onset: recent, may be associated with loss
duration: stable, may be worse in morning
attention: usually normal
consciousness: clear

103
Q

On Folstein MMSE, what score = impairment

A

<24 c/w impairment

104
Q

can MMSE distinguish dementia from delirium?

A

no

105
Q

in the mini cog test what results = demented?

A

when recall = 0

or if recall is 1 or 2 and the clock is abnormal

106
Q

characteristics of major depression

A 
o	Acute, nonprogressive
o	Depression
o	Affective before cognitive
o	Attention impaired
o	Orientation intact
o	Vocal memory complaint
o	Gives up on testing
o	Language  intact
o	Patient complains
o	Better at night
o	Criticizes self
o	Self-referred
107
Q

characteristics of dementia

A 
o	Insidious &amp; progressive
o	Depression mild if present
o	Cognitive before affective 
o	Recent memory impaired
o	Orientation impaired
o	Minimizes memory problem
o	Patient makes effort 
o	Possibly aphasic
o	Family complains
o	Sundowning
o	Criticizes others
o	Referred by others
108
Q

PHQ-2 is a Screen for ____

A

Depression

109
Q

Treatment of Dementia- can use what 2 meds?

A
  • Cholinesterase inhibitors

- Memantine

110
Q

in dementia, _______ shows improvement in surrogate end points for mod-severe disease

A

Memantine

111
Q

in treating dementia, does Cholinesterase inhibitors

or Memantine have better improvement in surrogate endpoints and is better tolerated by patients?

A

Memantine

112
Q

The “Real” Treatment of Dementia consists of Managing behavioral sx, such as?

A

o Aggression
o Wandering
o Physical and chemical restraints
o Co-morbid depression

113
Q

when treating dementia you should Recognize and manage _____ stress

A

caregiver

114
Q

______ is the cardinal feature for diagnosis of delirium

A

INATTENTION

115
Q

what are the three subtypes of delirium ?

A

o Hyperactive – agitated, hyperalert
o Hypoactive – calm and confused, lethargic
o Mixed – features of both

116
Q

what are some Modifiable risk factors in regards to Delirium ?
(8)

A
  • Medications
  • Polypharmacy (>3 new inpt meds)
  • Physical restraints and catheters
  • Sleep deprivation
  • Immobility
  • Uncontrolled pain
  • Medical illness (organ failure, electrolytes, etc)
117
Q

what should be included in the evaluation of delirium?

7

A
  • Vital signs, pulse ox, volume status
  • Focused exam including determining baseline cognition, urine output, last BM
  • Blood glucose
  • Review medications
  • Consider medication withdrawal as a cause
  • Testing – CBC, BMP, UA, CXR, EKG
  • Additional testing if clinically indicated
118
Q

what Is the most important thing to do in regards to managing delirium?

A

identifying underlying cause

119
Q

how do you manage delirium?

A
  1. Try to identify underlying cause
  2. Prevent complications and provide supportive care
    o Avoid bed rest, catheters, mobilize patient
    o Sleep at night, awake during day
    o Monitor nutrition status and output
    o Consider aspiration precautions
    o Enlist the help of family
120
Q

name 3 Psychological Expressions of Anxiety

A
  • Insomnia
  • Irritability
  • Poor coping skills
121
Q

Goals of Palliative Care

A
  • Improve the quality of life of patients living with debilitating, chronic or terminal illness
  • Prevention and relief of suffering by early identification, assessment, and treatment of distressing symptoms
  • Accomplished by combined efforts of an interdisciplinary team
122
Q

Palliative Care Definition

A
  • Collaborative, comprehensive, interdisciplinary approach to treating “total pain” (includes physical, psychosocial, and spiritual needs of patients and families)
  • Appropriate at any stage of illness and simultaneously with all other medical treatments
123
Q

Palliative Care vs. Hospice

A
  • Hospice, as defined by the Medicare hospice benefit, is a health care delivery system under which support and services are provided to a patient with a terminal illness where the focus is on comfort rather than curing an illness.
  • Thus, hospice can be considered a program that delivers palliative care to patients at the end of life, while palliative care can be appropriately offered to patients at any time along the trajectory of any type of serious illness, even concurrent with restorative, life-prolonging therapies.
  • Hospice is a model of palliative care that is offered to patients at the end of life when curative or life-prolonging therapy is no longer indicated.
  • While all care that is delivered by hospices can be considered palliative care, not all palliative care is delivered in hospices.
124
Q

The majority of nonfatal injuries in adults aged 65 and older treated in ED in the US in 2001 were caused by what?

A

falls

125
Q

WHEN evaluating delirium, what lab tests should be done?

A

CBC, BMP, UA, CXR, EKG

126
Q

when is palliative care appropriate?

A

Appropriate at any stage of illness and simultaneously with all other medical treatments

*GERIATRICS (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions