Gerontology

Question 1

Physiologic Changes

As humans age, h_____ declines because of loss of vertebral c_____ and bone; by age __ height has decreased from its peak by 2.5% to 5%; this loss becomes more rapid after age 70.

Compression fractures of vertebrae are a sign of _______ (kyphosis) and contribute to loss of height.

Lean body mass ____, and abdominal fat __creases with aging, while there is a loss of fat from the extremities and face.

Skeletal m______ loss begins at 50 years and continues because of loss of muscle fiber numbers and size.

Answer 1

As humans age, height declines because of loss of vertebral cartilage and bone; by age 70 height has decreased from its peak by 2.5% to 5%; this loss becomes more rapid after age 70.

Compression fractures of vertebrae are a sign of osteoporosis (kyphosis) and contribute to loss of height.

Lean body mass drops, and abdominal fat increases with aging, while there is a loss of fat from the extremities and face.

Skeletal muscle loss begins at 50 years and continues because of loss of muscle fiber numbers and size.

Question 2

Skin and Hair

With aging, the skin at______; the epidermis and dermis th___, and there is less subdermal f__ and coll____ (less elasticity).

Skin is fragile and slower to h____.

____ production is lower and skin drier (xerosis) due to decreased sebaceous and s_____ gland activity.

There is a decrease in s_______ to touch, vibration, and temperature as well as reduction in vitamin __ synthesis. Fewer m______ lead to graying of hair.

Answer 2

With aging, the skin atrophies; the epidermis and dermis thin, and there is less subdermal fat and collagen (less elasticity).

Skin is fragile and slower to heal.

Oil production is lower and skin drier (xerosis) due to decreased sebaceous and sweat gland activity.

There is a decrease in sensitivity to touch, vibration, and temperature as well as reduction in vitamin D synthesis. Fewer melanocytes lead to graying of hair.

Question 3

(1)

Soft wartlike skin lesions that appear “pasted on”. Mostly seen on the back and trunk. Benign.

Answer 3

Seborrheic Keratoses

Question 4

(1)

Bright purple-colored patches with well-demarcated edges. Located on the extensor surfaces of the forearms and hands after a minor trauma. Lesions eventually resolve over several weeks, but residual brown appearance can occur when hemosiderin deposits in the tissue. Benign.

Answer 4

Senile Purpura

Question 5

(1)

Also known as “liver spots.” Tan- to brown-colored macules with a “moth-eaten” border on the dorsum of the hands and forearms caused by sun damage. More common in light-skinned individuals. Benign.

Answer 5

Lentigines

Question 6

(1)

Condition that affects the lower legs and ankles secondary to impaired venous circulation (from peripheral vascular disease [PVD]). Can appear dry and scaly, ulcerated, neovascularized, and bronzed (from hemosiderin deposition).

Answer 6

Stasis Dermatitis

Question 7

(1)

Flat or thickened plaque with color varying from skin-colored to red, white, or yellow. May appear scaly or have a horny surface and is found on sun-damaged skin. Condition is secondary to sun exposure and has the potential for malignancy. It is a precancerous form of (1)

Answer 7

Actinic Keratosis (Solar Keratosis)

Flat or thickened plaque with color varying from skin-colored to red, white, or yellow. May appear scaly or have a horny surface and is found on sun-damaged skin. Condition is secondary to sun exposure and has the potential for malignancy. It is a precancerous form of squamous cell carcinoma.

Question 8

Nails

Growth slows, and nails become br____, y____, and thi____ Longitudinal r____ develop.

Answer 8

Growth slows, and nails become brittle, yellow, and thicker. Longitudinal ridges develop.

Question 9

Eyes

(1)

Condition caused by loss of elasticity of the lenses, which makes it difficult to accommodate or focus on close objects. Close vision is markedly affected. Onset is during early to mid-40s. Can be remedied with “reading glasses” or bifocal lenses. Cornea is less sensitive to touch. Arcus senilis, cataracts, glaucoma, and macular degeneration are more common.

Answer 9

Presbyopia

Question 10

(1)

Opaque grayish-to-white ring with a sharp outer border and an indistinct central border at the periphery of the cornea. Typically bilateral; unilateral finding associated with contralateral _____ disease. Develops gradually and is not associated with visual changes. Caused by deposition of ____. Sixty percent (60%) of patients have some evidence at age 60 years and nearly 100% by age 80 years.

In patients younger than 40 years, can be a sign of (1), check (1)

Answer 10

Arcus Senilis (Corneal Arcus)

Opaque grayish-to-white ring with a sharp outer border and an indistinct central border at the periphery of the cornea. Typically bilateral; unilateral finding associated with contralateral carotid artery disease. Develops gradually and is not associated with visual changes. Caused by deposition of lipids. Sixty percent (60%) of patients have some evidence at age 60 years and nearly 100% by age 80 years.

In patients younger than 40 years, can be a sign of elevated cholesterol. Check fasting lipid profile.

Question 11

(1)

Cloudiness and opacity of the lens of the eye(s) or its envelope (posterior capsular cataract). There are three types (nuclear, cortical, and posterior capsular). Color of the lens is white to gray. Cataracts cause gradual onset of decreased ____ vision, sensitivity to glare of car lights (driving at night), _____ around lights, b_____ vision, and d_____ vision. The red reflex ______.

Test: Red reflex (reflection is opaque g____ vs. orange-red glow)

Answer 11

Cataracts

Cloudiness and opacity of the lens of the eye(s) or its envelope (posterior capsular cataract). There are three types (nuclear, cortical, and posterior capsular). Color of the lens is white to gray. Cataracts cause gradual onset of decreased night vision, sensitivity to glare of car lights (driving at night), halos around lights, blurry vision, and double vision. The red reflex disappears.

Test: Red reflex (reflection is opaque gray vs. orange-red glow)

Question 12

(1)

Normally, the anterior chamber of the eye is modestly pressurized, helping to maintain the eye’s shape. Aging is associated with the loss of cells that help with efficient drainage of the anterior chamber. This loss causes increased anterior chamber pressure secondary to a bottleneck at the drainage canal.

Tests: (2)

Answer 12

Glaucoma

Tests: Visual fields and tonometer

Question 13

(1)

Loss of central visual fields results in loss of visual acuity and contrast sensitivity. May find ______ bodies.

Test: (1)

Answer 13

Macular Degeneration

Loss of central visual fields results in loss of visual acuity and contrast sensitivity. May find drusen bodies.

Test: Amsler grid to evaluate central-vision changes

Question 14

(1)

High-frequency hearing is lost first (e.g., a speaking voice is an example of high frequency). Presbycusis starts at about age 50 years. There are degenerative changes of the ossicles, fewer auditory n______, and atrophy of the hair cells resulting in _______ hearing loss.

Answer 14

Presbycusis (Sensorineural Hearing Loss)

High-frequency hearing is lost first (e.g., a speaking voice is an example of high frequency). Presbycusis starts at about age 50 years. There are degenerative changes of the ossicles, fewer auditory neurons, and atrophy of the hair cells resulting in sensorineural hearing loss.

Question 15

Heart

_____ation and tortuosity (______) of the arteries occurs.

Thi_____ intimal layer of arteries and ar_______ result in __creased systolic blood pressure (BP) because of increased vascular r______ (isolated systolic hypertension).

The mitral and aortic valves may contain c______ deposits.

Answer 15

Elongation and tortuosity (twisting) of the arteries occurs.

Thickened intimal layer of arteries and arteriosclerosis result in increased systolic blood pressure (BP) because of increased vascular resistance (isolated systolic hypertension).

The mitral and aortic valves may contain calcium deposits.

Question 16

Heart

(1) are less sensitive to changes in position.

There is decreased sensitivity of the ______ nervous system.

BP response is bl____. Maximum heart rate ___creases.

There is higher risk of _______ hypotension.

S__ heart sound is a normal finding in the elderly if not associated with heart disease.

The left ventricle ________ with aging (up to 10% increase in thickness).

Answer 16

Baroreceptors are less sensitive to changes in position.

There is decreased sensitivity of the autonomic nervous system.

BP response is blunted. Maximum heart rate decreases.

There is higher risk of orthostatic hypotension.

S4 heart sound is a normal finding in the elderly if not associated with heart disease.

The left ventricle hypertrophies with aging (up to 10% increase in thickness).

Question 17

Lungs

Total lung capacity remains relatively the _____ with aging.

Forced vital capacity (FVC) =

Forced expiratory volume in 1 second (FEV1) =

Residual volume (air left in the lungs at the end of expiration) ______ with age because of decrease in lung and chest wall com______.

The chest wall becomes st_____, and the diaphragm is fl____ and ____ efficient.

Answer 17

Total lung capacity remains relatively the same with aging.

Forced vital capacity (FVC) decreases with age.

Forced expiratory volume in 1 second (FEV1) decreases with age.

Residual volume (air left in the lungs at the end of expiration) increases with age because of decrease in lung and chest wall compliance.

The chest wall becomes stiffer, and the diaphragm is flatter and less efficient.

Question 18

Lungs

Mucociliary cl____ (fewer cilia) and c______ are less efficient.

The smaller airways collapse ______ during expiration.

Responses to hypoxia and hypercapnia __creases.

______ breath sounds and cr_____ are commonly found in the lung bases of elderly patients without presence of disease. Instruct the patient to “____” several times to inflate the lung bases (the benign crackles will disappear).

There is increased (1) diameter related to normal body changes.

Answer 18

Mucociliary clearance (fewer cilia) and coughing are less efficient.

The smaller airways collapse sooner during expiration.

Responses to hypoxia and hypercapnia decreases.

Decreased breath sounds and crackles are commonly found in the lung bases of elderly patients without presence of disease. Instruct the patient to “cough” several times to inflate the lung bases (the benign crackles will disappear).

There is increased anterior–posterior (AP) diameter related to normal body changes.

Question 19

Liver

Liver size and mass __creases due to at_____ (20%–40%).

Liver blood flow and perfusion __crease (up to 50% in some elders).

____ (lipofuscin) deposition in the liver is more common.

The liver function test results (alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase)?

Metabolic clearance of drugs is ____ by 20% to 40% because the cytochrome P450 (CYP450) enzyme system is less efficient.

The LDL and cholesterol levels __crease with aging.

Answer 19

Liver size and mass decreases due to atrophy (20%–40%).

Liver blood flow and perfusion decrease (up to 50% in some elders).

Fat (lipofuscin) deposition in the liver is more common.

The liver function test result (alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase) is not significantly changed.

Metabolic clearance of drugs is slowed by 20% to 40% because the cytochrome P450 (CYP450) enzyme system is less efficient.

The LDL and cholesterol levels increase with aging.

Question 20

Renal System

Renal size and mass __crease by 25% to 30%.

The steepest decline in renal mass occurs after the age of __.

Starting at the age of 40 years, the (1) rate starts to decrease. By age 70, up to 30% of renal function is lost.

Renal clearance of _____, concentrating and diluting ability, and response to s_____ is less effective.

The serum (1) is a less reliable indicator of renal function in the elderly because of the decrease in _____ mass, creatine production, and creatinine clearance. Serum creatinine can be in the normal range, even if renal function is markedly reduced.

The risk of kidney damage from Rx(1) is much higher.

The renin and angiotensin II levels are ____ in the elderly.

Answer 20

Renal size and mass decrease by 25% to 30%.

The steepest decline in renal mass occurs after the age of 50.

Starting at the age of 40 years, the glomerular filtration rate (GFR) starts to decrease. By age 70, up to 30% of renal function is lost.

Renal clearance of drugs, concentrating and diluting ability, and response to sodium is less effective.

The serum creatinine is a less reliable indicator of renal function in the elderly because of the decrease in muscle mass, creatine production, and creatinine clearance. Serum creatinine can be in the normal range, even if renal function is markedly reduced.

The risk of kidney damage from nonsteroidal anti-inflammatory drugs (NSAIDs) is much higher.

The renin and angiotensin II levels are lower in the elderly.

Question 21

Genitourinary System

The capacity of the bladder __creases with age.

Both the com______ of the bladder and the rate of urine f_____ decrease. These factors contribute to the increased amount of urine that _______ in the bladder after urination (residual urine). Normally, the bladder holds approximately 300 to 400 mL.

Prostatic _______ occurs with age for men.

In postmenopausal women, the urethra becomes thi____ and sh____, and the ability of the urinary sphincter to close tightly decreases (because of declining estrogen).

Urinary in_______ is two or three times more common in (1) gender.

_______ dysfunction affects approximately 40% of men aged 40 years and 70% of men aged 70 years.

Answer 21

The capacity of the bladder decreases with age.

Both the compliance of the bladder and the rate of urine flow decrease. These factors contribute to the increased amount of urine that remains in the bladder after urination (residual urine). Normally, the bladder holds approximately 300 to 400 mL.

Prostatic hypertrophy occurs with age for men.

In postmenopausal women, the urethra becomes thinner and shortens, and the ability of the urinary sphincter to close tightly decreases (because of declining estrogen).

Urinary incontinence is two or three times more common in women.

Erectile dysfunction affects approximately 40% of men aged 40 years and 70% of men aged 70 years.

Question 22

Musculoskeletal System

Muscle st____ and power ___creases with age and can contribute to morbidity in the elderly.

Deterioration of articular _______ is common after age of 40.

Stiffness in the _____ that improves with activity is a common symptom of (1)

Bone resorption is more ______ than bone deposition in women compared with men (4:1).

Fractures heal more _______ because of decrease in the number of osteoblasts.

Answer 22

Muscle strength and power decreases with age and can contribute to morbidity in the elderly.

Deterioration of articular cartilage is common after age of 40.

Stiffness in the morning that improves with activity is a common symptom of osteoarthritis (degenerative joint disease [DJD]).

Bone resorption is more rapid than bone deposition in women compared with men (4:1).

Fractures heal more slowly because of decrease in the number of osteoblasts.

Question 23

Gastrointestinal System

Rec____ gums and ___ mouth are common.

Decreased sensitivity of the taste buds results in decrease in ______.

There is decreased efficiency in ______ some (1) (e.g., folic acid, vitamin B12) and minerals (e.g., calcium) by the small intestines.

______ gastric emptying occurs.

Higher risk of gast____ and gastrointestinal (GI) damage from decreased production of _______.

Answer 23

Receding gums and dry mouth are common.

Decreased sensitivity of the taste buds results in decrease in appetite.

There is decreased efficiency in absorbing some vitamins (e.g., folic acid, vitamin B12) and minerals (e.g., calcium) by the small intestines.

Delayed gastric emptying occurs.

Higher risk of gastritis and gastrointestinal (GI) damage from decreased production of prostaglandins.

Question 24

Gastrointestinal System

Increased risk of _____ cancer (age >__ years is strongest risk factor).

Div____ are common.

Large bowel (colon) transit time is _____.

Con_______ is more common. Fecal impaction may lead to a small amount of runny, soft stool. Laxative abuse is more common.

Fecal incontinence may occur because of loss of _____ mass and weakness of external anal _____, drug side effects, underlying disease, neurogenic disorders, or a combination of these factors.

Answer 24

Increased risk of colon cancer (age >50 years is strongest risk factor).

Diverticuli are common.

Large bowel (colon) transit time is slower.

Constipation is more common. Fecal impaction may lead to a small amount of runny, soft stool. Laxative abuse is more common.

Fecal incontinence may occur because of loss of muscle mass and weakness of external anal sphincter, drug side effects, underlying disease, neurogenic disorders, or a combination of these factors.

Question 25

Endocrine System Minor atrophy of the p\_\_\_\_\_\_ occurs. \_\_creased levels of insulin are seen along with mild peripheral insulin \_\_\_\_\_\_\_. Changes or disorders of the circadian rhythm hormonal secretion (g\_\_\_\_ hormone, mel\_\_\_\_\_, and other hormones) can cause changes in _____ patterns.

Answer 25

Minor atrophy of the pancreas occurs. Increased levels of insulin are seen along with mild peripheral insulin resistance. Changes or disorders of the circadian rhythm hormonal secretion (growth hormone, melatonin, and other hormones) can cause changes in sleep patterns.

Question 26

Sex Hormones ## Footnote Testes are active for the entire life cycle. (2) production \_\_creases markedly with age. (2) production \_\_creases significantly in women because of ovarian failure (menopause). Higher serum (1) concentration in some postmenopausal women may cause frontal balding on the head and excess hair growth on the mustache area and/or on the chin. Adipose tissue is able to synthesize small amounts of estrogen and has been tied to (1) in elderly men. In the United States, up to 3% of those aged 65 to 74 years are sexually active, and some studies have shown that older adults in their 80s can _____ sexually active.

Answer 26

Testes are active for the entire life cycle. Dehydroepiandrosterone (DHEA) and testosterone production decreases markedly with age. Estrogen and progesterone production decreases significantly in women because of ovarian failure (menopause). Higher serum testosterone concentration in some postmenopausal women may cause frontal balding on the head and excess hair growth on the mustache area and/or on the chin. Adipose tissue is able to synthesize small amounts of estrogen and has been tied to gynecomastia in elderly men. In the United States, up to 3% of those aged 65 to 74 years are sexually active, and some studies have shown that older adults in their 80s can remain sexually active.

Question 27

Immune System Older adults are less likely to present with _____ during infections. Typical body temperature is slightly lower. There is a decreased ______ response to vaccines. Immune system is ____ active, and there is higher risk of \_\_\_\_\_\_\_. (1) immunity is affected more by aging than (1) immunity. * (1) immunity involves the activity of T lymphocytes, macrophages, and cytokines. * (1) immunity is associated with B lymphocytes and antibody (immunoglobulins or IgG) production.

Answer 27

Older adults are less likely to present with fever during infections. Typical body temperature is slightly lower. There is a decreased antibody response to vaccines. Immune system is less active, and there is higher risk of infection. Cellular immunity is affected more by aging than humoral immunity. * Cellular or cell-mediated immunity involves the activity of T lymphocytes, macrophages, and cytokines. * Humoral immunity is associated with B lymphocytes and antibody (immunoglobulins or IgG) production.

Question 28

Hematologic System Any changes to RBC life span, blood volume, or total number of circulating leukocytes? Increased risk of thrombi and emboli why? Increased risk of iron and folate-deficiency anemia why?

Answer 28

There are no changes in the red blood cell (RBC) life span, the blood volume, or the total number of circulating leukocytes. There is a higher risk of thrombi and emboli because of increased platelet responsiveness. Increased risk of iron and folate-deficiency anemia due to decreased efficiency of the GI tract to absorb vitamin B12 and folate.

Question 29

Neurologic System Hallmark of aging is slowed r\_\_\_\_\_times, decreased pro\_\_\_\_\_, and increased risk of f\_\_\_\_. Cognitive function remains stable if no underlying \_\_\_\_\_, but ability to solve problems is affected by reaction times. (1) testing may show differences in ability to differentiate color, pupillary response, and \_\_creased corneal reflex. G\_\_\_reflex decreases. Deep tendon reflexes may be brisk or ab\_\_\_\_\_. Neurologic testing may be impaired by medications, causing slower reaction times. Benign essential tr\_\_\_\_\_ is more common.

Answer 29

Hallmark of aging is slowed reaction times, decreased proprioception, and increased risk of falls. Cognitive function remains stable if no underlying dementia, but ability to solve problems is affected by reaction times. Cranial nerve testing may show differences in ability to differentiate color, pupillary response, and decreased corneal reflex. Gag reflex decreases. Deep tendon reflexes may be brisk or absent. Neurologic testing may be impaired by medications, causing slower reaction times. Benign essential tremor is more common.

Question 30

Pharmacologic Issues Drug clearance is affected by * r\_\_\_\_\_ impairment * less efficient liver (1) system * ____ gastric emptying, \_\_creased gastric pH * decreased serum al\_\_\_\_\_\_, and relatively higher ratio of \_\_\_:\_\_\_\_tissue (extends fat-soluble drugs)

Answer 30

* renal impairment * less efficient liver CYP450 enzyme system * slow gastric emptying, increased gastric pH * decreased serum albumin, and relatively higher ratio of fat:muscle tissue (extends fat-soluble drugs)

Question 31

Pharmacologic Issues Older adults have an increased sensitivity to ben\_\_\_\_\_ and anti\_\_\_\_\_\_ drugs such as hypnotics, ______ antidepressants, antih\_\_\_\_\_, and antip\_\_\_\_\_. The American Geriatrics Society has made a list of inappropriate medications for the elderly (\_\_\_\_\_criteria; Agency for Healthcare Research and Quality, National Guideline Clearinghouse, & American Geriatrics Society, 2019).

Answer 31

Older adults have an increased sensitivity to benzodiazepines and anticholinergic drugs such as hypnotics, tricyclic antidepressants (TCAs), antihistamines, and antipsychotics. The American Geriatrics Society has made a list of inappropriate medications for the elderly (Beers criteria; Agency for Healthcare Research and Quality, National Guideline Clearinghouse, & American Geriatrics Society, 2019).

Question 32

Exam Tips **(1)** (benign) appears as a wart-like growth that looks pasted on; found mostly on the back, color can range from tan, brown, to black. * *Memory tip:* The letter *b* in *seborrheic* is a reminder for *benign*. Actinic Keratosis is a precursor of **(1)** * *Memory tip:* The letter *c* in *actinic* is a reminder for *cancer*. * Do not confuse this with seborrheic keratosis, which is benign (common mistake). **(1)** is a white or gray ring in the margin of the cornea or on the periphery of the iris (\_\_\_\_deposits).

Answer 32

Seborrheic keratosis (benign) appears as a wart-like growth that looks pasted on; found mostly on the back, color can range from tan, brown, to black. * *Memory tip:* The letter *b* in *seborrheic* is a reminder for *benign*. Actinic keratosis is a precursor of squamous cell cancer. * *Memory tip:* The letter *c* in *actinic* is a reminder for *cancer*. * Do not confuse this with seborrheic keratosis, which is benign (common mistake). Arcus senilis (corneal arcus) is a white or gray ring in the margin of the cornea or on the periphery of the iris (cholesterol deposits).

Question 33

Exam Tips Most common cause of blindness in the United States is **(1)**. In developing countries, (1) are the most common cause of blindness. * Cataracts increase sensitivity to gl\_\_\_\_ of (1) * ___ reflex test on cataracts appear as gr\_\_\_-to-w\_\_\_\_ reflection (mature cataracts appear white). **Presbycusis** is a ______ type of hearing loss (\_\_\_\_ ear). Hearing loss initially occurs in the ____ -frequency range.

Answer 33

Most common cause of blindness in the United States is macular degeneration. In developing countries, cataracts are the most common cause of blindness. * Cataracts increase sensitivity to glare of car lights (driving at night). * Red reflex test on cataracts appear as grayish-to-white reflection (mature cataracts appear white). Presbycusis is a sensorineural type of hearing loss (inner ear). Hearing loss initially occurs in the high-frequency range.

Question 34

Exam Tips ## Footnote S4 in elderly is? FEV1 and FVC \_\_\_crease with age, but residual volume \_\_creases. (1) immunity is affected more by age than (1) immunity. Anticholinergic drugs cause **(5)**

Answer 34

S4 in elderly is not associated with heart disease symptoms and is considered normal. FEV1 and FVC decrease with age, but residual volume increases. Cellular immunity is affected more by age than humoral immunity. Anticholinergic drugs cause **constipation, urinary retention** (especially men with benign prostatic hyperplasia [BPH]), **blurred vision, dry mouth, and orthostatic hypotension.**

Question 35

Danger Signals Retinal \_\_\_\_\_ \_\_\_\_\_ Arteritis (\_\_\_\_ Cell Arteritis) \_\_\_\_\_ Angle-closure \_\_\_\_\_ C\_\_\_\_\_\_ Accident (1) (Precursor of Squamous Cell Carcinoma) \_\_\_\_\_\_ of the Hip Colorectal \_\_\_\_\_ Severe B\_\_\_\_\_Infections Elder A\_\_\_\_\_

Answer 35

Retinal Detachment Temporal Arteritis (Giant Cell Arteritis) Acute Angle-closure Glaucoma Cerbrovascular Accident Actinic Keratosis (Precursor of Squamous Cell Carcinoma) Fractures of the Hip Colorectal Cancer Severe Bacterial Infections Elder Abuse

Question 36

(1) **New onset or sudden increase in number of _floaters_ or _specks_ on the visual field, _flashes of light_, and the sensation that a _curtain_ is covering part of the visual field**. Considered a medical emergency that can lead to blindness if not treated. Risk factors are extreme \_\_\_\_\_sightedness, history of c\_\_\_\_\_\_ surgery, and family or personal history. Treated with _____ surgery or \_\_\_\_pexy (freezing).

Answer 36

Retinal Detachment Considered a medical emergency that can lead to blindness if not treated. Risk factors are extreme nearsightedness, history of cataract surgery, and family or personal history. Treated with laser surgery or cryopexy (freezing).

Question 37

(1) **Temporal headache (one-sided) with tenderness or induration over temporal artery; may be accompanied by sudden visual loss in one eye (amaurosis fugax). Scalp tenderness and jaw claudication on affected side.** Associated with **(1)\*** Screening test is **(1)** with or without a C-reactive protein (CRP), which is usually elevated. Temporal artery _____ is definitive diagnosis. Considered an ophthalmologic _______ (can cause blindness).

Answer 37

Temporal Arteritis (Giant Cell Arteritis) Associated with **polymyalgia rheumatica.** Screening test is **erythrocyte sedimentation rate (ESR)** with or without a C-reactive protein (CRP), which is usually elevated. Temporal artery biopsy is definitive diagnosis. Considered an ophthalmologic emergency (can cause blindness).

Question 38

(1) Older adult with **acute onset of severe eye pain, severe headache, and nausea and vomiting. The eye(s) is(are) reddened with profuse tearing. Complains of blurred vision and halos around lights**. Call 911. Do not delay treatment, as blindness can occur without intervention. _______ is done in the ED to quickly measure the intraocular pressure, which will be elevated.

Answer 38

Acute Angle-closure Glaucoma Call 911. Do not delay treatment, as blindness can occur without intervention. Tonometry is done in the ED to quickly measure the intraocular pressure, which will be elevated.

Question 39

Cerbrovascular Accident Cerebrovascular accident (CVA) is a sudden onset of neurologic dysfunction that worsens within hours. Also called a stroke or “brain attack.” Deficits can include changes such as _____ vision, (1) (loss of vision in half of the visual field), severe h\_\_\_\_\_\_, sl\_\_\_\_speech, one-sided upper and/or lower ex\_\_\_\_\_ numbness or w\_\_\_ness, and con\_\_\_\_\_. Signs and symptoms are dependent on l\_\_\_\_\_\_ of infarct. Two types of CVAs: (2). (1) is more common. In comparison,a (1) is a temporary episode that generally lasts fewer than 24 hours.

Answer 39

Cerebrovascular accident (CVA) is a sudden onset of neurologic dysfunction that worsens within hours. Also called a stroke or “brain attack.” Deficits can include changes such as blurred vision, hemianopia (loss of vision in half of the visual field), severe headache, slurred speech, one-sided upper and/or lower extremity numbness or weakness, and confusion. Signs and symptoms are dependent on location of infarct. Two types of CVAs: ischemic and hemorrhagic. Ischemic is more common. In comparison,a transient ischemic attack (TIA) is a temporary episode that generally lasts fewer than 24 hours.

Question 40

(1) **Small _rough, scaly, pink-to-reddish lesions_ that enlarge slowly over years. Located in _sun_-_exposed_ areas such as the cheeks, nose, back of neck, arms, chest.** More common in \_\_\_\_-skinned individuals. \_\_\_\_\_\_\_\_ cell precancerous skin lesions. Diagnostic method of choice is (1). Small number of lesions can be treated with (1). Larger numbers with wider distribution are treated with (1) cream.

Answer 40

Actinic Keratosis More common in light-skinned individuals. Squamous cell precancerous skin lesions. Diagnostic method of choice is biopsy. Small number of lesions can be treated with cryotherapy. Larger numbers with wider distribution are treated with 5-fluorouracil cream.

Question 41

Fractures of the Hip Acute onset of l\_\_\_, guarding, and/or inability or difficulty with _____ weight on the affected side. New onset of hip or groin pain; may be referred to the anterior thigh or knee. Unequal leg \_\_\_\_\_and _____ rotation of affected leg. History of (1) Fractures of the hip are a major cause of m\_\_\_\_ and m\_\_\_\_\_ in the elderly. Up to 20% of elderly with hip fractures ___ from indirect complications (e.g., pneumonia).

Answer 41

Acute onset of limping, guarding, and/or inability or difficulty with bearing weight on the affected side. New onset of hip or groin pain; may be referred to the anterior thigh or knee. Unequal leg length and external rotation of affected leg. History of osteoporosis or osteopenia. Fractures of the hip are a major cause of morbidity and mortality in the elderly. Up to 20% of elderly with hip fractures die from indirect complications (e.g., pneumonia).

Question 42

Colorectal Cancer Unexplained (1) anemia (23%), blood on rectum (37%), h\_\_\_\_chezia, m\_\_\_\_\_, abdominal p\_\_\_\_ (34%), and/or \_\_\_\_in bowel habits. \_\_\_symptoms during early stages, diagnosed due to screening. Presentation depends on location. \_\_\_\_\_\_ cancer can present with tenesmus, rectal pain, and diminished-caliber stools (\_\_\_\_\_like stools). About 20% of cases have distant metastases at time of presentation. Refer to a (1).

Answer 42

Unexplained iron-deficiency anemia (23%), blood on rectum (37%), hematochezia, melena, abdominal pain (34%), and/or change in bowel habits. No symptoms during early stages, diagnosed due to screening. Presentation depends on location. Rectal cancer can present with tenesmus, rectal pain, and diminished-caliber stools (ribbonlike stools). About 20% of cases have distant metastases at time of presentation. Refer to a gastroenterologist.

Question 43

Severe Bacterial Infections Atypical presentation is common. Older adults/elderly with bacteremia or sepsis may be **\_\_febrile**. About one-third to one-half of people with severe bacterial infections do ___ develop fever and/or chills. Some present with slightly lower than normal body temperature (\<37°C [98.6°F]). The white blood cell (WBC) count can be \_\_\_\_\_. Atypical presentations also include a sudden decline in **\_\_\_\_\_\_ status** (confusion, dementia), the new onset of urine/bowel \_\_\_\_\_\_, falling, worsening inability to perform activities (1), and/or loss of app\_\_\_\_\_. Serious infections include pn\_\_\_\_\_, pyelo\_\_\_\_\_, bacterial endo\_\_\_\_\_, s\_\_\_\_\_, and others. The most common infection in older adults (\>65 years) is **(1)**.

Answer 43

Atypical presentation is common. Older adults/elderly with bacteremia or sepsis may be **afebrile**. About one-third to one-half of people with severe bacterial infections do not develop fever and/or chills. Some present with slightly lower than normal body temperature (\<37°C [98.6°F]). The white blood cell (WBC) count can be normal. Atypical presentations also include a sudden **decline in mental status** (confusion, dementia), the new onset of urine/bowel incontinence, falling, worsening inability to perform activities of daily living (ADLs), and/or loss of appetite. Serious infections include pneumonia, pyelonephritis, bacterial endocarditis, sepsis, and others. The most common infection in older adults (\>65 years) is urinary tract infection (**UTI**).

Question 44

Elder Abuse ## Footnote Screen for abuse, n\_\_\_\_, and fin\_\_\_\_\_ exploitation. Presence of bruising, skin tears, lacerations, and fractures that are poorly \_\_\_\_\_\_ Presence of _____ transmitted disease, v\_\_\_\_ and/or r\_\_\_\_ bleeding, bruises on breasts are indicators of possible _____ abuse. Mal\_\_\_\_, poor h\_\_\_\_\_, and pr\_\_\_\_\_ injuries

Answer 44

Screen for abuse, neglect, and financial exploitation. Presence of bruising, skin tears, lacerations, and fractures that are poorly explained Presence of sexually transmitted disease, vaginal and/or rectal bleeding, bruises on breasts are indicators of possible sexual abuse. Malnutrition, poor hygiene, and pressure injuries

Question 45

Interview Elder Alone With These Three Questions ## Footnote Do you feel ____ where you live? Who handles your b\_\_\_\_ and f\_\_\_\_\_\_? Who prepares your m\_\_\_\_?

Answer 45

Do you feel safe where you live? Who handles your bills and finances? Who prepares your meals?

Question 46

Top Three Leading Causes of Death (\>65 Years) 1. (1) Disease 2. (1) (lung and colorectal) 3. Chronic lower ______ diseases ie (1)

Answer 46

1. Heart disease (myocardial infarction [MI], heart failure, arrhythmias) 2. Cancers (lung and colorectal) 3. Chronic lower respiratory diseases (chronic obstructive pulmonary disease [COPD])

Question 47

Cancer in Older Adults (1) the most common risk factors for cancer. Eighty percent (80%) of all cancers occur in people older than ___ years of age. Cancers among older adults may be caused by gene-related D\_\_\_\_ damage, f\_\_\_\_\_ genetics, decrease in imm\_\_\_\_\_\_, decreased healing rates, en\_\_\_\_\_\_, and h\_\_\_\_\_ influences.

Answer 47

Aging the most common risk factors for cancer. Eighty percent (80%) of all cancers occur in people older than 55 years of age. Cancers among older adults may be caused by gene-related DNA damage, familial genetics, decrease in immunity, decreased healing rates, environment, and hormonal influences.

Question 48

Cancer in Older Adults * *Cancer with highest mortality:* (1) * *Cancer with second-highest mortality:* (1) * *Median age of diagnosis:* * *Breast cancer:* __ years old * *Prostate cancer:* ___ years old * *Lung cancer:* __ years old

Answer 48

* *Cancer with highest mortality:* Lung and bronchial cancer (both genders) * *Cancer with second-highest mortality:* Colorectal cancer (both genders) * *Median age of diagnosis:* * *Breast cancer:* 61 years old * *Prostate cancer:* 68 years old * *Lung cancer:* 70 years old

Question 49

Lung Cancer The cancer with the ______ mortality (both genders). About one out of four cancer deaths are caused by lung cancer. Most patients with lung cancer are older adults. Fewer than 2% of people diagnosed with lung cancer are younger than age 45 years. * Most common risk factor:* S\_\_\_\_\_ (causes 80% of cases); other risk factors include radon exposure (10%), occupational exposures to carcinogens (9%–15%), and outdoor pollution (1%–2%) * Most common type of lung cancer:* (1) (84%)

Answer 49

The cancer with the highest mortality (both genders). About one out of four cancer deaths are caused by lung cancer. Most patients with lung cancer are older adults. Fewer than 2% of people diagnosed with lung cancer are younger than age 45 years. ## Footnote * Most common risk factor:* Smoking (causes 80% of cases); other risk factors include radon exposure (10%), occupational exposures to carcinogens (9%–15%), and outdoor pollution (1%–2%) * Most common type of lung cancer:* Non–small cell lung carcinoma (84%)

Question 50

Lung Cancer USPSTF Screening = When to stop screening?

Answer 50

Annual low-dose computed tomography (LDCT) screening for lung cancer in adults (aged 55–80 years) who have at least a 30-pack-year smoking history and currently smoke (or have quit within the past 15 years) *Discontinue annual screening:* Patient stops smoking for 15 years or longer or develops a health problem that substantially limits life expectancy (or the ability or willingness for curative lung surgery).

Question 51

# Classic Case of Lung Cancer Classic Case of Lung Cancer An older male s\_\_\_\_\_\_ (or ex-smoker) presents with a new onset of productive _____ with large amounts of thin mucoid phlegm (bronchorrhea) and occasional \_\_\_\_-tinged phlegm. The patient complains of worsening ______ of breath or dyspnea. He reports a persistent, dull achy ____ pain that does not go away. If the tumor is obstructing a bronchus, it can result in recurrent pn\_\_\_\_\_\_\_ of the same lobe. Some may have ____ loss.

Answer 51

An older male smoker (or ex-smoker) presents with a new onset of productive cough with large amounts of thin mucoid phlegm (bronchorrhea) and occasional blood-tinged phlegm. The patient complains of worsening shortness of breath or dyspnea. He reports a persistent, dull achy chest pain that does not go away. If the tumor is obstructing a bronchus, it can result in recurrent pneumonia of the same lobe. Some may have weight loss.

Question 52

Lung Cancer Treatment Plan ## Footnote Order chest (1) (e.g., nodules, lesions with irregular borders, pleural effusion). The next imaging exam needed is a (1) Gold standard is a positive lung (1) Baseline labs include complete (1), _____ panel, ____ enzymes, b\_\_\_\_\_, cr\_\_\_\_\_\_. Refer patient to a (1) for bronch\_\_\_\_ and tumor \_\_\_\_\_.

Answer 52

Order chest radiograph (e.g., nodules, lesions with irregular borders, pleural effusion). The next imaging exam needed is a CT scan. Gold standard is a positive lung biopsy. Baseline labs include complete blood count (CBC), chemistry panel, liver enzymes, bilirubin, creatinine. Refer patient to a pulmonologist for bronchoscopy and tumor biopsy.

Question 53

Colorectal Cancer The _____ most common cause of cancer deaths in the United States. About 20% of cases have distant metastases at time of presentation. It is staged using the (1) staging system (stages I–IV). * *Risk factors:* Advancing ____ (most common), inflammatory ______ disease, or a _____ history of colorectal cancer, colonic p\_\_\_\_\_\_ * *Lifestyle risk factors:* Lack of regular _____ activity, high-\_\_\_diet, low-\_\_\_\_diet, ob\_\_\_\_\_

Answer 53

The second most common cause of cancer deaths in the United States. About 20% of cases have distant metastases at time of presentation. It is staged using the tumor-node-metastasis (TNM) staging system (stages I–IV). * *Risk factors:* Advancing age (most common), inflammatory bowel disease, or a family history of colorectal cancer, colonic polyps * *Lifestyle risk factors:* Lack of regular physical activity, high-fat diet, low-fiber diet, obesity

Question 54

Colorectal Cancer Screening = what about Cologuard?

Answer 54

Start at 50 years Colonoscopy every 10 years or Sigmoidoscopy ever 5 years or High sensitivity FOBT annually DNA-based screening FOBT (Cologuard) is now available in place of the screening colonoscopy, but it is only for average-risk individuals with no prior history of abnormal colonoscopy findings and/or no family history of colon cancer.

Question 55

Classic Case of Colorectal Cancer An older adult who presents with a change in _____ habits (74%) with hematochezia or m\_\_\_\_\_ (51%) and/or abdominal ____ (3%); may be asymptomatic and present only with unexplained (1) anemia (23%). The patient may report an\_\_\_\_ and unintentional ____ loss. A\_\_\_\_\_\_ during early stages; diagnosed by screening. Presentation depends on location. Patients with rectal cancer can present with ten\_\_\_\_, rectal pain, and diminished-caliber stools (\_\_\_\_like stools).

Answer 55

An older adult who presents with a change in bowel habits (74%) with hematochezia or melena (51%) and/or abdominal pain (3%); may be asymptomatic and present only with unexplained iron-deficiency anemia (23%). The patient may report anorexia and unintentional weight loss. Asymptomatic during early stages; diagnosed by screening. Presentation depends on location. Patients with rectal cancer can present with tenesmus, rectal pain, and diminished-caliber stools (ribbonlike stools).

Question 56

Colorectal Cancer Treatment Plan ## Footnote Baseline labs include C\_\_\_, F\_\_\_\_, (1) panel, and U\_\_. Check _____ blood in stool (e.g., guaiac based, stool DNA). Serum _________ antigen (CEA) is useful in follow-up. Refer to (1) for (1) and management

Answer 56

Baseline labs include CBC, FOBT, chemistry panel, and urinalysis (UA). Check occult blood in stool (e.g., guaiac based, stool DNA). Serum carcinoembryonic antigen (CEA) is useful in follow-up. Refer to gastroenterologist for colonoscopy and management

Question 57

(1) **A cancer of the bone marrow that affects the plasma cells of the immune system (production of monoclonal immunoglobulins).** The racial background with the highest incidence is people of **(1)** descent (doubled or tripled compared with other races). Multiple myeloma is a cancer found mostly in _____ adults.

Answer 57

Multiple Myeloma The racial background with the highest incidence is people of African descent (doubled or tripled compared with other races). Multiple myeloma is a cancer found mostly in older adults.

Question 58

CRAB = Criteria for Multiple Myeloma

Answer 58

**C**alcium levels elevated **R**enal insufficiency **A**nemia **B**one disease

Question 59

Classic Case of Multiple Myeloma Older-to-el\_\_\_\_\_\_ adult who complains of ____ pain with generalized weakness. The bone pain is usually located on the c\_\_\_\_\_ skeleton (chest/back/shoulders/hips/pelvis), worsens with movement, and rarely occurs at night. The majority have an\_\_\_\_\_ (73%).

Answer 59

Older-to-elderly adult who complains of bone pain with generalized weakness. The bone pain is usually located on the central skeleton (chest/back/shoulders/hips/pelvis), worsens with movement, and rarely occurs at night. The majority have anemia (73%).

Question 60

Multiple Myeloma Treatment Plan ## Footnote Baseline labs include C\_\_\_, F\_\_\_\_, (1) panel, and U\_\_. Refer patient to a (1).

Answer 60

Baseline labs include CBC, FOBT, chemistry panel, and UA. Refer patient to a hematologist.

Question 61

(1) The most lethal cancer in terms of prognosis, with a 5-year survival rate of 8.2%. More than 95% of cases arise from the \_\_\_\_crine portion. Most patients already have m\_\_\_\_\_\_ by time of diagnosis. The most common presentation is w\_\_\_ness (asthenia; 86%), weight loss (85%), anorexia (83%), abdominal pain (79%), and j\_\_\_\_\_(56%).

Answer 61

Pancreatic Cancer The most lethal cancer in terms of prognosis, with a 5-year survival rate of 8.2%. More than 95% of cases arise from the exocrine portion. Most patients already have metastases by time of diagnosis. The most common presentation is weakness (asthenia; 86%), weight loss (85%), anorexia (83%), abdominal pain (79%), and jaundice (56%).

Question 62

Pancreatic Cancer Treatment Plan ## Footnote Initial labs include A\_\_\_\_, A\_\_\_, A\_\_\_\_, bi\_\_\_\_, li\_\_\_\_, and (1) tumor marker. Refer to a (1) surgeon for (1) procedure or other interventions.

Answer 62

Initial labs include aspartate transaminase (AST), aspartate aminotransferase (ALT), alkaline phosphatase, bilirubin, lipase, and CA 19-9 tumor marker. Refer to a gastrointestinal (GI) surgeon for Whipple procedure or other interventions.

Question 63

Exam Tips ## Footnote *Ribbonlike stool (low-caliber stool) in older adult with iron-deficiency anemia:* Rule out (1) Know signs and symptoms of retinal detachment = Know signs and symptoms of acute angle-closure glaucoma = Know signs and symptoms of hip fracture = Actinic keratosis is precancer of (1) cancer. *Temporal arteritis:* Check ________ rate with/without CRP; both \_\_\_\_\_\_. Leading cause of death is ____ disease.

Answer 63

*Ribbonlike stool (low-caliber stool) in older adult with iron-deficiency anemia:* Rule out colon cancer. Know signs and symptoms of retinal detachment = new onset/increase in floaters, specks in visual field, flashes of light, sensation that a curtain is covering visual field Know signs and symptoms of acute angle-closure glaucoma = acute onset severe eye pain, severe headache, nausea and vomiting, eye is reddened with profuse tearing, blurry vision and halos around lights Know signs and symptoms of hip fracture = acute onset limp, guarding, difficulty bearing weight on affected side, hip/groin pain, anterior thigh or knee pain, unequal leg length and external rotation affected leg, hx of osteoporosis Actinic keratosis is precancer of squamous cell skin cancer. *Temporal arteritis:* Check sedimentation rate with/without CRP; both elevated. Leading cause of death is heart disease.

Question 64

Clinical Pearls ## Footnote Any patient with unexplained iron-deficiency anemia who is older, male, or postmenopausal should be referred for a (1) (GI bleed, colon cancer). If the chemistry profile shows marked elevations in the serum (1) and/or alkaline \_\_\_\_\_\_, it is usually indicative of cancerous metastasis of the bone.

Answer 64

Any patient with unexplained iron-deficiency anemia who is older, male, or postmenopausal should be referred for a colonoscopy (GI bleed, colon cancer). If the chemistry profile shows marked elevations in the serum calcium and/or alkaline phosphatase, it is usually indicative of cancerous metastasis of the bone.

Question 65

Atypical Presentations in the Elderly Atypical disease presentations are more common in this age group. The immune system becomes ____ robust as people age, and there is increased risk of bacterial and viral _____ because of changes in sk\_\_\_ and mucosal barriers, decreased _____ and humoral immunity, and impaired cell sig\_\_\_\_\_. Vaccines may not be as effective in the elderly because of decreased _____ response.

Answer 65

Atypical disease presentations are more common in this age group. The immune system becomes less robust as people age, and there is increased risk of bacterial and viral infections because of changes in skin and mucosal barriers, decreased cellular and humoral immunity, and impaired cell signaling. Vaccines may not be as effective in the elderly because of decreased antibody response.

Question 66

Atypical Presentations in the Elderly Older adults and the elderly are more likely to be \_\_symptomatic or present with subtle symptoms. The elderly are ____ likely to have a high ____ during an infection. Instead, they are more likely to suffer \_\_\_-grade temperature elevations or acute c\_\_\_\_\_ dysfunction such as con\_\_\_\_, ag\_\_\_\_, and del\_\_\_\_. Cognitive dysfunction in the elderly may also result from use of multiple pres\_\_\_\_\_\_ to manage multiple comorbid conditions. \_\_\_pharmacy increases the chances of adverse drug reactions and drug–drug interactions.

Answer 66

Older adults and the elderly are more likely to be asymptomatic or present with subtle symptoms. The elderly are less likely to have a high fever during an infection. Instead, they are more likely to suffer low-grade temperature elevations or acute cognitive dysfunction such as confusion, agitation, and delirium. Cognitive dysfunction in the elderly may also result from use of multiple prescriptions to manage multiple comorbid conditions. Polypharmacy increases the chances of adverse drug reactions and drug–drug interactions.

Question 67

Bacterial Pneumonia Fever and chills may be m\_\_\_\_\_ or mild (oral temp \>100.0°F or rectal \>99.5°F). Increased _______ requirement, not cough, may be the only prominent symptom. If present, cough may be m\_\_\_\_ and produce little to no sputum (especially if the patient is de\_\_\_\_\_). May stop e\_\_\_\_ and dr\_\_\_\_ water and start losing \_\_\_\_. More likely to become con\_\_\_\_\_ and w\_\_\_\_ with loss of appetite. May become ______ of bladder and bowel. \_\_\_\_\_cardia usually present. Increases the risk of f\_\_\_\_. The WBC count may be n\_\_\_\_\_ or mildly elevated. \_\_\_\_\_microbial and gram-\_\_\_\_\_organisms cause the majority of pneumonias in the elderly.

Answer 67

Fever and chills may be missing or mild (oral temp \>100.0°F or rectal \>99.5°F). Increased oxygen requirement, not cough, may be the only prominent symptom. If present, cough may be mild and produce little to no sputum (especially if the patient is dehydrated). May stop eating and drinking water and start losing weight. More likely to become confused and weak with loss of appetite. May become incontinent of bladder and bowel. Tachycardia usually present. Increases the risk of falls. The WBC count may be normal or mildly elevated. Polymicrobial and gram-negative organisms cause the majority of pneumonias in the elderly.

Question 68

(1) The **most common infection in elderly nursing home residents** and in **adults age 65 and older**. Patients usually have no fever or can be asymptomatic. May become acutely **confused or agitated.** May become **septic with mild symptoms**. **New onset of urinary incontinence.**

Answer 68

Urinary Tract Infections

Question 69

Acute Abdomen Elderly patients may have more subtle symptoms such as the ab\_\_\_\_ of abdominal g\_\_\_\_\_ and other signs of acute abdomen. The abdominal pain may be milder. The ____ count may be only slightly elevated, or it may be normal. Patient may have \_\_\_\_-grade fever with an\_\_\_\_\_ and \_\_\_\_ness.

Answer 69

Elderly patients may have more subtle symptoms such as the absence of abdominal guarding and other signs of acute abdomen. The abdominal pain may be milder. The WBC count may be only slightly elevated, or it may be normal. Patient may have low-grade fever with anorexia and weakness.

Question 70

Acute Myocardial Infarction May be \_\_symptomatic. Symptoms may consist of new-onset f\_\_\_\_\_, b\_\_\_\_ pain, and/or mild \_\_\_\_pain.

Answer 70

May be asymptomatic. Symptoms may consist of new-onset fatigue, back pain, and/or mild chest pain.

Question 71

Hypothyroidism Subtle and insidious symptoms such as sl\_\_\_\_ness, severe con\_\_\_\_\_, w\_\_\_\_ gain, and ___ skin. Hypothyroidism is very common in patients age 60 years or older. Problems with m\_\_\_\_\_. If severe, may mimic dem\_\_\_\_\_. Slower movements. Appears \_\_\_thetic.

Answer 71

Subtle and insidious symptoms such as sleepiness, severe constipation, weight gain, and dry skin. Hypothyroidism is very common in patients age 60 years or older. Problems with memory. If severe, may mimic dementia. Slower movements. Appears apathetic.

Question 72

Urinary Incontinence Is it a normal part of aging? May be short term and temporary (e.g., UTI, high intake of tea or coffee) or chronic. Two or three times more common in (1) gender Risk factors are ob\_\_\_\_, increasing par\_\_\_\_, \_\_\_\_\_delivery, menopause, a\_\_, sm\_\_\_\_, and d\_\_\_\_. Some foods and drinks worsen urinary incontinence because of their diuretic effect (e.g., t\_\_, caf\_\_\_\_, al\_\_\_\_, c\_\_\_\_\_drinks, c\_\_\_\_fruits, sp\_\_\_\_ foods). Some medications (di\_\_\_\_\_, sedatives) may have a similar effect.

Answer 72

Should not be considered a “normal” aspect of aging. Evaluate all cases. May be short term and temporary (e.g., UTI, high intake of tea or coffee) or chronic. Two or three times more common in women. Risk factors are obesity, increasing parity, vaginal delivery, menopause, age, smoking, and diabetes. Some foods and drinks worsen urinary incontinence because of their diuretic effect (e.g., tea, caffeine, alcohol, carbonated drinks, citrus fruits, spicy foods). Some medications (diuretics, sedatives) may have a similar effect.

Question 73

Urinary Incontinence Treatment Plan ## Footnote * First-line treatment:* **\_\_\_\_\_ modifications** for all types (stress, urge, mixed). If obese, advise **(1)** (most helpful for stress incontinence). **(1)** if smoker. * Dietary:* Avoid certain beverages such as? and excessive ____ intake (\>64 ounces); decrease fluid intake before \_\_\_time. * Constipation:* Treat to decrease risk of urinary re\_\_\_\_ and subsequent urge or over\_\_\_\_ incontinence. * \_\_\_\_\_ exercises (pelvic floor exercises):* All types of urinary incontinence, especially stress incontinence. Kegel exercises have been found to help with fecal incontinence.

Answer 73

* First-line treatment:* Lifestyle modifications for all types (stress, urge, mixed). If obese, advise weight loss (most helpful for stress incontinence). Smoking cessation if smoker. * Dietary:* Avoid certain beverages (alcohol, coffee, tea, carbonated drinks) and excessive fluid intake (\>64 ounces); decrease fluid intake before bedtime. * Constipation:* Treat to decrease risk of urinary retention and subsequent urge or overflow incontinence. * Kegel exercises (pelvic floor exercises):* All types of urinary incontinence, especially stress incontinence. Kegel exercises have been found to help with fecal incontinence.

Question 74

Urinary Incontinence Treatment Plan ## Footnote Use absorbent p\_\_\_\_ and \_\_\_\_wear made for urinary incontinence. For moderate to advanced pelvic organ pro\_\_\_\_\_ (cystocele, rectocele, enterocele, uterine prolapse, vaginal eversion), refer to urologist or gynecologist specializing in urinary incontinence and pelvic organ prolapse repair.

Answer 74

Use absorbent pads and underwear made for urinary incontinence. For moderate to advanced pelvic organ prolapse (cystocele, rectocele, enterocele, uterine prolapse, vaginal eversion), refer to urologist or gynecologist specializing in urinary incontinence and pelvic organ prolapse repair.

Question 75

(1) Increased intra-abdominal pressure (laughing, sneezing, bending, lifting) causes involuntary leakage of small-to-medium volume of urine. Highest incidence in middle-aged women (peak at 45–49 years). **Plan** (2)

Answer 75

Stress incontinence **Plan:** Kegel exercises; decongestant (pseudoephedrine) if no contraindications.

Question 76

(1) Sudden and strong urge to void immediately before involuntary leakage of urine. Involuntary loss of urine can range from moderate-to-large volumes. Condition also known as “overactive bladder.” Highest incidence in older men and women. **Plan:** Trial of Rx(1) or Rx(1)

Answer 76

Urge incontinence **Plan:** Trial of anticholinergics (oxybutynin/Ditropan) or tricyclic antidepressant (imipramine).

Question 77

(1) Frequent dribbling of small amounts of urine from overly full bladder; due to blockage of flow (e.g., benign prostatic hyperplasia [BPH]) or underactive detrusor muscle (e.g., spinal cord injury, multiple sclerosis). Highest incidence in older men. **Plan:** tx for (1)

Answer 77

Overflow incontinence **Plan:** BPH treatment.

Question 78

(1) Problems with mobility (walking to the toilet) or inability to pull down pants in a timely manner. Affects approximately 25% of women aged 57–85 years. **Plan:** Bedside \_\_\_\_, raised toilet seats with h\_\_\_\_\_, ______ therapy for strengthening and gait.

Answer 78

Functional incontinence **Plan:** Bedside commode, raised toilet seats with handles, physical therapy for strengthening and gait.

Question 79

(1) Symptoms that are a mixture of stress and urge incontinence

Answer 79

Mixed Incontinence

Question 80

*Kegel Exercises* Tell the patient to: Identify the _____ used to ____ urinating (stop urinating midstream to confirm this). Do not tighten muscles of the abdomen, buttocks, thighs, and legs at the same time. Sq\_\_\_\_\_\_ and hold these muscles and slowly count to \_\_\_\_. R\_\_\_\_\_ and release these same muscles to a slow count of \_\_\_\_. Repeat this ___ times. Aim for at least ____ sets of __ repetitions ___ times a day for ___ to 20 weeks.

Answer 80

Identify the muscles used to stop urinating (stop urinating midstream to confirm this). Do not tighten muscles of the abdomen, buttocks, thighs, and legs at the same time. Squeeze and hold these muscles and slowly count to five. Relax and release these same muscles to a slow count of five. Repeat this 10 times. Aim for at least three sets of 10 repetitions three times a day for 15 to 20 weeks.

Question 81

*Behavioral Bladder Training* ## Footnote Bladder training to de\_\_\_\_ urination after feeling the ___ to urinate. At first, have the patient try holding off urinating for ___ minutes each time. The goal is to ______ the time between trips to the bathroom to every 2 to 4 hours. \_\_\_\_\_\_ voiding helps to empty the bladder more completely to avoid \_\_\_\_\_. Double voiding means urinating and then waiting a few minutes and voiding again.

Answer 81

Bladder training to delay urination after feeling the urge to urinate. At first, have the patient try holding off urinating for 10 minutes each time. The goal is to lengthen the time between trips to the bathroom to every 2 to 4 hours. 1. Double voiding helps to empty the bladder more completely to avoid overflow. Double voiding means urinating and then waiting a few minutes and voiding again.

Question 82

* Anticholinergics for Incontinence* * (2) Rx* * Contraindications:* Urinary \_\_\_\_\_, gastric \_\_\_\_\_\_, severe decreased ______ of GI tract, uncontrolled narrow-angle \_\_\_\_\_

Answer 82

* Oxybutynin (Ditropan)*2.5 to 5 mg orally three times a day (immediate release); other formulations include extended release, transdermal patch (twice a week), transdermal gel. * Tolterodine (Detrol, Detrol LA):*1 to 2 mg immediate-release tablet, 2 to 4 mg extended-release capsule * Contraindications:* Urinary retention, gastric retention, severe decreased motility of GI tract, uncontrolled narrow-angle glaucoma

Question 83

* Beta-3-Adrenergic Agonists for Incontinence* * Rx(1)* * Indication =* * Contraindications (1)*

Answer 83

*Mirabegron (Myrbetriq):* 25 to 50 mg extended-release tablets Second-line therapy Contraindications: Hypersensitivity

Question 84

Pelvic Organ Prolapse in Women **Definition =** **Cause =** Herniation of the bladder (1), rectum (1), uterus (uterine \_\_\_\_\_), small bowel (1), or vagina (vaginal ____ prolapse) Early stage symptoms? Patient education =

Answer 84

Pelvic organ prolapse is **when 1 or more of the organs in the pelvis slip down from their normal position and bulge into the vagina** Caused by weakening of pelvic muscles and supporting ligaments Herniation of the bladder (cystocele), rectum (rectocele), uterus (uterine prolapse), small bowel (enterocele), or vagina (vaginal vault prolapse Usually asymptomatic in early stage Advise the patient to avoid heavy lifting or excessive straining, which can worsen condition, and to avoid chronic constipation, because straining worsens pelvic organ prolapse.

Question 85

Pelvic Organ Prolapse: Cystocele (Bladder) Bulging of the \_\_\_terior vaginal wall; early stage is usually _______ in all types of pelvic organ prolapse. **Symptoms**: Urinary _______ and voiding d\_\_\_\_\_\_\_ (e.g., needing to reduce the prolapse using a finger in the vagina for urination or defecation). **Plan:** Refer for **(1)** placement, _____ repair.

Answer 85

Bulging of the anterior vaginal wall; early stage is usually asymptomatic in all types of pelvic organ prolapse. **Symptoms**: Urinary incontinence and voiding difficulties (e.g., needing to reduce the prolapse using a finger in the vagina for urination or defecation). **Plan:** Refer for pessary placement, surgical repair.

Question 86

Pelvic Organ Prolapse: Rectocele (rectum) Bulging on the \_\_\_\_terior vaginal wall; herniation ranges from mild to rectal prolapse. **Symptoms**: Feeling of rectal \_\_\_\_ness or pr\_\_\_\_, sensation that rectum does not completely \_\_\_\_\_; rectal prolapse can cause fecal in\_\_\_\_\_\_\_. **Plan:** (1) exercises; avoid ______ during bowel movement; treat con\_\_\_\_\_\_\_; refer for (1) placement or _____ repair.

Answer 86

Bulging on the posterior vaginal wall; herniation ranges from mild to rectal prolapse. **Symptoms**: Feeling of rectal fullness or pressure, sensation that rectum does not completely empty; rectal prolapse can cause fecal incontinence. **Plan:** Kegel exercises; avoid straining during bowel movement; treat constipation; refer for pessary placement or surgical repair.

Question 87

Pelvic Organ Prolapse: Uterine prolapse (uterus) Cervix descends \_\_\_line (apical) into vagina; cervix feels f\_\_\_\_ with p\_\_\_\_-pink color and \_\_\_visible; with third-degree full prolapse, a tubular saclike protrusion is seen outside the vagina. **Symptoms**: Vaginal discharge or bl\_\_\_\_\_, sensation of vaginal f\_\_\_ness, feeling that something is falling in the vagina, low-\_\_\_ pain. **Plan:** Avoid heavy l\_\_\_\_ and st\_\_\_\_\_; refer for (1) placement or ______ repair by urogynecologist.

Answer 87

Cervix descends midline (apical) into vagina; cervix feels firm with pale-pink color and os visible; with third-degree full prolapse, a tubular saclike protrusion is seen outside the vagina. **Symptoms**: Vaginal discharge or bleeding, sensation of vaginal fullness, feeling that something is falling in the vagina, low-back pain. **Plan:** Avoid heavy lifting and straining; refer for pessary placement or surgical repair by urogynecologist.

Question 88

Pelvic Organ Prolapse: Enterocele (small intestines) Small bowel slips into the area between the _____ and _____ wall of the vagina, bulging external vagina. **Symptoms**: Pu\_\_\_ sensation inside pelvis, pelvic pr\_\_\_\_\_ or pain, low-\_\_\_\_pain, dyspar\_\_\_\_\_ **Plan:** Refer for _____ repair.

Answer 88

Small bowel slips into the area between the uterus and posterior wall of the vagina, bulging external vagina. **Symptoms**: Pulling sensation inside pelvis, pelvic pressure or pain, low-back pain, dyspareunia. **Plan:** Refer for surgical repair.

Question 89

Pelvic Organ Prolapse Evaluation During the gynecologic exam (**\_\_\_\_\_\_ exam**, speculum exam), instruct the patient to **(1)** so that herniation becomes more visible and palpable.

Answer 89

During the gynecologic exam (bimanual exam, speculum exam), instruct the patient to bear down or strain so that herniation becomes more visible and palpable.

Question 90

Chronic Constipation **(2)** types of constipation Is constipation a common GI complaint? Self-treatment is common with over-the-counter (OTC) f\_\_\_\_ and lax\_\_\_\_\_\_. Constipation has many _____ causes such as prescription and OTC drugs, neurologic disease (Parkinson’s disease, dementia), irritable bowel syndrome (IBS), diabetes, hypothyroidism, and others. \_\_\_\_\_\_ factors that contribute to constipation are immobility, low-fiber diet, dehydration, milk intake, and ignoring the urge to have bowel movement. Drugs that cause constipation are i\_\_\_\_ supplements, \_\_\_\_-blockers, calcium channel blockers, antih\_\_\_\_\_, anti\_\_\_\_\_\_, antipsychotics, op\_\_\_\_\_, and \_\_\_\_\_\_-containing antacids.

Answer 90

**Idiopathic** and **Functional** constipation Constipation is the most common GI complaint. Self-treatment is common with over-the-counter (OTC) fiber and laxatives. Constipation has many secondary causes such as prescription and OTC drugs, neurologic disease (Parkinson’s disease, dementia), irritable bowel syndrome (IBS), diabetes, hypothyroidism, and others. Lifestyle factors that contribute to constipation are immobility, low-fiber diet, dehydration, milk intake, and ignoring the urge to have bowel movement. Drugs that cause constipation are iron supplements, beta-blockers, calcium channel blockers, antihistamines, anticholinergics, antipsychotics, opiates, and calcium-containing antacids.

Question 91

Classic Case Chronic Constipation Older adult complains of history of long-term constipation (years). Describes stool as d\_\_\_ and hard “b\_\_\_-like” pieces or as l\_\_\_\_-volume stools that are difficult to pass. Reports of st\_\_\_\_\_often to pass the stool. Accompanied by feelings of f\_\_\_ness and bl\_\_\_\_\_. Patient takes laxatives daily (laxative \_\_\_\_\_). Has noted (1) that is bleeding (reports bright-red blood on toilet paper and blood streaks on stool surface).

Answer 91

Older adult complains of history of long-term constipation (years). Describes stool as dry and hard “ball-like” pieces or as large-volume stools that are difficult to pass. Reports of straining often to pass the stool. Accompanied by feelings of fullness and bloating. Patient takes laxatives daily (laxative abuse). Has noted hemorrhoid that is bleeding (reports bright-red blood on toilet paper and blood streaks on stool surface).

Question 92

Treatment Plan for Chronic Constipation ## Footnote Education and be\_\_\_\_\_ modification (bowel re\_\_\_\_\_). Teach “toilet” hy\_\_\_\_ such as going to the bathroom at the _____ time each day; advise not to ignore the \_\_\_\_to defecate. Dietary changes such as eating dried and/or drinking _____ juice. Increase intake of fr\_\_\_\_ and v\_\_\_\_\_\_. Ingest bulk-forming f\_\_\_\_\_\_ (25–35 g/day) once daily. Do not take with medication (will absorb drugs). Take with full glass of water (can cause intestinal obstruction).

Answer 92

Education and behavior modification (bowel retraining). Teach “toilet” hygiene such as going to the bathroom at the same time each day; advise not to ignore the urge to defecate. Dietary changes such as eating dried prunes and/or drinking prune juice. Increase intake of fruit and vegetables. Ingest bulk-forming fibers (25–35 g/day) once daily. Do not take with medication (will absorb drugs). Take with full glass of water (can cause intestinal obstruction).

Question 93

Treatment Plan for Chronic Constipation ## Footnote Increase physical activity, especially w\_\_\_\_\_\_. Increase ______ intake to __ to __ glasses/day (if no contraindication). Consider Rx(1) treatment. ____ daily use of laxatives (except for fiber supplements) and ch\_\_\_\_\_\_ treatment with laxatives.

Answer 93

Increase physical activity, especially walking. Increase fluid intake to 8 to 10 glasses/day (if no contraindication). Consider laxative treatment. Avoid daily use of laxatives (except for fiber supplements) and chronic treatment with laxatives.

Question 94

Type of Laxative (1) * Psyllium (Metamucil) * Wheat dextrin (Benefiber) * Methylcellulose (Citrucel) * Polycarbophil (FiberCon) Notes: Two types: (1) and (1) fiber (bran, psyllium); _____ water, adding ____ to stool; constipation, IBS, diverticulitis

Answer 94

Bulk-forming * Psyllium (Metamucil) * Wheat dextrin (Benefiber) * Methylcellulose (Citrucel) * Polycarbophil (FiberCon) Notes: Two types: Soluble and insoluble fiber (bran, psyllium); absorbs water, adding bulk to stool; constipation, IBS, diverticulitis

Question 95

Type of Laxative (1) Bisacodyl (Dulcolax), oral and suppository Senna extract (Senokot), oral Aloe vera juice *Notes*: _______ colon directly, causing con\_\_\_\_\_\_\_ ; drug class: anthraquinone

Answer 95

Stimulants (irritants) Bisacodyl (Dulcolax), oral and suppository Senna extract (Senokot), oral Aloe vera juice *Notes*: Stimulates colon directly, causing contractions; drug class: anthraquinone

Question 96

Type of Laxative (1) Sorbitol Lactulose (Cephulac) Polyethylene glycol or PEG 3350 (MiraLAX) Glycerin suppositories *Notes*: Draws _____ by osmosis to increase fluid retention in the colon; suppositories are for rectal use only

Answer 96

Osmotics (hyperosmotic agents) Sorbitol Lactulose (Cephulac) Polyethylene glycol or PEG 3350 (MiraLAX) Glycerin suppositories *Notes*: Draws fluid by osmosis to increase fluid retention in the colon; suppositories are for rectal use only

Question 97

Type of Laxative (1) Magnesium citrate Magnesium hydroxide (Milk of Magnesia) Magnesium sulfate (Epsom salts) *Notes:* Saline attracts _____ into the intestinal lumen (small and large intestines), Not examined in older adults, use with caution due to hypermagnesemia risk, Side effects: Fluid and electrolyte imbalance

Answer 97

Saline Laxatives Magnesium citrate Magnesium hydroxide (Milk of Magnesia) Magnesium sulfate (Epsom salts) *Notes:* Saline attracts water into the intestinal lumen (small and large intestines), Not examined in older adults, use with caution due to hypermagnesemia risk, Side effects: Fluid and electrolyte imbalance

Question 98

Type of Laxative (1) Linaclotide (Linzess) Plecanatide (Trulance) *Notes:* Stimulates intestinal _____ secretion and tr\_\_\_\_\_; for IBS, chronic idiopathic constipation; Contraindications: Mechanical GI ______ (known or suspected)

Answer 98

Guanylate cyclase-C receptor agonist Linaclotide (Linzess) Plecanatide (Trulance) *Notes:* Stimulates intestinal fluid secretion and transit; for IBS, chronic idiopathic constipation; Contraindications: Mechanical GI obstruction (known or suspected)

Question 99

Type of Laxative (1) Lubiprostone (Amitiza) *Notes:* Idiopathic chronic constipation, IBS; Contraindications: History of mechanical obstruction

Answer 99

Chloride channel activators Lubiprostone (Amitiza) *Notes: \_\_\_\_\_* chronic constipation, IBS; Contraindications: History of mechanical \_\_\_\_\_\_

Question 100

Type of Laxative (1) Prucalopride (Motegrity) Methylnaltrexone (Relistor) Naloxegol (Movantik) Mineral oil *Notes:* I\_\_\_\_\_\_ chronic constipation; O\_\_\_\_\_-induced constipation \_\_\_\_\_\_\_ maintenance laxatives prior to starting therapy Contraindications: GI \_\_\_\_\_or patients at risk for obstruction Lubricants are ___ absorbed

Answer 100

5-HT(4) receptor agonists Opioid antagonists Lubricants Prucalopride (Motegrity) Methylnaltrexone (Relistor) Naloxegol (Movantik) Mineral oil *Notes:* Idiopathic chronic constipation; opioid-induced constipation Opioid-induced constipation Discontinue maintenance laxatives prior to starting therapy Contraindications: GI obstruction or patients at risk for obstruction Lubricants are not absorbed

Question 101

Type of Laxative (1) Docusate sodium (Colace) *Notes: \_\_\_\_\_* stool (does not stimulate colon), Stool becomes soft and sl\_\_\_\_\_

Answer 101

Stool Softeners Docusate sodium (Colace) *Notes:* Softens stool (does not stimulate colon), Stool becomes soft and slippery

Question 102

Dementia and Cognitive Impairment ## Footnote The most common cause of neurodegenerative dementia in elderly is? The most common cause of non-neurodegenerative dementia is? One of the most helpful methods of diagnosing dementia is by eliciting a thorough **\_\_\_\_\_ of the changes** in the patient’s m\_\_\_\_, be\_\_\_\_, function, and personality from **\_\_\_\_\_ members and close contacts of the patient**.

Answer 102

The most common cause of neurodegenerative dementia in elderly is **Alzheimer’s** disease (60%–80%). The most common cause of non-neurodegenerative dementia is **Vascular** dementia (CVA). One of the most helpful methods of diagnosing dementia is by eliciting a thorough **history of the changes** in the patient’s memory, behavior, function, and personality from **family members and close contacts of the patient.**

Question 103

Dementia and Cognitive Impairment ## Footnote Assessment of f\_\_\_\_\_ status and c\_\_\_\_\_\_ testing (cognitive performance scales) of the patient is important. Ruling out secondary causes is done by ordering laboratory tests for syp\_\_\_\_\_, vitamin ____ deficiency, (1) hormone, syphilis (only if high clinical suspicion based on sexual history or travel). Preferred Imaging (1)

Answer 103

Assessment of **functional status** and **cognitive testing** (cognitive performance scales) of the patient is important. Ruling out secondary causes is done by ordering laboratory tests for syphilis, vitamin B12 deficiency, thyroid-stimulating hormone (TSH), syphilis (only if high clinical suspicion based on sexual history or travel). **MRI** is preferred over CT when scan of the brain is indicated.

Question 104

Assessment of Functional Status *Activities of Daily Living* ***(1)** Index of Independence in Activities of Daily Living* ***(1)** Instrumental Activities of Daily Living Scale* ***(1)** Physical Frailty Phenotype*

Answer 104

*Activities of Daily Living* ***Katz** Index of Independence in Activities of Daily Living* ***Lawton** Instrumental Activities of Daily Living Scale* ***Fried** Physical Frailty Phenotype*

Question 105

*Activities of Daily Living* **Self-care activities that are necessary for “\_\_\_\_\_\_\_” living depending on the person’s environment (e.g., home, retirement community, nursing home).** ***(1) ADLs**:* Eating (self-feeding), personal hygiene (brushing teeth, bathing), ambulation (walking, wheelchairs), bowel and bladder management ***(1) ADLs**:* Shopping and preparing meals, housework, using electronics (stoves, telephones, TV), managing finances, driving a car ***(1) ADLs**:* Fulfilling multiple roles (spouse, parent, caretaker) while also participating in recreational or occupational tasks

Answer 105

**Self-care activities that are necessary for “independent” living depending on the person’s environment (e.g., home, retirement community, nursing home).** ## Footnote ***Basic ADLs:*** Eating (self-feeding), personal hygiene (brushing teeth, bathing), ambulation (walking, wheelchairs), bowel and bladder management ***Instrumental ADLs (IADLs):*** Shopping and preparing meals, housework, using electronics (stoves, telephones, TV), managing finances, driving a car ***Advanced ADLs (AADLs)**:* Fulfilling multiple roles (spouse, parent, caretaker) while also participating in recreational or occupational tasks

Question 106

*Katz Index of Independence in Activities of Daily Living* Measure used to assess an older adult’s \_\_\_\_\_\_\_. Contains ___ items. Each item is scored a “**\_\_**” (**independence**; ability to perform tasks with no supervision, direction, or personal assistance) or “\_\_” (**dependence**; needs supervision, direction, personal assistance, or total care). The highest possible score is __ points (**independent**) lowest is __ points (patient very **dependent**)

Answer 106

Measure used to assess an older adult’s **independence**. Contains **six** items. Each item is scored a **“1”** (independence; ability to perform tasks with no supervision, direction, or personal assistance) or **“0”** (dependence; needs supervision, direction, personal assistance, or total care). The highest possible score is **6** points (**independent**) lowest is **0** points (patient very **dependent**)

Question 107

*Katz Index of Independence in Activities of Daily Living* ## Footnote * (1)* *:* Able to bathe self completely or needs help in bathing only one body part (e.g., back, genitals) * (1)* *:* Can get clothes from closet/drawer and put on clothes without help (except tying shoelaces) * (1)* *:* Able to get on/off toilet, including pants/underwear, cleans genital area without help * (1)**:* Able to move in/out of bed or chair unassisted; mechanical transfer aids acceptable * (1)* *:* Has complete control (urination and defecation) * (1)**:* Can get food from plate into mouth; able to feed self (okay if another person prepares food)

Answer 107

* Bathing**:* Able to bathe self completely or needs help in bathing only one body part (e.g., back, genitals) * Dressing**:* Can get clothes from closet/drawer and put on clothes without help (except tying shoelaces) * Toileting**:* Able to get on/off toilet, including pants/underwear, cleans genital area without help * Transferring**:* Able to move in/out of bed or chair unassisted; mechanical transfer aids acceptable * Continence**:* Has complete control (urination and defecation) * Feeding**:* Can get food from plate into mouth; able to feed self (okay if another person prepares food)

Question 108

*Lawton Instrumental Activities of Daily Living Scale* Measure used to assess an older adult’s **\_\_\_\_\_\_**. This instrument is most useful for identifying how a person is functioning at the present time and to identify improvement or deterioration over time. Contains **eight** categories that are considered more **\_\_\_\_\_\_** than the activities measured in the Katz Index. Individuals are scored according to their highest level of functioning in each category. A summary score ranges from **\_\_ (low function, dependent) to __ (high function, independent)**

Answer 108

Measure used to assess an older adult’s **independence**. This instrument is most useful for identifying how a person is functioning at the present time and to identify improvement or deterioration over time. Contains **eight** categories that are considered more **complex** than the activities measured in the Katz Index. Individuals are scored according to their highest level of functioning in each category. A summary score ranges from **0 (low function, dependent)** to **8 (high function, independent)**

Question 109

*Lawton Instrumental Activities of Daily Living Scale* 1. Ability to use t\_\_\_\_\_\_ 2. Sh\_\_\_\_\_ 3. ____ preparation 4. \_\_\_\_\_keeping 5. L\_\_\_\_\_\_ 6. Mode of tr\_\_\_\_\_\_ 7. Responsibility for own m\_\_\_\_\_\_ 8. Ability to handle f\_\_\_\_\_

Answer 109

1. Ability to use telephone 2. Shopping 3. Food preparation 4. Housekeeping 5. Laundry 6. Mode of transportation 7. Responsibility for own medications 8. Ability to handle finances

Question 110

*Fried Physical Frailty Phenotype* _Five criteria used to measure frailty_ \_\_\_\_\_ loss (\>10 lb) \_\_\_\_\_ness (grip strength; measure with a digital hand dynamometer) Ex\_\_\_\_\_ (self-report) Walking _____ (15 feet) Physical _____ (kcal/week). An individual who meets **one or two of the criteria** has **(1)**; an individual who meets **three or more criteria** is considered **(1)**

Answer 110

_Five criteria used to measure frailty_ Weight loss (\>10 lb) Weakness (grip strength; measure with a digital hand dynamometer) Exhaustion (self-report) Walking speed (15 feet) Physical activity (kcal/week). An individual who meets **one or two of the criteria** has **“intermediate” frailty**; an individual who meets **three or more** criteria is considered **“frail.”**

Question 111

Cognitive Performance Scales * (1) (MMSE)* * Mini-\_\_\_Test* * (1) III (ACE-III)* * (1) (RISE)* * (1) (Short Form; GDS-SF)* * (1)-9 (PHQ-9)*

Answer 111

* Mini-Mental State Examination (MMSE)* * Mini-Cog Test* * Addenbrooke’s Cognitive Examination III (ACE-III)* * Revised Index of Social Engagement (RISE)* * Geriatric Depression Scale (Short Form; GDS-SF)* * Patient Health Questionnaire-9 (PHQ-9)*

Question 112

*Mini-Mental State Examination (MMSE)* A brief screening exam to assess for cognitive impairment. High sensitivity and specificity. 0 to 10 (\_\_\_\_\_) 10 to 20 (\_\_\_\_\_) 20 to 25 (\_\_\_\_) 25 to 30 (\_\_\_\_\_\_ significance; mild deficits)

Answer 112

A brief screening exam to assess for cognitive impairment. High sensitivity and specificity. 0 to 10 (severe) 10 to 20 (moderate) 20 to 25 (mild) 25 to 30 (questionable significance; mild deficits)

Question 113

*Mini-Mental State Examination (MMSE)* (1) * Ask about year/season/date/day/month * Where are we now? Name state (county, town/city, hospital, floor) (1) * Name three unrelated objects and instruct the patient to recite all three words (1) * Serial 7s (ask the patient to count backward from 100 by sevens) * *Alternative*: Instruct the patient to spell world backward (1) * Say to the patient, “Earlier I told you the names of three things. Can you tell me what they were?” (1) * Show the patient two simple objects (e.g., pencil, coin); instruct patient to name them. * Instruct the patient to repeat the phrase “No ifs, ands, or buts.” * Give the patient one blank piece of paper. Instruct patient to “take the paper in your right hand, fold it in half, and put it on the floor.” * Write on the paper “Close your eyes.” Instruct the patient to read and do what it says. (1) * *Writing a sentence:* Instruct the patient to make up and write a sentence about anything. * *Copying a design:* Use a questionnaire with a picture of two pentagons that intersect.

Answer 113

Orientation to time and place * Ask about year/season/date/day/month * Where are we now? Name state (county, town/city, hospital, floor) Short-term memory * Name three unrelated objects and instruct the patient to recite all three words Attention and calculation * Serial 7s (ask the patient to count backward from 100 by sevens) * *Alternative*: Instruct the patient to spell world backward Recall * Say to the patient, “Earlier I told you the names of three things. Can you tell me what they were?” Language * Show the patient two simple objects (e.g., pencil, coin); instruct patient to name them. * Instruct the patient to repeat the phrase “No ifs, ands, or buts.” * Give the patient one blank piece of paper. Instruct patient to “take the paper in your right hand, fold it in half, and put it on the floor.” * Write on the paper “Close your eyes.” Instruct the patient to read and do what it says. Complex commands * *Writing a sentence:* Instruct the patient to make up and write a sentence about anything. * *Copying a design:* Use a questionnaire with a picture of two pentagons that intersect.

Question 114

*Mini-Mental State Examination (MMSE)* ## Footnote Orientation to time and place = Short-term memory = Attention and calculation = Recall = Language = Complex commands =

Answer 114

Orientation to time and place * Ask about year/season/date/day/month * Where are we now? Name state (county, town/city, hospital, floor) Short-term memory * Name three unrelated objects and instruct the patient to recite all three words Attention and calculation * Serial 7s (ask the patient to count backward from 100 by sevens) * *Alternative*: Instruct the patient to spell world backward Recall * Say to the patient, “Earlier I told you the names of three things. Can you tell me what they were?” Language * Show the patient two simple objects (e.g., pencil, coin); instruct patient to name them. * Instruct the patient to repeat the phrase “No ifs, ands, or buts.” * Give the patient one blank piece of paper. Instruct patient to “take the paper in your right hand, fold it in half, and put it on the floor.” * Write on the paper “Close your eyes.” Instruct the patient to read and do what it says. Complex commands * *Writing a sentence:* Instruct the patient to make up and write a sentence about anything. * *Copying a design:* Use a questionnaire with a picture of two pentagons that intersect.

Question 115

*Mini-Cog Test* A \_\_-minute tool to screen for cognitive impairment in older adults in the primary care setting. High sensitivity and specificity. Score range is 0 to 2 = 3 to 5 =

Answer 115

A 3-minute tool to screen for cognitive impairment in older adults in the primary care setting. High sensitivity and specificity. Score range is 0 to 2 (dementia) 3 to 5 (no dementia)

Question 116

Mini Cog Test Step 1: (1) * Instruct the patient to repeat three words. There are six versions of words that can be used (two examples listed here): – B\_\_\_\_, s\_\_\_\_, ch\_\_\_\_ (version 1) – L\_\_\_\_, s\_\_\_\_\_, t\_\_\_\_ (version 2) Step 2: (1) * Instruct the patient to draw a clock by putting in the numbers first; indicate a specific time by saying “set the hands to __ past 11 ” or “set the hands at ___ minutes after 8.” Step 3: (1) * Ask the patient to recall the three words you stated in Step 1.

Answer 116

Step 1: Three-word recognition (one point for each word) * Instruct the patient to repeat three words. There are six versions of words that can be used (two examples listed here): – Banana, sunrise, chair (version 1) – Leader, season, table (version 2) Step 2: Clock drawing (score as normal or abnormal) * Instruct the patient to draw a clock by putting in the numbers first; indicate a specific time by saying “set the hands to 10 past 11” or “set the hands at 20 minutes after 8.” Step 3: Three-word recall * Ask the patient to recall the three words you stated in Step 1.

Question 117

(1) Screening test that is composed of tests of attention, orientation, memory, language, visual perceptual, and visuospatial skills. It is useful in the detection of mild cognitive impairment, Alzheimer’s disease, and frontotemporal dementia.

Answer 117

*Addenbrooke’s Cognitive Examination III (ACE-III)*

Question 118

(1) Measures social engagement and ease in interactions with others—for example, engaging in planned activities, accepting invitations, pursuing involvement in facility life, initiating interactions, and reacting positively to interactions. Used for patients in long-term care facilities.

Answer 118

*Revised Index of Social Engagement (RISE)*

Question 119

(1) A 15-question screening tool for depression in older adults that takes just 5 to 7 minutes to complete. It can help the provider quickly determine if further assessment is necessary.

Answer 119

*Geriatric Depression Scale (Short Form; GDS-SF)*

Question 120

(1) A nine-item depression scale to assist in the diagnosis of depression and monitor treatment response. It is one of the most validated tools in mental health and can be used for all patient populations.

Answer 120

*Patient Health Questionnaire-9 (PHQ-9)*

Question 121

(1) A **reversible, temporary process.** Duration is usually **brief (hours to days).** Acute and dramatic onset. Patient may be excitable, irritable, and combative, with short attention span, memory loss, and disorientation. Secondary to medical condition, drug, intoxication, adverse reaction to medicine. *Treatment (1)*

Answer 121

Delirium (Acute Confusional State) Remove offending agent and/or treat illness, infection, or metabolic derangement and delirium resolves.

Question 122

Delirium *Etiology* ## Footnote Prescription medications (o\_\_\_\_\_, sed\_\_\_\_\_, hypnotics, anti\_\_\_\_\_, p\_\_\_pharmacy) \_\_\_\_\_\_ abuse (alcohol, heroin, hallucinogens), pl\_\_\_\_ (jimsonweed, salvia) Drug–drug \_\_\_\_\_\_, adverse reactions, psychiatric illness Abrupt drug w\_\_\_\_\_\_ (alcohol, benzodiazepines, drugs) Preexisting medical conditions, I\_\_\_ patients with sensory overload In\_\_\_\_\_, s\_\_\_\_ (UTI and pneumonia most common infections) E\_\_\_\_\_\_ imbalance, h\_\_\_ failure, r\_\_\_\_ failure

Answer 122

Prescription medications (opioids, sedatives, hypnotics, antipsychotics, polypharmacy) Substance abuse (alcohol, heroin, hallucinogens), plants (jimsonweed, salvia) Drug–drug interactions, adverse reactions, psychiatric illness Abrupt drug withdrawal (alcohol, benzodiazepines, drugs) Preexisting medical conditions, ICU patients with sensory overload Infections, sepsis (UTI and pneumonia most common infections) Electrolyte imbalance, heart failure, renal failure

Question 123

(1) This condition occurs in both delirium and dementia. Starting at dusk/sundown, the patient becomes very agitated, confused, and combative; symptoms resolve in the morning; seen more with dementia; recurs commonly.

Answer 123

“Sundowning” Phenomenon

Question 124

“Sundowning” *Treatment Plan* ## Footnote Avoid q\_\_\_\_ and d\_\_\_ rooms. Have well-\_\_\_ room with a r\_\_\_\_, T\_\_, or cl\_\_\_\_. F\_\_\_\_\_\_ surroundings are important; do not move fur\_\_\_\_\_ or change de\_\_\_\_. Avoid d\_\_\_\_\_ that affect cognition (antihistamines, sedatives, hypnotics, narcotics). Maintain r\_\_\_\_\_\_. Observe and minimize tr\_\_\_\_\_\_. Use dis\_\_\_\_\_\_ (e.g., watch TV, take a walk, play music, reminisce).

Answer 124

Avoid quiet and dark rooms. Have well-lit room with a radio, TV, or clock. Familiar surroundings are important; do not move furniture or change decor. Avoid drugs that affect cognition (antihistamines, sedatives, hypnotics, narcotics). Maintain routines. Observe and minimize triggers. Use distraction (e.g., watch TV, take a walk, play music, reminisce).

Question 125

(1) An irreversible brain disorder that involves loss of learned cognitive and physical/motor skills. The presentation and the signs and symptoms are determined by the etiology and location of the brain damage. Gradual and insidious onset except if caused by stroke or acute brain damage.

Answer 125

Dementia

Question 126

Dementia Dementia affects _____ skills adversely. ***\_\_\_\_\_\_\_ function*** is defined as self-regulation skills, attention, planning, multitasking, self-control, motivation, and decision-making skills. These higher level cognitive skills are regulated in the **\_\_\_\_ lobes** of the brain.

Answer 126

Dementia affects executive skills adversely. ***Executive function*** is defined as self-regulation skills, attention, planning, multitasking, self-control, motivation, and decision-making skills. These higher level cognitive skills are regulated in the **frontal lobes** of the brain.

Question 127

Dementia *Differential Diagnosis* ## Footnote It is important to obtain a thorough health/medical/drug \_\_\_\_\_. The patient should be accompanied by _____ during the interview. Family members (and friends) will report patient’s signs and symptoms. Refer to (1) for further assessment. Rule out correctable causes such as vitamin ____ deficiency, \_\_\_\_thyroidism, major dep\_\_\_\_\_\_, infection, adverse/drug interactions, heavy metal poisoning, neuro\_\_\_\_\_\_, and others. **Parkinson’s dementia** and dementia with **(1)** may resemble each other. Remember that **normal pressure \_\_\_\_\_\_\_** can cause dementia-like symptoms that mimic **Alzheimer’s disease**. The preferred imaging test for dementia signs/symptoms is **(1)** of the brain

Answer 127

It is important to obtain a thorough health/medical/drug history. The patient should be accompanied by family during the interview. Family members (and friends) will report patient’s signs and symptoms. Refer to neurologist for further assessment. Rule out correctable causes such as vitamin B12 deficiency, hypothyroidism, major depression, infection, adverse/drug interactions, heavy metal poisoning, neurosyphilis, and others. **Parkinson’s dementia and dementia with Lewy bodies (DLB)** may resemble each other. Remember that **normal pressure hydrocephalus can cause dementia-like symptoms that mimic Alzheimer’s disease**. The preferred imaging test for dementia signs/symptoms is **MRI** of the brain

Question 128

(1) The early phase of some brain disorders such as Alzheimer’s disease, cerebrovascular dementia, Parkinson’s disease, frontotemporal dementia. The **(1)** has shown high diagnostic accuracy in individuals with mild cognitive impairment.

Answer 128

* Mild Cognitive Impairment* * The **ACE-III** has shown high diagnostic accuracy in individuals with mild cognitive impairment.*

Question 129

Alzheimer’s Disease Rare before age ___ years. Prevalence _____ every 5 years after the age of 65. Accumulation of _______ **plaques**/**tangles** causes permanent damage to brain. **\_\_\_crease** in **(1) production**. Average life expectancy of person age 65 years or older (when diagnosed) is __ to __ years. S\_\_\_\_\_\_ occur in 10% to 20% of patients with Alzheimer’s disease.

Answer 129

Rare before age 60 years. Prevalence doubles every 5 years after the age of 65. Accumulation of neurofibrillary plaques/tangles causes permanent damage to brain. Decrease in acetylcholine production. Average life expectancy of person age 65 years or older (when diagnosed) is 4 to 8 years. Seizures occur in 10% to 20% of patients with Alzheimer’s disease.

Question 130

Alzheimer’s Disease **(3) As**

Answer 130

**Aphasia** (difficulty expressing and understanding language) **Apraxia** (difficulty with gross motor movements such as walking, inability to perform previously learned task) **Agnosia** (inability to recognize familiar people or objects)

Question 131

Does this describe Mild, Moderate, or Severe Alzheimer's? And what is the expected life expectancy? Unable to feed self Incontinent of bowel and bladder Unable to control movements, so they stop walking and use wheelchair or are bedridden Incoherent or mute and have difficulty communicating pain Apathetic

Answer 131

*Severe (1–3 years):* Disease symptoms are severe, and the patient requires total care.

Question 132

Does this describe Mild, Moderate, or Severe Alzheimer's? And what is the expected life expectancy? Problems coming up with the right word when talking Forgetting something that was just read or seen/repeats same questions. Forgets important dates Losing or misplacing important objects; getting lost on familiar routes Problems managing personal finances and money; poor judgment Becomes withdrawn, anxious, and/or depressed; easily upset; personality changes

Answer 132

*Mild (2–4 years):* Usually still functioning independently, but family or friends may notice early symptoms.

Question 133

Does this describe Mild, Moderate, or Severe Alzheimer's? And what is the expected life expectancy? Wanders and gets lost Has problems with speech and following instructions Stops paying bills May start a conversation and forget to complete sentences Loses ability to read and write Has problems recognizing familiar people (agnosia) and is unable to recall current or past information about themselves Demonstrates personality and behavior changes like delusions or compulsions

Answer 133

*Moderate (2–10 years):* Usually the longest stage; requires greater levels of care.

Question 134

Alzheimer's *Treatment Plan* Most patients with Alzheimer’s disease are taken care of at ____ by a ____ member or caregiver during the early stages of the disease. As disease progresses, many patients are placed in skilled _____ facilities, or \_\_\_\_\_-living dementia units. In later stages of the disease, families may consider _____ care.

Answer 134

Most patients with Alzheimer’s disease are taken care of at home by a family member or caregiver during the early stages of the disease. As disease progresses, many patients are placed in skilled nursing facilities, or assisted-living dementia units. In later stages of the disease, families may consider hospice care.

Question 135

Alzheimer's Treatment ***Mild to moderate (MMSE 10–26)**:* Begin trial of a **(1) inhibitor** (increases longevity of acetylcholine), such as **\_\_\_\_\_ (Aricept), _____ (Exelon), g\_\_\_\_\_\_**, or **(1) receptor agonist** **\_\_\_\_\_\_\_ (Namenda)** PO daily to BID. ***Moderate-to-advanced dementia (MMSE \<17)**:* Add (1) (10 mg BID) to cholinesterase inhibitor or use memantine \_\_\_\_\_. ***Severe dementia (MMSE \<10)**:* Continue memantine or _____ drug. Improvement within __ to\_\_ months. ___ if no longer effective.

Answer 135

***Mild to moderate (MMSE 10–26)**:* Begin trial of a **cholinesterase inhibitor** (increases longevity of acetylcholine), such as **donepezil (Aricept), rivastigmine (Exelon), galantamine,** or **N-methyl-d-aspartate (NMDA) receptor agonist** **memantine (Namenda)** PO daily to BID. ***Moderate-to-advanced dementia (MMSE \<17)**:* Add **memantine** (10 mg BID) to cholinesterase inhibitor or use memantine alone. ***Severe dementia (MMSE \<10)**:* Continue memantine or discontinue drug. Improvement within 3 to 6 months. Stop if no longer effective.

Question 136

*Adjunct Treatment* Alzheimer's ## Footnote \_\_\_\_\_ activity and ex\_\_\_\_\_ have been shown to slow functional decline in patients. * \_\_\_\_\_\_ (caprylidene):* Prescription triglyceride-rich medical food (consumed as a shake) that addresses diminished cerebral ______ metabolism by assisting the body in metabolizing ______ bodies as an alternative fuel source for the brain. Should be medically supervised. * Vitamin \_\_:* 2,000 IU daily recommended for mild-to-moderate Alzheimer’s disease. Not recommended for other forms of dementia.

Answer 136

Physical activity and exercise have been shown to slow functional decline in patients. * Axona (caprylidene):* Prescription triglyceride-rich medical food (consumed as a shake) that addresses diminished cerebral glucose metabolism by assisting the body in metabolizing ketone bodies as an alternative fuel source for the brain. Should be medically supervised. * Vitamin E:* 2,000 IU daily recommended for mild-to-moderate Alzheimer’s disease. Not recommended for other forms of dementia.

Question 137

Alzheimer's *Rehabilitation* ## Footnote * C\_\_\_\_\_\_ rehabilitation:* May help during early stages of dementia. * O\_\_\_\_\_\_\_ therapy:* May improve performance of ADLs.

Answer 137

* Cognitive rehabilitation:* May help during early stages of dementia. * Occupational therapy:* May improve performance of ADLs.

Question 138

*Driving and Early-Stage or Mild Dementia* Evaluate for s\_\_\_\_\_ and monitor reg\_\_\_\_\_. Ask family or close contacts about patient’s dr\_\_\_\_ ability, traffic acc\_\_\_\_\_, getting l\_\_\_, difficulty making decisions, and so forth. *Complications* Death is usually due to an overwhelming infection such as pn\_\_\_\_\_ and s\_\_\_\_\_. \_\_\_ fractures are also a common cause of death (from complications).

Answer 138

*Driving and Early-Stage or Mild Dementia* Evaluate for safety and monitor regularly. Ask family or close contacts about patient’s driving ability, traffic accidents, getting lost, difficulty making decisions, and so forth. *Complications* Death is usually due to an overwhelming infection such as pneumonia and sepsis. Hip fractures are also a common cause of death (from complications).

Question 139

#1 Cause of Dementia #2 Cause of Dementia

Answer 139

#1 Alzheimer’s disease #2 Vascular dementia

Question 140

(1) Type of Dementia **Brain Pathology:** Deposits of **beta amyloid protein and neurofibrillary tangles** on the **frontal** and **temporal** lobes **Presentation:** Early signs are **short-term memory loss** such as difficulty remembering names and recent events, plus wandering, apathy, **apraxia, aphasia, and agnosia.** Progression to impaired judgment, **executive** skills, confusion, and **behavioral** changes. Terminal stage is characterized by difficulty speaking, swallowing, and walking.

Answer 140

Alzheimer’s disease (#1 cause of dementia)

Question 141

(1) Type of Dementia **Brain Pathology:** **Multi-infarct/ischemic damage** due to **atherosclerotic plaques,** bleeding, and/or blood clots **Presentation:** Symptoms of **stroke** with **cognitive symptoms** such as memory loss, impaired executive function, impaired judgment, and apathy; location of infarct determines symptoms.

Answer 141

Vascular dementia (#2 cause of dementia)

Question 142

(1) Type of Dementia **Brain Pathology:** Alpha-synuclein protein (1) **Presentation:** Causes sleep disturbance/insomnia, **\_\_\_\_\_ hall\_\_\_\_\_**; executive function is impaired plus **(1)** (muscle rigidity, tremors), with fluctuations in alertness and cognition; sensitive to adverse effects of neuroleptics.

Answer 142

Dementia with Lewy bodies ## Footnote **Brain Pathology:** Alpha-synuclein protein (**Lewy bodies**) **Presentation:** Causes sleep disturbance/insomnia, **visual hallucinations;** executive function is impaired plus **parkinsonism** (muscle rigidity, tremors), with fluctuations in alertness and cognition; sensitive to adverse effects of neuroleptics.

Question 143

(1) Type of Dementia **Brain Pathology: Loss of dopamine receptors** in the **basal ganglia of the substantia nigra** **Presentation:** Causes **rigidity, bradykinesia, difficulty initiating voluntary movements, pill-rolling tremor, masked facies, depression**, plus features of **DLB** (sleep disturbance, **visual hallucinations**); 40% of these patients develop dementia

Answer 143

Parkinson’s disease

Question 144

(1) previously known as (1) Type of Dementia **Brain Pathology:** Orbital and frontal areas of brain (orbitofrontal) **Presentation:** Causes **personality change**, social withdrawal, loss of spontaneity, loss of motivation/desire to do task (abulia), **impulsive**, **disinhibition**; exhibits utilization behavior (e.g., uses and reuses same object as in using a spoon to eat, comb hair, waving it)

Answer 144

Frontotemporal dementia (Pick’s disease)

Question 145

(1) Type of Disease **Brain Pathology** Mixture of two or more types (e.g., Alzheimer’s and vascular dementia) **Presentation:** If Alzheimer’s and vascular dementia, symptoms of both conditions are present

Answer 145

Mixed dementia

Question 146

(1) Type of Dementia **Brain Pathology:** Chronic thiamine (vitamin B1) deficiency due to chronic alcohol abuse causes brain damage **Presentation:** Causes confusion, disorientation, indifference, horizontal movement nystagmus (both eyes); thiamine IV in high doses can help, but if late diagnosis, permanent brain damage. If caught early, treatment with high-dose thiamine may reverse some symptoms. Most have permanent brain damage

Answer 146

Wernicke–Korsakoff syndrome (or Wernicke’s encephalopathy)

Question 147

(1) Type of Dementia **Brain Pathology:** Increased amount of cerebrospinal fluid (but normal intracranial pressure) **Presentation:** Causes difficulty walking (body bent forward, legs wide apart, slow). Impaired thinking, executive function impaired, reduced concentration, apathy, changes in personality; brain shunt surgery to decrease intercranial pressure may help.

Answer 147

Normal pressure hydrocephalus

Question 148

Parkinson’s Disease More common after __ years of age. Men are ____ likely to have Parkinson’s disease (PD) than women (1.5:1). **Classic three symptoms (3)** Parkinson’s d\_\_\_\_\_ is common (up to 40%). Dep\_\_\_\_\_\_ is common (up to two-thirds of all patients)

Answer 148

Progressive neurodegenerative disease with marked **decrease in dopamine** production More common after 50 years of age. Men are more likely to have Parkinson’s disease (PD) than women (1.5:1). The classic three symptoms are **tremor (worse at rest), muscular rigidity, and bradykinesia.** Parkinson’s dementia is common (up to 40%). Depression is common (up to two-thirds of all patients)

Question 149

Classic Case of Parkinson's Disease An elderly patient complains of a gradual onset of motor symptoms such as pill-rolling _____ of the hands and cogwheel ______ with difficulty _______ voluntary movement. Walks with slow _______ gait. Has poor balance and often falls (1). Generalized muscular _____ with ______ facies. Mood disorders such as anxiety and \_\_\_\_\_\_. Excessive daytime \_\_\_\_\_iness. Difficulty with ______ function (making plans, decisions, tasks). May have signs and symptoms of d\_\_\_\_\_\_ . Worsening of seborrheic dermatitis (white scales, erythema).

Answer 149

An elderly patient complains of a gradual onset of motor symptoms such as pill-rolling tremors of the hands and cogwheel rigidity with difficulty initiating voluntary movement. Walks with slow shuffling gait. Has poor balance and often falls (postural instability). Generalized muscular rigidity with masked facies. Mood disorders such as anxiety and depression. Excessive daytime sleepiness. Difficulty with executive function (making plans, decisions, tasks). May have signs and symptoms of dementia. Worsening of seborrheic dermatitis (white scales, erythema).

Question 150

Parkinson's Treatment Plan Mild PD symptoms = Mod-Severe PD symptoms =

Answer 150

Mild PD symptoms = do not markedly interfere with function, it is usually **not necessary to prescribe carbidopa–levodopa** immediately after diagnosis. Mod-Severe PD symptoms = **Consider treatment** for significant bradykinesia or gait disturbance, moderate-to-severe hand tremors (dominant hand), depending on patient preference, and the degree that the tremors interfere with ADLs, work, and social function. Ask the patient about fatigue (71%), which is more common than tremors (68%). May nap more frequently.

Question 151

* First Line Drug for Parkinson's* * (1)* Start at ____ doses. Sinemet 25/100 mg (half tablet) PO BID to TID with meal or snack to avoid \_\_\_\_\_. Titrate up ______ to control symptoms. Sudden withdrawal or dose reductions of levodopa or dopamine agonists (e.g., bromocriptine, ropinirole) may be associated (rarely) with \_\_kinetic crisis or parkinsonism-hyper\_\_\_\_\_\_ syndrome (fever, autonomic dysfunction, muscular rigidity, altered mental status). *Adverse effects:* Motor fluctuations ((1) phenomenon), \_\_\_kinesia, \_\_\_tonia, dizziness, somnolence, nausea, headache. Eventually will develop _____ dyskinesia (treat with benztropine, amantadine, others).

Answer 151

Carbidopa–levodopa (Sinemet) TID (dopamine precursor) Start at low doses. Sinemet 25/100 mg (half tablet) PO BID to TID with meal or snack to avoid nausea. Titrate up slowly to control symptoms. Sudden withdrawal or dose reductions of levodopa or dopamine agonists (e.g., bromocriptine, ropinirole) may be associated (rarely) with akinetic crisis or parkinsonism-hyperpyrexia syndrome (fever, autonomic dysfunction, muscular rigidity, altered mental status). *Adverse effects:* Motor fluctuations (wearing-off phenomenon), dyskinesia, dystonia, dizziness, somnolence, nausea, headache. Eventually will develop tardive dyskinesia (treat with benztropine, amantadine, others).

Question 152

*Dopamine agonists for Parkinson's* Ergot types, such as bromocriptine (Parlodel), have limited use in Parkinson’s disease; replaced by newer dopamine agonists that are _nonergot_ types, such as (1) Rx * Do not ____ discontinue dopamine agonists. Dopamine withdrawal syndrome (8%–19%) causes ____ attacks, an\_\_\_\_, cr\_\_\_\_drug. * *Adverse effects:* Can cause _____ control disorders (compulsive gambling, sex, or shopping)

Answer 152

Ergot types, such as bromocriptine (Parlodel), have limited use in Parkinson’s disease; replaced by newer dopamine agonists that are nonergot types, such as Pramipexole (Mirapex) * Do not abruptly discontinue dopamine agonists. Dopamine withdrawal syndrome (8%–19%) causes panic attacks, anxiety, craving drug. * *Adverse effects:* Can cause impulse control disorders (compulsive gambling, sex, or shopping)

Question 153

* Monoamine oxidase-B* (*MAO-B) inhibitors:* (2) Rx Do these have any dietary restrictions? How does this drug help in treatment of Parkinsons? *Adverse effects:* May cause insomnia, j\_\_\_\_ness, hall\_\_\_\_\_. Do not combine with MAOIs or ______ antagonists (SSRIs, triptans).

Answer 153

Selegiline (Eldepryl) or Rasagiline (Azilect) Does not have dietary restrictions like monoamine oxidase inhibitors (MAOIs). MAO-B inhibitors **decrease the normal activity of an enzyme -- monoamine oxidase -- that breaks down dopamine after it completes its activity in the brain**. *Adverse effects:* May cause insomnia, jitteriness, hallucinations. Do not combine with MAOIs or serotonin antagonists (SSRIs, triptans).

Question 154

Treatment for tardive dyskinesia (extrapyramidal symptoms) ## Footnote * Administer anti\_\_\_\_\_\_**:* Rx(1) (Cogentin). * Administer _______ (Symmetrel/Osmolex ER):* Anti\_\_\_\_\_(treats type A influenza) and ______ agonist.

Answer 154

* Administer anticholinergics**:* Benztropine (Cogentin). * Administer amantadine (Symmetrel/Osmolex ER):* Antiviral (treats type A influenza) and dopamine agonist.

Question 155

*Nonpharm Treatment of Parkinson's* ## Footnote * Nonpharmacologic:* Ex\_\_\_\_, ph\_\_\_\_ therapy, sp\_\_\_\_ therapy, m\_\_\_fulness, and med\_\_\_\_\_ * Device assistance or surgery:* Consider continuous in\_\_\_\_\_\_ or deep _____ stimulation

Answer 155

* Nonpharmacologic:* Exercise, physical therapy, speech therapy, mindfulness, and meditation * Device assistance or surgery:* Consider continuous infusions or deep brain stimulation

Question 156

Parkinson's Complications ## Footnote *Acute \_\_\_\_\_\_:* Loss of voluntary movement; sudden exacerbation of Parkinson’s disease D\_\_\_\_\_ (40%) Frequent _____ may result in fractures of the face, hips, and so on. Drug-related adverse effects such as _____ dyskinesia, dyst\_\_\_\_, _____ fluctuations

Answer 156

*Acute akinesia:* Loss of voluntary movement; sudden exacerbation of Parkinson’s disease Dementia (40%) Frequent falls may result in fractures of the face, hips, and so on. Drug-related adverse effects such as tardive dyskinesia, dystonia, motor fluctuations

Question 157

(1) The most common type of action or postural tremor. Usually seen in the arms or the hands and may progress to include the head. Exact etiology is unknown. Can occur in children and adults. It is ___ curable, but the symptoms can be controlled by medication. In some patients with essential tremor, the tremors can ______ with anxiety and may _____ with small amounts of alcohol. Medications can be taken as needed (anxiety) or daily

Answer 157

Essential Tremor Can occur in children and adults. It is not curable, but the symptoms can be controlled by medication. In some patients with essential tremor, the tremors can worsen with anxiety and may improve with small amounts of alcohol. Medications can be taken as needed (anxiety) or daily

Question 158

Essential Tremor Treatment Rx(1) 60 to 320 mg per day. Long-acting version Rx(1) is also effective, but it provides the ____ response as “regular” propranolol. *Contraindications (beta-blockers):* A\_\_\_\_, C\_\_\_\_, second- to third-degree (1), \_\_\_\_cardia. Rx(1) Refer to (1) for evaluation and treatment.

Answer 158

Propranolol 60 to 320 mg per day. Long-acting propranolol (Inderal LA) is also effective, but it provides the same response as “regular” propranolol. *Contraindications (beta-blockers):* Asthma, COPD, second- to third-degree heart block, bradycardia. Primidone (Mysoline) 25 to 750 mg per day at bedtime Refer to neurologist for evaluation and treatment.

Question 159

Neurocognitive Findings ## Footnote * (1):* Loss of motivation or desire to do tasks; loss of willpower; indifference to social norms (e.g., urinates in public) * (1):* Intense need to move because of severe feelings of restlessness * (1):* Reduced voluntary muscle movement (e.g., Parkinson’s disease) * (1):* Memory loss; (1) is memory loss of recent events (occurs during disease), and (1) is memory loss of events in the past (before the onset of disease)

Answer 159

* Abulia:* Loss of motivation or desire to do tasks; loss of willpower; indifference to social norms (e.g., urinates in public) * Akathisia:* Intense need to move because of severe feelings of restlessness * Akinesia:* Reduced voluntary muscle movement (e.g., Parkinson’s disease) * Amnesia:* Memory loss; anterograde amnesia is memory loss of recent events (occurs during disease), and retrograde amnesia is memory loss of events in the past (before the onset of disease)

Question 160

Neurocognitive Findings ## Footnote * (1):* Problems recalling words or names * (1):* Difficulty using (speech) and/or understanding language; can include difficulty with speaking, comprehension, and written language * (1):* Difficulty with or inability to remember learned motor skill * (1):* Inability to recognize familiar objects placed in the palm (place a coin on palm with eyes closed and ask patient to identify object)

Answer 160

* Anomia:* Problems recalling words or names * Aphasia:* Difficulty using (speech) and/or understanding language; can include difficulty with speaking, comprehension, and written language * Apraxia:* Difficulty with or inability to remember learned motor skill * Astereognosis:* Inability to recognize familiar objects placed in the palm (place a coin on palm with eyes closed and ask patient to identify object)

Question 161

Neurocognitive Findings ## Footnote * (1):* Difficulty coordinating voluntary movement * (1):* “Lying” or fabrication of events due to inability to remember the event * (1):* Abnormal involuntary jerky movements * (1):* Abnormal movements and muscle tone (continuous muscle spasms)

Answer 161

* Ataxia:* Difficulty coordinating voluntary movement * Confabulation:* “Lying” or fabrication of events due to inability to remember the event * Dyskinesia:* Abnormal involuntary jerky movements * Dystonia:* Abnormal movements and muscle tone (continuous muscle spasms)

Question 162

Exam Tips ## Footnote A question will ask you to identify the MMSE “activity” that is being performed. When a person is asked to interpret a proverb (given by the nurse practitioner [NP]), it is a test of _____ thinking. Wernicke–Korsakoff syndrome is caused by (1) deficiency The (1) is the most popular screening test for dementia and the most commonly used test for Alzheimer’s disease. (1) disease is the most common cause of dementia in the United States. (1) dementia is the second most common cause of dementia. Recognize classic presentation of Parkinson’s and Alzheimer’s diseases.

Answer 162

A question will ask you to identify the MMSE “activity” that is being performed. When a person is asked to interpret a proverb (given by the nurse practitioner [NP]), it is a test of abstract thinking. Wernicke–Korsakoff syndrome is caused by vitamin B1 (thiamine) deficiency The MMSE is the most popular screening test for dementia and the most commonly used test for Alzheimer’s disease. Alzheimer’s disease is the most common cause of dementia in the United States. Vascular dementia is the second most common cause of dementia. Recognize classic presentation of Parkinson’s and Alzheimer’s diseases.

Question 163

Exam Tips Recognize the “sundowning” phenomenon. First-line treatment for Parkinson’s disease is (1)Rx immediate release. Selegiline (Eldepryl) is an _____ drug ______ food interactions. It affects the ______ system; any drug that alters serotonin will increase risk of serotonin syndrome. * Drugs that alter serotonin are the S\_\_\_\_, S\_\_\_\_, T\_\_\_\_, MAOIs, and tr\_\_\_\_\_. Allow at least ___ days (or longer) to pass before starting another drug that affects serotonin. Essential tremor is an “\_\_\_\_\_” or postural tremor (not a resting tremor). First-line treatment for essential tremor is Rx(1).

Answer 163

Recognize the “sundowning” phenomenon. First-line treatment for Parkinson’s disease is levodopa (Sinemet) immediate release. Selegiline (Eldepryl) is an MAO-B drug without food interactions. It affects the serotonin system; any drug that alters serotonin will increase risk of serotonin syndrome. * Drugs that alter serotonin are the SSRIs, SNRIs, TCAs, MAOIs, and triptans. Allow at least 14 days (or longer) to pass before starting another drug that affects serotonin. Essential tremor is an “action” or postural tremor (not a resting tremor). First-line treatment for essential tremor is beta-blockers (propranolol).

Question 164

Clinical Pearls ## Footnote Refer patients with suspected Alzheimer’s disease and Parkinson’s disease to a (1) for diagnostic evaluation and management. (1) is a common cause of acute mental status changes in the elderly. Order a (1) in all elderly patients with acute mental status changes or delirium. Idiopathic Parkinson’s disease is associated with low serum vitamin ____ levels due to levodopa. Check the vitamin B12 level. Some clinicians postpone levodopa use in early-onset Parkinson’s disease (younger than 60 years) because of higher incidence of levodopa-related \_\_\_\_\_\_\_\_. \_\_\_\_\_\_\_ drugs can exacerbate or worsen Parkinson’s disease symptoms.

Answer 164

Refer patients with suspected Alzheimer’s disease and Parkinson’s disease to a neurologist for diagnostic evaluation and management. UTI is a common cause of acute mental status changes in the elderly. Order a UA in all elderly patients with acute mental status changes or delirium. Idiopathic Parkinson’s disease is associated with low serum vitamin B12 levels due to levodopa. Check the vitamin B12 level. Some clinicians postpone levodopa use in early-onset Parkinson’s disease (younger than 60 years) because of higher incidence of levodopa-related dyskinesia. Cholinergic drugs can exacerbate or worsen Parkinson’s disease symptoms.

Question 165

Pharmacologic Issues: Older Adults Drug clearance is affected by r\_\_\_\_ impairment, a less efficient liver cytochrome ____ system, malabsorption, and relatively higher \_\_\_\_:\_\_\_\_\_ tissue ratio (extends half-life, fat-soluble drugs). Older adults have an increased sensitivity to ben\_\_\_\_\_\_, hyp\_\_\_\_, T\_\_\_, and antip\_\_\_\_\_. The American Geriatrics Society (AGS) provides a _____ Criteria^® list of potentially inappropriate medication use in older adults (**_AGS, 2019_**). \_\_\_prescribing measures should be used when appropriate for elderly patients.

Question 166

Beers Criteria: Potentially Inappropriate Medications for Older Adults

Answer 166

Question 167

Beers Criteria: Potentially Inappropriate Medications for Older Adults

Answer 167

Question 168

Geriatric Syndromes Associated with Polypharmacy ## Footnote * (1):* Anticholinergics, calcium channel blockers, opioids * (1):* Anticholinergics, antihypertensives, sulfonylureas (long-term use) * D\_\_\_\_ and D\_\_\_\_\_\_\_:* Anticholinergics, benzodiazepines, corticosteroids, H2 antagonists, sedative hypnotics * (1):* Anticonvulsants, antidepressants (SSRIs and TCAs), antihypertensives (specifically alpha-blockers → orthostatic hypotension), antipsychotics, benzodiazepines, opioids * (1):* Anticholinesterase inhibitors, antidepressants, antihistamines, antihypertensives (specifically calcium channel blockers, diuretics, alpha-1 blockers), antipsychotics, opioids, sedative-hypnotics

Answer 168

* Constipation:* Anticholinergics, calcium channel blockers, opioids * Dizziness:* Anticholinergics, antihypertensives, sulfonylureas (long-term use) * Delirium and dementia:* Anticholinergics, benzodiazepines, corticosteroids, H2 antagonists, sedative hypnotics * Falls:* Anticonvulsants, antidepressants (SSRIs and TCAs), antihypertensives (specifically alpha-blockers → orthostatic hypotension), antipsychotics, benzodiazepines, opioids * Urinary incontinence:* Anticholinesterase inhibitors, antidepressants, antihistamines, antihypertensives (specifically calcium channel blockers, diuretics, alpha-1 blockers), antipsychotics, opioids, sedative-hypnotics