Gerontology Flashcards

Question 1

Q

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

A

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

Q

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

A

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

Q

(1)

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

Answer

A

Seborrheic Keratoses

Question 4

Q

(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

A

Senile Purpura

Question 5

Q

(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

A

Lentigines

Question 6

Q

(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

A

Stasis Dermatitis

Question 7

Q

(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

A

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

Q

Nails

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

Answer

A

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

Question 9

Q

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

A

Presbyopia

Question 10

Q

(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

A

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

Q

(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

A

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

Q

(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

A

Glaucoma

Tests: Visual fields and tonometer

Question 13

Q

(1)

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

Test: (1)

Answer

A

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

Q

(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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

Sex Hormones

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

Exam Tips

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

A

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

Q

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

A

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

Q

(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

A

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

Q

(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

A

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

Q

(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

A

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

Q

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

A

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

Q

(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

A

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

Q

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

A

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

Q

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

A

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

Q

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

A

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

Q

Elder Abuse

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

A

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

Q

Interview Elder Alone With These Three Questions

Do you feel ____ where you live?

Who handles your b____ and f______?

Who prepares your m____?

Answer

A

Do you feel safe where you live?

Who handles your bills and finances?

Who prepares your meals?

Question 46

Q

Top Three Leading Causes of Death (>65 Years)

(1) Disease
(1) (lung and colorectal)
Chronic lower ______ diseases ie (1)

Answer

A

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

Question 47

Q

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

A

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

Q

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

A

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

Q

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

A

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.

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

Q

Lung Cancer USPSTF Screening

=

When to stop screening?

Answer

A

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

Q

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

A

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

Q

Lung Cancer Treatment Plan

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

A

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

Q

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

A

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

Q

Colorectal Cancer Screening

=

what about Cologuard?

Answer

A

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

Q

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

A

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

Q

Colorectal Cancer Treatment Plan

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

A

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

Q

(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

A

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

Q

CRAB

=

Criteria for Multiple Myeloma

Answer

A

Calcium levels elevated

Renal insufficiency

Anemia

Bone disease

Question 59

Q

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

A

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

Q

Multiple Myeloma Treatment Plan

Baseline labs include C___, F____, (1) panel, and U__.

Refer patient to a (1).

Answer

A

Baseline labs include CBC, FOBT, chemistry panel, and UA.

Refer patient to a hematologist.

Question 61

Q

(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

A

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

Q

Pancreatic Cancer Treatment Plan

Initial labs include A____, A___, A____, bi____, li____, and (1) tumor marker.

Refer to a (1) surgeon for (1) procedure or other interventions.

Answer

A

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

Q

Exam Tips

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

A

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

Q

Clinical Pearls

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

A

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.

Answer 65

A

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.

Answer 66

A

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.

Answer 67

A

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.

Answer 68

A

Urinary Tract Infections

Answer 69

A

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.

Answer 70

A

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

Answer 71

A

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.

Answer 72

A

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.

Answer 73

A

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.

Answer 74

A

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.

Answer 75

A

Stress incontinence

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

Answer 76

A

Urge incontinence

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

Answer 77

A

Overflow incontinence

Plan: BPH treatment.

Answer 78

A

Functional incontinence

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

Answer 79

A

Mixed Incontinence

Answer 80

A

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.

Answer 81

A

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.

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.

Answer 82

A

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

Answer 83

A

Mirabegron (Myrbetriq): 25 to 50 mg extended-release tablets

Second-line therapy

Contraindications: Hypersensitivity

Answer 84

A

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.

Answer 85

A

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.

Answer 86

A

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.

Answer 87

A

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.

Answer 88

A

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.

Answer 89

A

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

Answer 90

A

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.

Answer 91

A

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).

Answer 92

A

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).

Answer 93

A

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.

Answer 94

A

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

Answer 95

A

Stimulants (irritants)

Bisacodyl (Dulcolax), oral and suppository

Senna extract (Senokot), oral

Aloe vera juice

Notes: Stimulates colon directly, causing contractions; drug class: anthraquinone

Answer 96

A

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

Answer 97

A

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

Answer 98

A

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)

Answer 99

A

Chloride channel activators

Lubiprostone (Amitiza)

Notes: _____ chronic constipation, IBS; Contraindications: History of mechanical ______

Answer 100

A

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

Answer 101

A

Stool Softeners

Docusate sodium (Colace)

Notes: Softens stool (does not stimulate colon), Stool becomes soft and slippery

Answer 102

A

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.

Answer 103

A

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.

Answer 104

A

Activities of Daily Living

Katz Index of Independence in Activities of Daily Living

Lawton Instrumental Activities of Daily Living Scale

Fried Physical Frailty Phenotype

Answer 105

A

Self-care activities that are necessary for “independent” living depending on the person’s environment (e.g., home, retirement community, nursing home).

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

Answer 106

A

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)

Answer 107

A

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)

Answer 108

A

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)

Answer 109

A

Ability to use telephone
Shopping
Food preparation
Housekeeping
Laundry
Mode of transportation
Responsibility for own medications
Ability to handle finances

Answer 110

A

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.”

Answer 111

A

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)*

Answer 112

A

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)

Answer 113

A

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.

Answer 114

A

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.

Answer 115

A

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)

Answer 116

A

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.

Answer 117

A

Addenbrooke’s Cognitive Examination III (ACE-III)

Answer 118

A

Revised Index of Social Engagement (RISE)

Answer 119

A

Geriatric Depression Scale (Short Form; GDS-SF)

Answer 120

A

Patient Health Questionnaire-9 (PHQ-9)

Answer 121

A

Delirium (Acute Confusional State)

Remove offending agent and/or treat illness, infection, or metabolic derangement and delirium resolves.

Answer 122

A

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

Answer 123

A

“Sundowning” Phenomenon

Answer 124

A

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).

Answer 125

A

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.

Answer 126

A

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

Answer 127

A

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

Answer 128

A

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.

Answer 129

A

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)

Answer 130

A

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

Answer 131

A

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

Answer 132

A

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

Answer 133

A

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.

Answer 134

A

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.

Answer 135

A

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.

Answer 136

A

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

Answer 137

A

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).

Answer 138

A

1 Alzheimer’s disease

Answer 139

A

Alzheimer’s disease

(#1 cause of dementia)

Answer 140

A

Vascular dementia

(#2 cause of dementia)

Answer 141

A

Dementia with Lewy bodies

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.

Answer 142

A

Parkinson’s disease

Answer 143

A

Frontotemporal dementia (Pick’s disease)

Answer 144

A

Mixed dementia

Answer 145

A

Wernicke–Korsakoff syndrome (or Wernicke’s encephalopathy)

Answer 146

A

Normal pressure hydrocephalus

Answer 147

A

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)

Answer 148

A

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).

Answer 149

A

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.

Answer 150

A

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).

Answer 151

A

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)

Answer 152

A

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).

Answer 153

A

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

Answer 154

A

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

Answer 155

A

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

Answer 156

A

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

Answer 157

A

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.

Answer 158

A

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)

Answer 159

A

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)

Answer 160

A

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)

Answer 161

A

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.

Answer 162

A

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).

Answer 163

A

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.

Answer 164

A

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

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Gerontology Flashcards

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