Download Geriatrics Update via Board Review Questions

Geriatrics Update via Board
Review Questions
From ABIM 2015
Copyright ABIM
Q1: Insomnia Treatment
• A 68-year-old man who has insomnia is establishing care in
your office because he recently moved to the area to live
closer to his children. The patient is due for a refill of
lorazepam, 2 mg orally at bedtime, prescribed by his previous
physician for insomnia. According to the patient's medical
records, the patient's physician prescribed lorazepam after a
thorough evaluation for insomnia revealed no underlying
medical or psychological disorder. Over the past year, the
lorazepam dosage was gradually increased, and the patient
states that the current dosage has been effective. He reports
no adverse effects from the medication; he does not have any
difficulties with cognition or gait and has had no falls.
Which of the following should you do now?
A. Continue lorazepam
B. Discontinue lorazepam and begin clonazepam
C. Inform the patient that you will not prescribe a
benzodiazepine because of the risk of cognitive
deficits, falls, and hip fractures in older adults
using this medication
D. Provide educational material regarding the risks of
benzodiazepine use, discuss a stepwise
medication-tapering protocol, and review
measures to improve sleep hygiene
Rationale
•
As part of The American Board of Internal Medicine Foundation Choosing Wisely Campaign, the
American Geriatrics Society recommends against the use of benzodiazepine drugs for adults 65
years of age or older as first-line treatment for insomnia. This recommendation is based on
studies that have demonstrated increased risk of cognitive deficits, falls, and hip fractures in older
adults using benzodiazepines. Although the patient in this question has not had adverse events
due to the medication, continuing to take it will continue to put him at risk. A trial of improved
sleep habits (e.g., sleep hygiene techniques) is usually the best first approach and may improve
symptoms of insomnia. An attempt at nonpharmacologic management by improving sleep
hygiene has not been documented in the patient's medical records and would be appropriate. A
recent study demonstrated that providing patients with educational material about the risk of
benzodiazepines and information on how to safely taper the medication effectively elicited
shared decision making about the overuse of benzodiazepines and led to increased
benzodiazepine discontinuation. An intervention that educates patients about inappropriate
medication use and empowers them to share in the decision-making process to de-prescribe can
be more effective than unilaterally stopping medication. This latter approach may harm the
patient-provider relationship. In addition, patients may seek medications from another source if
they are not provided adequate education regarding the harms of the medication. Abrupt
discontinuation of benzodiazepines is not recommended because the patient can experience
withdrawal symptoms. Clonazepam has not been found to be safer than lorazepam in geriatric
patients.
Choosing Wisely:
Don’t use benzodiazepines or other sedativehypnotics in older adults as first choice for
insomnia, agitation, or delirium.
Large-scale studies consistently show that the risk of motor vehicle
accidents, falls, and hip fractures leading to hospitalization and death
can more than double in older adults taking benzodiazepines and
other sedative-hypnotics. Older patients, their caregivers, and their
providers should recognize these potential harms when considering
treatment strategies for insomnia, agitation, or delirium. Use of
benzodiazepines should be reserved for alcohol withdrawal
symptoms/delirium tremens or severe generalized anxiety disorder
unresponsive to other therapies.
For further information, see the following:
• Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S.
Reduction of inappropriate benzodiazepine prescriptions among
older adults through direct patient education: The EMPOWER
Cluster Randomized Trial. JAMA Intern Med. 2014;174(6):890–898.
doi:10.1001/jamainternmed.2014.949.
• Schutte-Rodin S, Broch L, Buysse D, et al. Clinical guideline for the
evaluation and management of chronic insomnia in adults. J Clin
Sleep Med. 2008;4:487–504.
• AGS Choosing Wisely Workgroup. American Geriatrics Society
identifies another five things that healthcare providers and patients
should question. J Am Geriatr Soc. 2014;62:950–960.
Q2: Managing Hypertension
• A 75-year-old man comes to your office to establish primary care. The
patient has hypertension but no known history of diabetes mellitus or
chronic kidney disease. He smoked one pack of cigarettes daily for 20
years, but quit more than 20 years ago. His current daily medications are
aspirin, 81 mg; lisinopril, 5 mg; and hydrochlorothiazide, 25 mg. Home
blood pressures measured over the past week were 132/65 mm Hg,
146/78 mm Hg, 149/82 mm Hg, and 139/75 mm Hg. The review of
systems is unremarkable.
• On physical examination, the patient appears well. Sitting blood pressure
is 149/85 mm Hg and sitting pulse rate is 80 per minute. Standing blood
pressure is 135/80 mm Hg and standing pulse rate is 88 per minute. On
standing, he does not become lightheaded. The lungs are clear; heart
sounds are regular with no murmurs, rubs, or gallops. He has no carotid
or abdominal bruits. Peripheral pulses are strong. There is no lowerextremity edema.
• Lab: Creatinine = 1.0 (0.7-1.5), K+ = 3.9 (3.5 – 5.0)
Which of the following should you recommend now for
management of this patient's hypertension?
A. Decrease hydrochlorothiazide to 12.5 mg
daily
B. Increase lisinopril to 7.5 mg daily
C. Add amlodipine, 2.5 mg daily
D. Continue current regimen
Rationale
•
The prevalence of hypertension in adults older than age 65 years is
approximately 70%. The best evidence supports pharmacologic treatment of
elevated blood pressure in older adults to prevent stroke, heart failure, and
coronary artery disease. The goal blood pressure, however, has been a point of
debate, with some observational evidence indicating that lower blood pressure
(possibly due to overtreatment) is associated with higher mortality and other
adverse outcomes, such as injurious falls. The Eighth Joint National Committee
recently recommended treatment of blood pressure in adults older than age 60
without diabetes mellitus or chronic kidney disease to a goal of less than 150
mm Hg systolic and less than 90 mm Hg diastolic. A corollary to this
recommendation indicates that in older adults whose treated blood pressure is
currently less than 140 mm Hg (the old goal) and who seem to tolerate this
lower blood pressure, there is no need to decrease medication. In this case,
the patient is at goal according to the current guidelines. Despite a few
measures below 140 mm Hg, there is no indication to decrease his medication
dosage, although continued monitoring for overtreatment is warranted, given
his slight decrease in systolic blood pressure with orthostatic positioning.
For further information, see the following:
• James PA, Oparil S, Carter BL, et al. 2014 evidencebased guideline for the management of high blood
pressure in adults: report from the panel members
appointed to the Eighth Joint National Committee
(JNC 8). JAMA. 2014;311(5):507–520.
• Tinetti ME, Han L, Lee DH, et al. Antihypertensive
medications and serious fall injuries in a nationally
representative sample of older adults. JAMA Intern
Med. 2014;174(4):588–595.
Q3: Screening in the Elderly
• You are seeing an 85-year-old woman in your primary care practice
at a continuing care retirement community. Two months ago, the
patient had a non-ST-segment elevation myocardial infarction that
was complicated by heart failure. She also has hypertension and
hyperlipidemia. She says that she feels well and is participating in
cardiac rehabilitation without symptoms. Her medications are
metoprolol, lisinopril, atorvastatin, and aspirin.
• On physical examination, heart rate is 68 beats per minute and
blood pressure is 120/65 mm Hg. There is no jugular venous
distention. Cardiopulmonary examination is normal. No peripheral
edema is present.
• At the end of the visit, the patient mentions that she is due for her
annual mammogram. You recall that she has had them annually for
more than 30 years, with biopsies of benign lesions on at least two
occasions.
Which of the following represents the source of greatest harm
from breast cancer screening for this patient?
A. Diagnosis of cancer that is unlikely to benefit
from treatment
B. Stress from false-positive result
C. Pain and discomfort of the procedure
D. Cost of the procedure
Rationale
•
Important questions remain about how long to continue screening mammograms for
older women. In part, the dilemma is related to the lack of inclusion of women older
than age 75 in breast cancer screening trials. Current guidelines recommend that
women should consider stopping annual screening mammography when their life
expectancy is less than 10 years. In the case presented in this question, the previously
healthy 85-year-old woman now has coronary artery disease and congestive heart
failure. While her recovery has progressed smoothly and her overall prognosis seems
good, her level of health and life expectancy now predict that she has a median survival
of 5 to 7 years (instead of 10 years). Initiating discussions about life expectancy and
stopping screening can be difficult for patients and health care providers. A recent
review recommends that the conversation focus on potential harms for a patient who
has limited life expectancy. For this patient, who has endured mammograms for years
(including false-positives and biopsies) and is willing to continue them, it is unlikely that
psychological stress, discomfort, or cost will be the major limiting factor. For her, the
greatest risk is diagnosis of a tumor that would not have otherwise shortened her life or
adversely impacted her quality of life. Specifically, the potential harms of surgery,
radiation, or chemotherapy and the stress of the diagnosis all present significant
potential negative effects.
An ideal screening test would be a reasonably priced, noninvasive procedure. This
screening test must identify a disease that is clinically significant and that, if left
untreated, will cause significant morbidity and mortality. In addition, the ideal screening
test must be for a disease that has a preclinical phase, a presymptomatic stage for which
the disease is detectable. Finally, the disease must have an acceptable treatment
course. The ideal screening test must also be sensitive and specific.
We offer screening tests to those individuals who would consider initiating treatment of
the disease.
For further information, see the following:
• Walter LC, Schonberg MA. Screening
mammography in older women: a review.
JAMA. 2014;311:1336–1347.
Q4: Medications for Alzheimer’s Disease
•
•
•
A 70-year-old man who has Alzheimer's disease has been treated with donepezil, 10
mg orally at bedtime, for the past six months covered by Medicare Part D. He returns
to your office with his wife for a periodic follow-up visit. He has not had nausea,
diarrhea, headache, weight loss, changes in sleep, falls, or syncope. Six months ago,
the patient was unable to perform instrumental activities of daily living (IADLs) such as
paying bills, managing medications, and driving a car. He was able to independently
perform all ADLs and was able to recognize all his family members.
The patient's wife states that she is uncertain if the donepezil is helping her husband's
cognition and worries about the number of medicines he takes. The patient continues
to be dependent in all IADLs. He now needs help choosing proper clothing for the
season; otherwise he remains independent in ADLs.
Findings on physical examination, including orientation, are normal. Laboratory
studies are unremarkable. The patient's score on the Mini Mental State Examination is
20 of 30, which is unchanged from the same examination six months ago.
Which of the following should you recommend
now?
A. Increase the dosage of donepezil to 23 mg
orally daily
B. Discontinue the donepezil
C. Continue the donepezil for an additional six
months
D. Taper off the donepezil for a trial period
Rationale
•
Acetylcholinesterase inhibitors (AChEIs) can improve short-term global function in
patients who have moderate Alzheimer's disease, but the average effect of changes in
cognition is small. Providers should determine cognitive, functional, and behavioral
goals of treatment with patients and caregivers before initiating therapy, and should
consider discontinuing AChEIs after a reasonable trial period on the medication (e.g., 12
weeks) if goals of treatment are not met. A trial period off the medication can be
helpful to determine whether cognitive decline continues at the same rate without
medication or if such decline is accelerated. Six months of medication would be
considered an adequate trial period on the medication, and an additional six months is
not necessary to know whether the patient will experience notable benefit. Abrupt
discontinuation of donepezil is not recommended in the absence of significant adverse
effects, and there is no evidence in the question that the burden of the medication
outweighs the benefit. Donepezil, 10 mg orally at bedtime, is an adequate dosage. A
23-mg formulation of donepezil is available, and in the study by Farlow et al., patients
who took the 23-mg formulation experienced a modest improvement in cognition
compared with those who took the 10-mg formulation. However, in this study
comparing efficacy of the two medication regimens, more individuals in the higher
dosage group withdrew from therapy because of adverse events. If after tapering the
donepezil, the patient's family thinks his dementia has clearly worsened, the medication
can be restarted.
Q5: Management of Delirium
•
•
•
An 83-year-old man who has mild dementia and chronic kidney disease stage 3 was admitted to
the hospital for pyelonephritis, Escherichia coli bacteremia, and acute on chronic renal failure.
Since the admission two days ago, his laboratory parameters have been improving, with a
decrease in leukocytosis, repeat negative blood cultures, and slight decrease in his serum
creatinine. Despite having mild dementia, at baseline the patient was conversant, recognized his
family, could express his needs, and could process simple information. He also has peripheral
arterial disease. Current medications are ceftriaxone, aspirin, amlodipine, and acetaminophen.
Currently on hospital day 2, it is noted that he loses track of his ideas in mid-sentence while
talking and starts picking at the bed sheets. His family says that he is more confused than
previously, seems drowsy every time they visit, and now does not recognize his son. The patient
has repeatedly been told that he is in the hospital with an infection, and each time he has been
told this he has become upset. Last evening, he repeatedly tried to climb out of bed and removed
his intravenous line. Today, he pulled out his intravenous line again even though staff had
covered it up to hide it from sight.
On physical examination, temperature is 38.3 C (100.9 F), heart rate is 96 per minute, and blood
pressure is 148/70 mm Hg. The patient appears restless and is oriented only to person. His speech
is mildly distorted, and he cannot repeat three numbers.
Which of the following should you recommend?
A.
B.
C.
D.
Keeping the television on for distraction
Initiating a bedside sitter
Placing bilateral wrist restraints
Administration of quetiapine, 25 mg once
Rationale
•
The best treatment for delirium is to take measures to prevent its occurrence. Once an
older adult with medical illness has delirium, there are few proven effective treatments.
In addition to treating the underlying causes of delirium, it is generally recommended
that attention be paid to potential discomfort; the sleep-wake cycle; maximizing vision,
hearing, and nutrition; family involvement; and providing a soothing and familiar
environment. The American Geriatrics Society recently listed avoidance of physical
restraints to manage the behavioral symptoms of the hospitalized older adult with
delirium as a recommendation on their second list of 5 things patients and providers
should question. This is part of the Choosing Wisely Campaign. Physical restraints may
lead to increased agitation and injury in people who have dementia or delirium, or both,
and should be used as a last resort. If attempts to protect and hide this patient's
intravenous line do not work, the next step would be to provide a bedside sitter who
could redirect the patient. While turning on the television is a common strategy used
for medical inpatients who are restless, it could interfere with the sleep-wake cycle in
delirious patients and potentially increase agitation through overstimulation. The
television should be reserved for patients who request it. There are no placebocontrolled trials of pharmacologic therapy for delirium treatment in older medical
inpatients (non-intensive care unit, non-surgical).
DSM-5 lists five criteria for delirium:
A. There is a disturbance in attention and awareness.
B. Delirium develops over a short period of time, typically hours to days. There is a change
in baseline attention and awareness. It fluctuates throughout the day.
C. There is also another disturbance in cognition, such as in memory, orientation, language,
and perception.
D. The disturbances in (A.) and (C.) are not better explained by another pre-existing,
established, or evolving neurocognitive disorder. (Having a neurocognitive disorder,
however, increases the risk of the development of delirium.)
E. There must also be evidence that the delirium is due to a direct physiological
consequence of another medical condition, substance intoxication or withdrawal, or
exposure to a toxin, or is due to multiple etiologies.
For further information, see the following:
• Moyer VA. Screening for cognitive impairment in older adults: U.S.
Preventive Services Task Force recommendation statement. Ann
Intern Med. 2014;160:791–797.
• Farlow MR, Salloway S, Tariot PN, et al. Effectiveness and
tolerability of high-dose (23 mg/d) versus standard-dose (10 mg/d)
donepezil in moderate to severe Alzheimer's disease: a 24-week,
randomized, double-blind study. Clin Ther. 2010;32(7):1234–1251.
• AGS Choosing Wisely Workgroup. American Geriatrics Society
identifies another five things that healthcare providers and patients
should question. J Am Geriatr Soc. 2014;62:950–960.
For further information, see the following:
• AGS Choosing Wisely Workgroup. American
Geriatrics Society identifies another five things that
healthcare providers and patients should question.
J Am Geriatr Soc. 2014;62:950–960.
• Holroyd-Leduc JM, Khandwala F, Sink KM. How can
delirium best be prevented and managed in older
patients in hospital? CMAJ. 2010;182:265–270.
Q7: Inpatient DVT Prophylaxis
•
•
•
An 80-year-old woman was admitted to the hospital for a heart failure exacerbation. On
hospital day 3, the patient is making steady progress with diuresis but still must have
more improvement in her condition to be discharged. At baseline, she could
independently perform her activities of daily living but needed help with shopping,
cleaning, and cooking because of shortness of breath with minimal exertion. She has
ischemic cardiomyopathy, coronary artery disease, hypertension, and hyperlipidemia.
Current medications are furosemide given intravenously, lisinopril, metoprolol, aspirin,
atorvastatin, potassium chloride, and heparin given subcutaneously twice daily.
Since admission, the patient has expressed her concern about receiving heparin
injections. She has had a moderate amount of bruising on her abdomen, which is
painful. She has asked her nurse several times if she really needs "those shots," and the
nurse has relayed her concerns to you.
BMI at dry weight is 17. On physical examination, heart rate is 70 beats per minute, and
blood pressure is 118/60 mm Hg. Jugular venous pressure is 11 cm at 45 degrees. An S3
gallop is heard. Crackles are heard halfway up in both lung fields. Ecchymoses are seen
on the abdomen, with no surrounding erythema. There is edema (2+) extending to the
knees. She can walk slowly but safely with a walker or assistance.
Which of the following
should you do now?
A. Continue the heparin, and explain its
necessity to the patient
B. Stop the heparin, and start enoxaparin daily
C. Stop the heparin, and encourage the patient
to walk with her family
D. Stop the heparin, and start venous foot
pumps
Rationale
•
It is generally recommended that adults older than age 40 who are hospitalized for medical reasons
and are expected to be less mobile for 3 days or more be given some form of deep venous
thrombosis (DVT) prophylaxis. These data are based on several randomized controlled trials.
However, whether these data apply to frail older adults is less clear. A systematic review and metaanalysis examined the evidence for harm and efficacy of pharmacologic prophylaxis of DVT in older
adults. For the most part, frail older adults are excluded from these trials because cognitive
impairment, renal insufficiency, and other comorbidities common among frail older adults are
exclusion criteria. The data on which the recommendations are based typically report reduction in a
composite endpoint. The majority of events prevented in these composite endpoints are
asymptomatic DVTs. There is no consistent reduction in fatal pulmonary embolism or mortality.
When data from the three trials that included a significant proportion of people older than age 75 are
pooled, a similar reduction in composite endpoints to other trials is seen in the active treatment
group (absolute risk reduction [ARR] range of 3.8% to 14.4%). However, two thirds of these events
are asymptomatic DVTs. The bleeding risk was not reported for subgroups. In the general
population, the authors report the absolute bleeding risk to be increased by 2% in the active
treatment group. Older age, moderate-to-severe renal insufficiency, and low body weight increase
the risk of bleeding over baseline in patients receiving these drugs.
•
Starting enoxaparin instead of twice-daily heparin could be considered; however, it is still an
injection. Given that this patient's quality of life is significantly worsened by these injections, it is
reasonable to stop injection therapy altogether. The current available data suggest that, at best, this
patient would gain a very small absolute risk reduction for symptomatic DVTs and an even smaller
ARR for pulmonary embolism. Patients like this one may not have been included in most studies.
Venous foot pumps have not been shown to reduce the risk of DVT.
For further information, see the following:
• Greig MF, Rochow SB, Crilly MA, Mangoni AA.
Routine pharmacological venous
thromboembolism prophylaxis in frail older
hospitalised patients: where is the evidence?
Age Ageing. 2013;42:428–434.
Q10: Dyspnea
• A 76-year-old woman comes to the emergency department for shortness of
breath for one day. For the past several days, she has had malaise, nasal
congestion, and a nonproductive cough and has needed to rest after walking
a short distance, which is unusual for her. The patient has no other
symptoms and specifically has not had fever, chest pain, palpitations, leg
swelling, lightheadedness, sputum production, hemoptysis, or
gastrointestinal symptoms. She has not traveled recently and has had no sick
contacts. She has osteoporosis and had stage 1 breast cancer, which was
treated 10 years ago. Since that time, she has regularly had normal
mammograms. There is no known history of lung disease, coronary artery
disease, or thromboembolism. Current outpatient medications are
alendronate and a calcium and vitamin D supplement.
• On physical examination the patient appears mildly tachypneic but there is
no increased work of breathing or diaphoresis. Temperature is 36.5 C (97.7
F), heart rate is 98 beats per minute, respirations are 22 per minute, and
blood pressure is 120/70 mm Hg. Arterial oxygen saturation is 97% on room
air. Cardiopulmonary and abdominal examinations are normal. No edema is
present.
• Labs: normal CBC
Which of the following is most appropriate
now?
A. Observation and outpatient investigation of
her symptoms
B. Ultrasound study of the lower extremities
C. CT angiogram
D. Initiation of a heparin drip
Rationale
•
By the two-level Wells score, this woman has an unlikely pretest probability of having a
pulmonary embolism (PE). While there is not an immediate alternative explanation of
her symptoms, it may be reasonable to observe her and have her follow up with her
primary care physician in several days. While traditionally a D-dimer level of 600 µg/L
(0.6 µg/mL) would be considered elevated, a recent prospective validation study found
that age-adjusted D-dimer cutoffs may help eliminate the need for further testing
among older people with non-high pretest probability of PE. The age-adjusted cutoff is
equivalent to age x 10. When this age-adjusted cutoff was used prospectively with a
group of older patients presenting to the emergency department with possible PE
symptoms, almost no one with a true PE was missed. Among those with non-high
pretest probability, 28.2% of the sample had a D-dimer less than 500 µg/L (0.5 µg/mL)
and 11.6% had a D-dimer between 500 µg/L (0.5 µg/mL) and their age-adjusted cutoff.
The 3-month failure rate among the latter group was 1 in 331 (0.3%), which is below the
accepted 3% failure rate from prior angiography studies. Among those older than 75
years, the 3-month failure rate was 0%.
•
Given the fact that the patient in this question has no leg pain or swelling, and her
pretest probability is unlikely for PE, ultrasound study of the lower extremities is likely to
be normal and a CT angiogram could unnecessarily expose her to a dye load. Similarly,
starting heparin with low clinical suspicion would not be indicated.
For further information, see the following:
• Righini M, Van Es J, Den Exter PL, et al. Ageadjusted D-dimer cutoff levels to rule out
pulmonary embolism: the ADJUST-PE study.
JAMA. 2014;311:1117–1124.
Q11: Dementia with Behavioral Disorder
•
•
•
An 82-year-old man who has moderately severe dementia comes into your clinic for
routine follow-up accompanied by his wife. In the past several months, he has had
frequent episodes of nocturnal awakening and wandering around the house. Several
times per week, he has become agitated and verbally aggressive, but he was usually
successfully redirected. Current medications are donepezil, 10 mg daily, and vitamin
D, 800 IU daily. He lives at home with his wife, and she must perform all instrumental
activities of daily living for him and assist with his bathing and dressing. An aide comes
in twice per week to help with the patient's bathing and other chores.
During the visit, you notice the patient's wife looks fatigued and unkempt. When you
ask her how she has been coping, she admits that she feels very overwhelmed. She
does not know how much longer she can provide nearly 24 hour per day care. She is
tearful as she describes her desire to keep her husband at home.
She and the patient have very limited financial resources. He is not hospice eligible.
They have two children who live in the area. She says that she does not like to "bother
them."
In addition to encouraging increased family support, which of the
following should you do to help decrease the patient's wife's distress?
A. Encourage the patient's wife to join a
longitudinal support group
B. Encourage the patient's wife to switch to you
for primary care
C. Start the patient on zolpidem, 5 mg at
bedtime
D. Start the patient on quetiapine, 25 mg at
bedtime
Rationale
•
•
According to Zarit, caregiver burden is defined as "The extent to which caregivers perceive that caregiving
has had an adverse effect on their emotional, social, financial, physical, and spiritual functioning."
Caregiver burden is a common occurrence among caregivers of older adults, particularly women who
reside with the person they care for and provide a significant number of hours of direct care. It is
important that the health care provider ask the caregiver about his or her own well-being, even if the
health care provider does not provide care to the caregiver. A small number of randomized controlled
trials have examined the effects of interventions aimed at patients and at caregivers and their impact on
caregivers' perception of burden and psychological distress. Some interventions have shown a small
positive effect. Support groups or psychoeducational interventions for caregivers of people who have
dementia and pharmacologic interventions (anticholinergic and antipsychotic drugs) for patients had
similar effects on caregiver burden, with effect sizes ranging from 0.09 to 0.27. However, many
psychosocial interventions significantly improved symptoms of distress in caregivers, even if the degree of
burden was not significantly impacted. During group meeting time, many caregiver support groups offer
supervision of loved ones who have dementia.
In this question, given the risks associated with antipsychotic agents, it is reasonable to recommend a
support group before prescribing quetiapine to the patient. Zolpidem is of questionable benefit for sleep,
in general, and has many adverse effects in older adults. It may make practical sense for the patient's
wife to start seeing the same physician as her husband for care, but it has not been studied as an
intervention for burnout and distress. A longitudinal support group provides the best ratio of safety and
efficacy among interventions that have been studied.
For further information, see the following:
• Adelman RD, Tmanova LL, Delgado D, et al.
Caregiver burden: a clinical review. JAMA.
2014;311(10):1052-1060.
• Zarit SH, Todd PA, Zarit JM. Subjective burden
of husbands and wives as caregivers: a
longitudinal study. Gerontologist.
1986;26:260–266.
Q12: End-of-Life Wishes
• An 85-year-old man who has stage IV congestive heart failure (CHF) is
being discharged from a Veterans Administration hospital after
treatment of an exacerbation of his condition. He has had several
previous CHF exacerbation episodes. During the current
hospitalization, he elects a do-not-resuscitate code status. The
patient is not depressed, and he understands his medical condition
and prognosis and the consequences of declining hospitalization and
resuscitation. At the time of discharge, the patient states that he has
strong preferences against any attempt at resuscitation and that he
does not want to be hospitalized again. He lives alone in Oregon, is
divorced, and is estranged from his only son. The patient does not
wish to contact his son. He states that he has no friends or family that
he trusts or can rely on and is concerned that if he collapses someone
will call emergency medical services and bring him back to the
hospital. He asks you what can be done to ensure that his
preferences are followed.
Which of the following should you do now?
A. Obtain an ethics consultation to determine who
can serve as the patient's surrogate if he loses
medical decision-making capacity
B. Reach out to the patient's estranged son to see if
he is willing to be a surrogate decision maker for
the patient
C. Help the patient complete a Physician Orders for
Life-Sustaining Treatment (POLST) form outlining
his preferences
D. Give the patient an advance directive form to
complete at a later date
Rationale
•
Patients who have a life-limiting illness and do not have a surrogate decision maker should
be helped to complete a Physician Orders for Life-Sustaining Treatment (POLST) form in
states that have POLST programs (e.g., Oregon). POLST forms allow patients to give
instructions that clearly address their preferences for life-sustaining treatment. The POLST
form is a medical order outlining current treatment preferences that can be followed when
a patient loses medical decision-making capacity. The patient did not give permission for
the physician to reach out to his estranged son, and so doing this is not an appropriate
option. Since the patient has decision-making capacity and has stated that he does not
have anyone who can serve as a surrogate for him, it would be most appropriate to
complete a Physician Orders for Life-Sustaining Treatment (POLST) form outlining his
preferences. An ethics consultation may be helpful as a next step if the patient does not
wish to complete a POLST form. The patient has indicated that he does not have anyone
who can serve as a surrogate for him; therefore, giving him an advance directive form to
complete at a later date puts him at risk for not identifying a surrogate and not having a
valid means of communicating his wishes if he were to lose medical decision-making
capacity.
For further information, see the following:
• Thaddeus MP. Making medical decisions for
patients without surrogates. N Engl J Med.
2013;369:1976–1978.
• National POLST Paradigm Task Force (NPPTF).
About the National POLST Paradigm.
http://www.polst.org/about-the-nationalpolst-paradigm/. Accessed December 23,
2014.
Q13: Man with Nocturia
• A 65-year-old man comes into your clinic for follow-up of
lower urinary tract symptoms. For several years, the patient
has had nocturia three times per night, daytime urinary
frequency and urgency, occasional episodes of incontinence,
and difficulty initiating urination. For the past year, he has
been taking tamsulosin, 0.4 mg daily, and has had some
improvement in his symptoms. However, he still has
symptoms that limit his activities. He wants to know what else
can be done. He is going on a trip in four months and would
like to have less worry about his urinary symptoms by the time
that he departs.
• Physical examination shows a smooth prostate, with no
nodules, that has an approximate volume of 30 mL. Postvoid
residual volume is 100 mL.
Which of the following should you recommend?
A.
B.
C.
D.
Continue current therapy
Add finasteride
Add tolterodine
Discontinue tamsulosin; begin terazosin
Rationale
•
•
A recent meta-analysis demonstrated a clinically significant improvement in International Prostate
Symptom Score (IPSS), storage subscale, and urinary frequency among men with benign prostatic
hyperplasia and lower urinary tract symptoms who were treated with both an alpha-adrenergic
blocker and an anticholinergic bladder agent compared with men who received alpha-adrenergic
blockers alone. All the men included in the analysis had a postvoid residual volume of less than
200 mL. There was a clinically insignificant increase in postvoid residual volume (average 11.6
mL), and the number needed to treat to cause 1 episode of acute urinary retention was 101 (95%
confidence interval [CI], 60 to 267). In addition, 5-alpha-reductase inhibitors have been shown to
improve scores on the IPSS among men with moderate prostatic enlargement, but a separate
systematic review found that benefit to occur primarily after one year of treatment. Prior to that
time, alpha-adrenergic blockers alone provide similar symptom relief. Nonselective alphaadrenergic blockers are no more effective in improving symptoms than are selective alphaadrenergic blockers and may cause more side effects.
Given the fact that the patient's trip is in 4 months, alpha-adrenergic blockers alone would not be
appropriate. While the patient does have some mild urinary retention, a slight increase in
postvoid residual is not likely to be harmful. He has significant storage symptoms and is asking for
additional therapy; therefore, an anticholinergic agent, such as tolterodine, should be tried.
For further information, see the following:
• Filson CP, Hollingsworth JM, Clemens JQ, et al. The
efficacy and safety of combined therapy with alphablockers and anticholinergics for men with benign
prostatic hyperplasia: a meta-analysis. J Urol.
2013;190:2153–2160.
• Fullhase C, Chapple C, Cornu JN, et al. Systematic
review of combination drug therapy for nonneurogenic male lower urinary tract symptoms. Eur
Urol. 2013;64:228–243.
Q14: Shoulder Injury
• A previously healthy 80-year-old woman comes into your
office for a follow-up visit and reports worsening pain in her
left shoulder since she tripped and fell more than one week
ago. The pain sometimes makes it difficult for her to fall
asleep. Shortly after she fell, the patient underwent
evaluation in the emergency department. She was told to
see her primary care physician if her symptoms persisted.
She has been wearing a sling. Current medication is
acetaminophen.
• A radiograph of the shoulder from the emergency
department shows no fracture, dislocation, or arthritis.
When examining this patient's shoulder, which of the following
maneuvers should you perform to demonstrate the painful arc
associated with a rotator cuff tear?
A. Examiner passively rotates the patient's arm into
full external rotation and assesses pain from 60 to
120 degrees.
B. Examiner applies pressure proximal to the
patient's wrist against external rotation by the
patient and assesses pain from 60 to 120 degrees.
C. Examiner brings the patient's arm into full
abduction and assesses pain from 60 to 120
degrees.
Rationale
• Shoulder pain and rotator cuff problems are very common in
geriatric practice. Hermans et al. performed a systematic review in
an attempt to determine the utility of physical examination
maneuvers in assessing patients with shoulder pain. The authors
note two types of examination maneuvers: pain-provocation tests
and strength tests. For the pain-provocation tests, the painful arc
(examiner passively brings the patient's arm into full abduction and
assesses pain from 60 to 120 degrees) has the most helpful
characteristics. The other tests listed as choices in this question are
strength tests and have different utility. The authors suggest that
generalist physicians develop proficiency in the findings that have
the best likelihood ratios (LRs) with the narrowest confidence
intervals (CIs), either independently or in combinations, as
performed by specialists. The authors believe that all the tests listed
as choices here fit these criteria.
For further information, see the following:
• Hermans J, Luime JJ, Meuffels DE, et al. Does
this patient with shoulder pain have rotator
cuff disease? The Rational Clinical
Examination systematic review. JAMA.
2013;310:837–847.
Q15: IPC Device
• A 78-year-old woman who had a hemorrhagic stroke was initially
admitted to acute medicine. No anticoagulant was administered
because of her central nervous system bleeding. Her outpatient
medications included aspirin and this was withheld. She also has
hypertension and low bone mass. Her other outpatient medications
were hydrochlorothiazide, lisinopril, and a calcium and vitamin D
supplement.
• You are asked to see the patient on transfer to acute rehabilitation
72 hours after her stroke. The physiatrist wants your opinion about
ordering an intermittent pneumatic compression (IPC) device for
her. On physical examination, the patient cannot raise her affected
arm or leg off the bed. Since having her stroke, she is incapable of
walking to the toilet without the help of another person. She has a
residual dense hemiplegia.
Which of the following should you tell your colleague will most
likely result from the use of an IPC device in this patient?
A.
B.
C.
D.
Reduced risk of deep venous thrombosis
Reduced mortality risk
Increased risk of falls
Increased risk of lower leg ischemia or
amputation
Rationale
•
Venous thromboembolism (VTE) is a common complication of stroke and can have lethal
consequences. Intermittent pneumatic compression (IPC) devices have not been well studied in
preventing VTE in the stroke population. The Clots in Legs Or sTockings after Stroke (CLOTS 3)
trial, a multicentre randomized controlled trial, studied the efficacy and adverse effects of IPC
devices in a stroke population. This large trial enrolled 2876 stroke patients within 3 days of their
event and randomized them to an IPC device or no device. Patients were immobile (i.e., could
not walk to the toilet without the help of another person). The primary outcome was deep
venous thrombosis (DVT). The mean duration of IPC use was 12.5 days (standard deviation [SD],
10.9), and the median duration was 9 days (interquartile range [IQR], 3 to 22). At 30 days,
patients receiving IPCs had a significant reduction in any DVT (symptomatic or asymptomatic,
proximal or calf) with 233 DVTs (16.2%), compared to those who had no IPC with 304 DVTs
(21.1%). This protective effect was persistent through 6 months. The effect was similar whether
anticoagulants were used or not. There was benefit to IPCs whether the stroke was hemorrhagic
or not. Other outcomes (pulmonary emboli, death) did not reach significance at 30 days. Falls
were not different between the groups. There was a slight increase in skin breaks in the IPC
group with 44 (3.1%), compared to those who had no IPC with 20 skin breaks (1.4%). Despite this,
the IPC group did not have a higher incidence of ischemia or limb amputation. In summary, IPC
devices do appear to have a role in VTE prevention after stroke.
For further information, see the following:
• Dennis M, Sandercock P, Reid J, et al.
Effectiveness of intermittent pneumatic
compression in reduction of risk of deep vein
thrombosis in patients who have had a stroke
(CLOTS 3): a multicentre randomised
controlled trial. Lancet. 2013 Aug
10;382(9891):516–524. doi: 10.1016/S01406736(13)61050-8. Epub 2013 May 31.
Q16: Screening for Alzheimer’s Disease
• A healthy 75-year-old man comes to your office for
his annual wellness visit. The patient states that his
neighbor was recently found to have Alzheimer's
disease. He asks what the experts have found
regarding screening for cognitive impairment in
older adults.
• Physical examination is unremarkable. Routine
laboratory studies show no abnormalities.
The USPSTF has concluded which of the following regarding the
evidence for screening for cognitive impairment in older adults?
A. The evidence is lacking and the balance of
benefits and harms cannot be determined.
B. The evidence is sufficient to recommend for
routine screening.
C. The evidence is sufficient to recommend
against routine screening.
Rationale
• In 2011, Medicare began covering the detection of cognitive impairment as
a part of the new annual wellness visit benefit. In March 2014, the United
States Preventive Services Task Force (USPSTF) published a report in the
Annals of Internal Medicine, "Screening for Cognitive Impairment in Older
Adults." According to the report, the USPSTF found no evidence of direct
benefits and harms of screening for cognitive impairment. Although the
task force found adequate evidence that some screening tools could
accurately identify dementia, they found that drug therapies and
nonpharmacologic interventions resulted in only small improvements in
cognitive function and caregiver outcomes. They found no published
evidence on the effect of screening on decision making or planning by
patients, clinicians, or caregivers. Evidence of the harms of screening and
nonpharmacologic interventions was also inadequate. Based on this
aforementioned lack of evidence, The USPSTF concluded that the evidence
on screening for cognitive impairment was lacking and that the balance of
benefits and harms could not be determined.
For further information, see the following:
• Moyer VA. Screening for cognitive impairment
in older adults: U.S. Preventive Services Task
Force recommendation statement. Ann Intern
Med. 2014;160:791–797.
Q17: Pre-op Evaluation
•
•
•
•
As a geriatrics consultant in a large urban hospital, you receive a request for
consultation on a 92-year-old man who is undergoing resection of a
colorectal cancer found on evaluation for anemia. The surgery resident
explains that the patient had a hip replacement for osteoarthritis and also
has hypertension, atrial fibrillation, and early dementia. You stop by the
waiting room to speak with the patient's daughter. She explains that before
the surgery the patient did well in managing his activities of daily living, but
in the past three months he has lost 4.5 kg (10 lb) and has reported low
energy.
Review of the patient's preoperative visit in the Anesthesiology Department
reveals that his outpatient medications are hydrochlorothiazide, 25 mg once
daily; acetaminophen, 500 mg three times daily; donepezil, 10 mg at
bedtime; and aspirin, 81 mg daily.
On physical examination, heart rate is 88 beats per minute and blood
pressure is 134/62 mm Hg.
Labs: Hgb = 9.8 (14-18), Ferritin = 18 (20-235)
Which of the following interventions would most likely reduce
this patient's risk of becoming more frail in the postoperative
period?
A.
B.
C.
D.
Avoidance of narcotic medications
Addition of metoprolol, 12.5 mg twice daily
Transfusion of 1 unit of packed red blood cells
Providing access to a nursing assistant for
mobility and orientation
Rationale
•
•
Adults older than age 65 undergo more than 4 million major operations annually in the
United States. Given their increased burden of comorbid illness and functional impairment,
they are more likely to have significant postoperative complications. In addition to specific
diagnoses, predictors of postoperative complications include poor nutrition, immobility, and
cognitive impairment—all indicators of frailty among older adults. The Hospital Elder Life
Program (HELP) was established to reduce the incidence of delirium and improve outcomes
for older adults in the acute care setting. A recent trial applied a modified version of the
HELP program (mHELP) to reduce frailty in the postoperative period through a nurse-based
intervention to improve mobility, mentation, and nutrition. The intervention appeared to
reduce frailty rates compared with matched historical controls on the same surgical service.
While frailty rates were improved at discharge, the advantage at three months after
discharge did not reach statistical significance.
Based on presentation, this patient does not appear to need beta-adrenergic blockade or
transfusion. While judicious use of pain medicine is advised, undoubtedly some amount of
low-dose opioid will be needed for adequate pain control.
For further information, see the following:
• Chen CC, Chen CN, Lai IR, et al. Effects of a
modified Hospital Elder Life Program on frailty
in individuals undergoing major elective
abdominal surgery. J Am Geriatr Soc.
2014;62:261–268.
Q18: Osteoporosis Risk
•
•
•
You see a 72-year-old woman in your primary care clinic for a periodic health maintenance
visit. The patient has felt well and is capable of a high level of function. She has knee
osteoarthritis. One year ago, she fell without injury. Current medications are
acetaminophen, 650 mg twice daily, and a calcium and vitamin D3 supplement taken twice
daily. She has never taken glucocorticoids or antiseizure medications. The patient does not
use tobacco and drinks two glasses of red wine nightly. Her mother did have a hip fracture
during the last year of life.
On physical examination, the patient appears well but has moderate obesity. Height is 152
cm (5 ft) and weight is 82 kg (181 lb). BMI is 35.3. Blood pressure is 135/80 mm/Hg, and
heart rate is 80 beats per minute and regular. Heart and lung examinations are normal.
Examination of the knees shows bilateral changes of osteoarthritis with crepitus and medial
joint-line tenderness. She uses her arms to push up from a sitting position to stand. Her gait
is slow (0.8 meter per second) but steady.
When offered a screening dual-energy x-ray absorptiometry (DEXA) scan, she politely states
that she would like to avoid any unnecessary tests, particularly if her baseline risk of
osteoporotic fracture is low.
In addition to age, which of the following screening information
is most helpful to quickly determine whether the patient is at
low risk for osteoporotic fracture?
A.
B.
C.
D.
Family history
Weight
Gait speed
Alcohol use
Rationale
•
Osteoporosis, a common and important medical problem, affects approximately 10% of
women older than age 50 and leads to fractures that contribute to pain, limited mobility,
and functional decline. A large number of older women, however, may be at relatively low
risk for osteoporosis and may be able to forgo bone mineral density (BMD) screening. The
Fracture Risk Assessment (FRAX) screening tool can provide a 10-year estimate of
probability of fracture but requires a collection of 11 different historical and health data
points plus bone mineral density. The Osteoporosis Self-Assessment Tool (OST), on the
other hand, utilizes two routinely available data points (age and weight) to calculate a
score that was recently demonstrated to be as effective as the FRAX (without BMD) in
identifying women at very low risk for osteoporosis. The formula is as follows: risk score
equals weight (kg) minus age (yr) times 0.2. A score of 0 or greater indicates very low risk
of osteoporosis, equivalent to a 10-year risk of hip fracture of 3% or less. These women
may, in turn, be able to forgo BMD screening with a limited risk of failing to identify
osteoporosis. However, it does not help risk-stratify women with a higher risk of fracture
and the need for medical therapy; it simply identifies women who may not need radiologic
screening.
For further information, see the following:
• Pang WY, Inderjeeth CA. FRAX without bone
mineral density versus osteoporosis selfassessment screening tool as predictors of
osteoporosis in primary screening of
individuals aged 70 and older. J Am Geriatr
Soc. 2014;62:442–446.
Q19: Chest Pain Evaluation
• A 72-year-old woman comes to the emergency department and
reports chest pain and dyspnea. The patient had the sudden onset of
left inframammary pain, with mild radiation to the throat. She
describes the pain as "a feeling of pressure" and says that she was
experiencing stress when it occurred. She has noticed that the pain is
worsened by exercise. The patient also has hypertension and
hyperlipidemia, but does not have diabetes mellitus. Current
outpatient medications are chlorthalidone, lisinopril, and
atorvastatin. She has a 20-pack-year smoking history but quit ten
years ago.
• On physical examination, the patient appears alert and
uncomfortable. BMI is 26. Temperature is 36.7 C (98.0 F), pulse rate
is 92 per minute and regular, respirations are 16 per minute and not
labored, and blood pressure in both arms is equal, 155/75 mm Hg.
The remainder of the examination is normal.
Which of the following is the strongest indication that this
patient's chest pain is likely associated with a myocardial
infarction?
A.
B.
C.
D.
E.
It is increased with exertion
It is associated with dyspnea
It is pressure-like
It radiates to the throat
It is induced by stress
Rationale
• There is speculation that the presentation of a myocardial infarction differs
by sex and possibly age. The large, prospective, international, multicenter
study of men and women presenting to the emergency department with
acute chest pain conducted by Rubini Gimenez et al. carefully collected
presenting symptoms and compared results by sex. However, it could not be
substantiated that there were differences that were clinically significant
enough to differentiate myocardial infarction between the sexes. The
median age of the women in the cohort was 70. Of the factors that were
studied, one of the highest likelihood ratios (LRs) for a myocardial infarction
among the women pertained to pain that was increased by exercise, with an
LR of 1.35 (95% confidence interval [CI], 1.10 to 1.65), and there was no
difference between the sexes. The following were not helpful in predicting
who was more or less likely to experience a myocardial infarction: pressurelike pain, LR of 1.0 (CI, 0.89 to 1.12); attendant dyspnea, LR of 1.01 (CI, 0.85
to 1.19); pain induced by emotional stress, LR of 0.71 (CI, 0.49 to 1.02); and
radiation of pain to the throat, LR of 0.94 (CI, 0.68 to 1.31).
For further information, see the following:
• Rubini Gimenez M, Reiter M, Twerenbold R, et
al. Sex-specific chest pain characteristics in
the early diagnosis of acute myocardial
infarction. JAMA Intern Med. 2014;174:241–
249
Q20: End-of-Life Decision Making
• A 75-year-old man who has end-stage prostate
cancer unresponsive to chemotherapy meets with
you to discuss hospice care. His health status has
been rapidly declining. The patient understands that
his life expectancy is limited and so has considered
hospice care as a treatment option. You have
answered all his questions, and he will likely elect
hospice care.
Which of the following should you say now?
A. Do you have an advance directive that outlines
your wishes?"
B. "Whom would you want to make decisions for you
if you were no longer able to make them
yourself?"
C. "If you were my father, I would recommend
hospice care for you."
D. "Do you prefer to independently make this
decision, or are there other people whom you
would like to be involved in helping you make this
decision?"
Rationale
• It is important to determine how patients prefer to make decisions (e.g.,
independently, in consultation with others, or even deferring to others). Older
adults may value autonomy or shared decision making with family members or
may prefer to defer decisions to surrogates. Therefore, it is important to
investigate how patients prefer to make decisions.
• Investigating how the patient in this question would like to make the decision at
hand would precede asking the patient whom they would want as a surrogate
decision maker when they lose decision-making capacity and asking them if they
have an advance directive. Ensuring that the patient has a surrogate decision
maker and an advance directive would be appropriate next steps. It is also
important to investigate how the patient prefers to make decisions prior to
making a care recommendation. It is beneficial to ask the patient whether they
would like you to make a recommendation because some patients may prefer to
independently make decisions.
For further information, see the following:
• Schenker Y, Barnato A. Expanding support for
"upstream" surrogate decision making in the
hospital. JAMA Intern Med. 2014;174(3):377–379.
• Should Clinicians Give Recommendations? GeriPal A Geriatrics and Palliative Care Blog.
http://www.geripal.org/2011/08/should-clinicansgive-recommendations.html. Accessed December
23, 2014.
Q21: Weight Loss
• An 80-year-old man who was widowed one year
ago undergoes evaluation for difficulty sleeping,
decreased appetite, decreased energy, and trouble
concentrating. The patient states that he has not
felt depressed. He continues to enjoy visiting with
his grandchildren and working in his garden.
• Over the past six months, the patient has lost 4.5 kg
(10 lb). Physical examination shows no changes
since his previous examination.
Which of the following should you
recommend now?
A. Investigate for an underlying medical cause of
his symptoms
B. Selective serotonin reuptake inhibitor
C. Cognitive behavioral therapy
D. Aerobic exercise
Rationale
• It is important to exclude a medical cause of the symptoms the patient is
experiencing (e.g., renal disease, anemia, hypothyroidism). The patient
says that he does not have depressed mood or anhedonia; therefore, his
condition does not meet the criteria for diagnosis of major depressive
disorder (MDD). Although symptoms of difficulty sleeping, decreased
appetite, decreased energy, and trouble concentrating are 4 of the 9
screening items for diagnosis of MDD, the patient must also affirm that
he has either depression or anhedonia for the diagnosis to be made.
Although the patient lost his wife one year ago, it is important to exclude
medical causes of the symptoms experienced by the patient before
making a diagnosis. Medications and medical conditions can cause the
symptoms experienced by the patient and should be excluded.
For further information, see the following:
• Mojtabai R. Diagnosing depression in older
adults in primary care. N Engl J Med.
2014;370:1180–1182
Q22: Dizziness
•
•
•
An 82-year-old man is referred to you by his dentist for a possible stroke or transient ischemic
attack. The patient was being seen by his dentist for a routine dental cleaning and examination
and was not given any medication. After the patient had been recumbent in the dental chair for
some time, he was repositioned and had the sudden onset of dizziness and extreme discomfort.
The dentist was alarmed and terminated the examination. Since your office is in the same building
as the dentist's, the patient was sent directly to you for an assessment.
The patient tells you that in the dentist's office he had an uncomfortable vertiginous sensation
and felt as if he would vomit. He was able to compose himself and is now feeling better. He has
chronic mild hearing loss but does not have tinnitus. He said that he had no change in his hearing
today. He has not had a headache. Occasionally, he has had slight dizziness, but these episodes
have never been as severe as today's. He has otherwise been feeling well. He also has
osteoarthritis and hypertension. Current medications are amlodipine, acetaminophen, and a
multiple-vitamin supplement.
At the time of the dental visit, blood pressure was 145/70 mm Hg in the left arm with the patient
sitting; pulse rate was 80 per minute and regular. Repeat blood pressure and pulse rate
measurements performed by you are similar, with no orthostatic changes. Neurologic
examination is performed, including a Dix-Hallpike maneuver. Mixed vertical torsional nystagmus
is noted with this maneuver. No nystagmus was noted on routine extra-ocular muscle testing.
Which of the following is the most likely
diagnosis?
A.
B.
C.
D.
Benign paroxysmal positional vertigo
Meniere's disease
Stroke
Vestibular neuritis
Rationale
• Dizziness is a geriatric syndrome. A common and important differential
diagnosis is benign paroxysmal positional vertigo. These patients experience
acute vertigo, and the prolonged recumbent position can be a trigger.
Physical examination shows positional nystagmus in 70% of patients. The
Dix-Hallpike maneuver is important to demonstrate this nystagmus with
positional change. The nystagmus with the maneuver varies, depending on
the vestibular semicircular canal affected by the offending canaliths. The
posterior canal is most commonly affected, and with this maneuver one will
see mixed vertical torsional nystagmus. If the horizontal canal is involved,
horizontal nystagmus is seen with the positional maneuver. The differential
diagnosis includes stroke. With a stroke, there is spontaneous nystagmus
with beating in various or changing directions. Another consideration is
vestibular neuritis. In this case, nystagmus is spontaneous and
predominantly horizontal. The same is true for Meniere's disease.
Vestibular migraine rarely has associated nystagmus, but it can be positional.
Horizontal nystagmus with extreme lateral gaze can be seen in normal
patients.
For further information, see the following:
• Kim JS, Zee DS. Benign paroxysmal positional
vertigo. N Engl J Med. 2014;370:1138–1147.
DOI: 10.1056/NEJMcp1309481.
Q23: Significant Hearing Loss
•
•
•
An 84-year-old man comes into your office for a periodic evaluation of his hearing
accompanied by his son. For many years, the patient has been followed by
otolaryngology and audiology for a sensorineural hearing loss. Over the years, he has
had numerous hearing aids and adjustments. He has accommodated to this treatment,
but over time the hearing aids have worked less well. The son says his father is struggling
with his hearing, seems embarrassed about it, is becoming more withdrawn, and is
socializing less. The patient seems to have memory loss but has otherwise been well and
active. He also has well-controlled hypertension and osteoarthritis. Current medications
are lisinopril, acetaminophen, and a multiple-vitamin supplement.
On physical examination, the patient is wearing hearing aids and is having difficulty
hearing. Mini Mental State Examination score is normal. Screening for depression is
negative. The patient says that he does not want to go out and socialize and that other
people are better off than he is.
Audiology reports that on a standardized test of speech perception in which sentences
were presented without visual cues while the patient was wearing hearing aids, his score
was worse than 40%. Both audiology and otolaryngology recommend a cochlear implant
(CI). The patient and his family are worried about surgery at his advanced age and want
your opinion about this matter.
When compared to younger populations with CIs, older patients
such as this with CIs are more likely to experience which of the
following?
A.
B.
C.
D.
Longer operative time
Poorer hearing outcomes
Longer hospital length of stay
Greater likelihood of perioperative medical
complications
E. Greater likelihood of surgical complications
Rationale
• In 2013, the Lasker-DeBakey Clinical Medical Research Award recognized
the pioneers of cochlear implantation. Profound deafness can impair
function and cognition in elderly patients. The Centers for Medicare and
Medicaid Services (CMS) does approve cochlear implants (CIs) when a
score of worse than 40% is present on standardized testing of speech
perception in which sentences are presented without visual cues while the
patient is wearing hearing aids. Patients and families will confer with
geriatricians and primary care providers when considering operative
intervention.
• The patient in this question meets the criteria for a CI. A systematic review
of CIs in geriatric patients does show that compared with younger
populations outcomes for geriatric patients are good, and operative times,
hospital lengths of stay, and surgical complications are comparable. For
those 80 years of age or older, nonsurgical complications, such as cardiac
arrhythmia, delirium, and urinary retention (2% to 4%), that required
hospitalization were more common.
For further information, see the following:
• O'Donoghue G. Cochlear implants—science,
serendipity, and success. N Engl J Med.
2013;369:1190–1193. DOI:
10.1056/NEJMp1310111.
• Clark JH, Yeagle J, Arbaje AI, et al. Cochlear implant
rehabilitation in older adults: literature review and
proposal of a conceptual framework. J Am Geriatr
Soc. 2012;60:1936–1945.
Q24: Cost Management
• You are on the planning committee of your hospital's new
Medicare Shared Savings Program. The first data analysis
of the program's 50,000 beneficiaries reveals a sharp
increase in the number of referrals for outpatient physical
therapy immediately after discharge from inpatient
rehabilitation for hip fracture. The Medical Director points
to long-standing evidence that for these patients
continued exercise after discharge from rehabilitation has
improved function and mobility. The Chief Financial
Officer (CFO) is not impressed and pushes the group to
consider more affordable options without compromising
the quality of care and health-related outcomes,
specifically strength and endurance.
Which of the following should you
recommend to satisfy the CFO's request?
A. Home-based, functionally oriented exercise
program
B. Automated telephone or email prompts to
exercise
C. Six-month fitness center membership
D. Inclusion of patient's partner or spouse in
exercise program
Rationale
• Prior evidence indicates that a continuation of outpatient
physical therapy after discharge from inpatient rehabilitation
after hip fracture can improve function. A recent randomized
controlled trial (Latham et al., 2014) examined the impact of
an independent home-based exercise program on objective
measures of physical function after discharge from
rehabilitation for hip fracture. Exercises were customized and
geared toward practical activities (e.g., standing up from a
chair and climbing steps). The intervention group had a 70%
adherence rate by patient report and had significantly better
physical function at six months than did the control subjects.
No cost-effectiveness data are yet available for this
intervention.
For further information, see the following:
• Latham NK, Harris BA, Bean JF, et al. Effect of a
home-based exercise program on functional
recovery following rehabilitation after hip
fracture: a randomized controlled trial. JAMA.
2014;311:700–708.
• Brown CJ, Flood KL. Mobility limitation in the
older patient: a clinical review. JAMA.
2013;310:1168–1177.
Q25: Cataract Surgery
• You evaluate your patient, a 78-year-old retired pharmacist, in clinic. He
has been in very good health except for mild chronic obstructive
pulmonary disease, for which he takes fluticasone-salmeterol by discus,
2 puffs once daily, with good relief and normal function. During the visit,
he states that his nighttime vision has worsened and his
ophthalmologist has diagnosed cataracts in both his eyes. The patient is
inclined to have cataract surgery on both eyes as offered by the
ophthalmologist, but he wants your opinion. He will have the first
surgery in one month and then the second surgery nine to ten months
later. He is otherwise completely fine according to his self-report.
• Physical examination is normal except for slightly decreased visual
acuity.
• From your perspective, the patient appears ready for cataract surgery.
You reassure the patient, but discuss the risks related to surgery.
The risk of which of the following is highest between
the first and second cataract surgeries?
A.
B.
C.
D.
Decline in cognition
Facial pain
Injurious falls
Vertigo
Rationale
•
•
As many as 50% of adults older than age 80 have cataracts. More than 3,000,000 adults
have cataract removal surgery each year in the United States. Cataracts can cause
important vision impairment among older adults that can limit key activities, such as
driving, and increase the risk of falls. It is perhaps surprising that some studies indicate
that fall rates among older adults can increase after cataract surgery. A recent analysis of
28,396 adults older than 60 in Western Australia looked specifically at the rate of falls
between first and second cataract surgeries. The study showed that the risk of an
injurious fall resulting in hospitalization more than doubled (odds ratio [OR], 2.14; 95%
confidence interval, 1.82 to 2.51) between the first and second cataract surgeries. One
explanation is that unequal vision and uncompensated refraction after the first surgery
lead to increased problems with depth perception. While cataract surgery remains quite
safe, with an overall complication rate of less than 2%, anticipation of these problems,
better correction of refraction, and more prompt performance of the second surgery may
reduce risk.
Decline in cognition is an uncommon complication in healthy patients. Facial pain and
vertigo are also uncommon complications.
For further information, see the following:
• Meuleners LB, Fraser ML, Ng J, Morlet N. The
impact of first- and second-eye cataract
surgery on injurious falls that require
hospitalization: a whole-population study. Age
and Ageing. 2014;43:341–346.
Q26:Which of the following instruments has the best evidence
supporting its use for screening for cognitive impairment?
A.
B.
C.
D.
Mini Mental State Examination (MMSE)
Memory Impairment Screen
Mini-COG Test
Montreal Cognitive Assessment (MOCA)
Rationale
• The Mini Mental State Examination (MMSE) is the most rigorously
studied instrument for cognitive impairment screening, with 25
published studies, and has been studied in various populations.
Pooled estimates across 14 studies (n = 10,185) yielded a
sensitivity of 88.3% (95% confidence interval [CI], 81.3 to 92.9)
and a specificity of 86.2% (95% CI, 81.8 to 89.7) for a cut-point of
23/24 or 24/25 in the detection of dementia.
• The other instruments have been studied in far fewer studies (4 to
7 studies each), had limited reproducibility in primary carerelevant populations, and had unknown optimum cut-points.
Sensitivity and specificity ranged widely in these studies of the
other instruments.
For further information, see the following:
• Moyer VA. Screening for cognitive impairment in older adults: U.S.
Preventive Services Task Force recommendation statement. Ann
Intern Med. 2014;160:791–797.
• Lin JS, O'Connor E, Rossom RC, et al. Screening for cognitive
impairment in older adults: an evidence update for the U.S.
Preventive Services Task Force [Internet]. Rockville (MD): Agency
for Healthcare Research and Quality (US); 2013 Nov. Report No.: 1405198-EF-1. U.S. Preventive Services Task Force Evidence
Syntheses, formerly Systematic Evidence Reviews.
http://www.ncbi.nlm.nih.gov/pubmed?term=Lin+JS%5Bauthor%5D+
AND+Screening+for+cognitive+impairment+in+older+adults%3A++a
n+evidence+update+for+the+U.S.+Preventive+Services+Task+Force+
&TransSchema=title&cmd=detailssearch. Accessed December 23,
2014.
Q27: Observation Status
• An 88-year-old woman who has mild dementia is brought to the emergency
department (ED) after having sustained a fall with no loss of consciousness.
The patient recently had symptoms of an upper respiratory tract infection,
with rhinorrhea, cough, and achiness.
• The patient was assessed in the ED and found to be volume depleted with
mild hyperkalemia. She was febrile and had a leukocytosis. She was referred
to an inpatient bed by the ED for "SIRS, rule out sepsis." The hospital
utilization review physician placed the patient on observation ("obs") status.
• The patient and her family were not specifically informed about the patient's
status, but they did receive a Medicare patient-oriented brochure on
observation status. After three days, she was judged to likely have had an
influenza-like illness. Her family members thought that she was too weak to
return home, and she was discharged to a skilled nursing home for a
subacute stay and reconditioning.
The patient's being placed and maintained on observation status
will most likely be the cause of which of the following?
A. Medicare Part A covering the patient's hospital
charges
B. The hospital incurring penalties because the
patient was not specifically informed of her
observation status
C. Administrative costs to determine the patient's
status being billed to the patient
D. The hospital recovering the costs for this patient
E. Medicare Part A not covering the patient's skilled
nursing home stay
Rationale
•
Observation ("obs") status has been used for years to help emergency department physicians clarify
diagnosis, monitor patients, and determine if admission was required. Over time, Medicare has
codified and refined its position on observation status. Sheehy et al. note that nationally, in 2011,
hospitals in the United States placed 8% of their patients—1.6 million patients per year—on
observation status, compared with 3% five years earlier. Given this frequent use, geriatricians need to
know the ramifications of this status. Medicare requires a minimum 3-day inpatient stay as a bridge to
coverage for a subsequent skilled nursing facility stay. This means that patients who go from a
prolonged "obs" stay (in this case 3 days) to a nursing facility will not be eligible for Medicare
reimbursement. Sheehy et al. write "In April 2013, CMS proposed rule changes that, if implemented,
would confer inpatient status to some longer stay observation patients." Observation patients are, in
essence, outpatients. As a result, observation stays are not covered under Medicare Part A, which
means these patients are subject to substantial co-payments and are liable for the costs of their
hospital medications. Sheehy et al. found that reimbursement for observation patients fell far below
the hospital's costs, particularly for general medical patients and those with longer stays. The
administrative costs to hospitals for determining each patient's status are not factored into
reimbursement and are not recoverable. Hospitals are under no obligation to inform patients of their
observation status, and most do not. In this question, the patient on observation status will be
responsible for significant hospital-associated costs, and her skilled nursing stay cannot be considered
for Medicare reimbursement.
For further information, see the following:
• Sheehy AM, Graf B, Gangireddy S, et al.
Hospitalized but not admitted. JAMA Intern
Med. 2013;173(21):1991–1998.
• Wachter RM. Observation status for
hospitalized patients: a maddening policy
begging for revision. JAMA Intern Med.
2013;173(21):1999–2000.
doi:10.1001/jamainternmed.2013.7306.
Q28: Mental Status Changes
Post-Hospitalization
•
•
A 67-year-old man who has diabetes mellitus is found to be comatose and is admitted to the
intensive care unit (ICU) for a hyperosmolar nonketotic state and sepsis from necrotizing
fasciitis of the leg. He responds well to fluids, antibiotics, and surgery, but after 24 hours of
coma he becomes delirious. His delirium lasts for 5 days. While in the ICU, he has episodes
of extreme agitation and receives propofol (aggregate dose of 800 mg) while receiving
mechanical ventilation and lorazepam (8 mg) for agitation. He also receives opioids for pain
associated with his necrotizing fasciitis. After a 10-day stay, he is discharged to a skilled
nursing facility for wound care and rehabilitation. He returns home 2 months after his initial
admission. Current outpatient medications are NPH insulin/regular insulin 70%/30%, aspirin,
levothyroxine, atorvastatin, lisinopril, and acetaminophen.
He has been followed by you in your office, and both he and his family feel that he is "just
not himself." He seems slower cognitively. You have asked a neuropsychologist to follow the
patient with you. Serial administrations of the Trail Making Test Part B of executive function
have yielded abnormal results. One year after his admission, the patient continues to show
deficits in his Trail Making Test Part B score. The patient and his family want to know what
happened to him. They are convinced that he is different since his illness 12 months ago.
Which of the following is most strongly associated with
this patient's persistent cognitive deficits?
A.
B.
C.
D.
E.
Total propofol dose
Total benzodiazepine dose
Opioid dose
Duration of delirium episode
Duration of coma
Rationale
• It has been known for some time that critical illness creates
neurocognitive and functional disabilities that can be long
lasting. Pandharipande et al. examined this issue in some
depth with careful prospective neuropsychological follow-up
among patients admitted to intensive care units (ICUs) with
medical and surgical illnesses. Many variables as well as ICU
drug exposure were carefully inventoried and analyzed. These
authors determined that the duration of delirium was
associated with poorer executive cognitive function, as
measured by the Trail Making Test Part B as long as 12 months
after the illness. Duration of coma did not affect the resultant
scores, nor did doses of benzodiazepine, propofol, and
opioids.
For further information, see the following:
• Pandharipande PP, Girard TD, Jackson JC, et al.;
BRAIN-ICU Study Investigators. Long-term
cognitive impairment after critical illness. N
Engl J Med. 2013;369:1306–1316. DOI:
10.1056/NEJMoa1301372.
• Herridge M, Cameron JI. Disability after critical
illness. N Engl J Med. 2013;369:1367–1369.
DOI: 10.1056.
Q29: Treatment for Weight Loss
•
•
•
•
A 93-year-old man is admitted to the hospital for monarticular arthritis. Calcium
pyrophosphate deposition disease is diagnosed. He lacks an appetite and has been
losing weight for months. He has no difficulty with chewing, swallowing, or feeding
himself. He has a remote history of a gastrectomy for a malignancy. The patient also has
progressive dementia of moderate severity and is cared for by his family. He has benign
prostatic hyperplasia, hypertension, chronic kidney disease, and diastolic dysfunction
with heart failure. Current outpatient medications are finasteride, tamsulosin,
furosemide, and multiple-vitamin, vitamin B12, and iron supplements.
On physical examination, the patient appears thin and cachectic. He is pleasant, but not
well oriented. He weighs 47 kg (103 lb). BMI is 17. Physical examination does not reveal
a source of his weight loss. Benign prostatic hyperplasia is noted on rectal examination.
His affect is flat, but he says that he is not depressed. Laboratory studies show that the
patient's chronic anemia is unchanged, as well as the findings below:
Lab studies: Creatinine = 1.5 (0.7-1.5), Albumin = 2.6 (3.5-5.5), Fecal occult blood =
negative. CXR negative
After the examination, you meet with the patient's daughter, who is concerned about
his anorexia and weight. She requests some sort of therapy.
Which of the following should you
recommend for this patient?
A.
B.
C.
D.
E.
Provision of feeding assistance
High-calorie supplements
Megestrol acetate
Mirtazapine
Dronabinol
Rationale
•
In concert with the American Board of Internal Medicine, the American Geriatrics Society
(AGS) has participated in the Choosing Wisely Campaign. This effort seeks to identify key
things that health care providers and patients should question. Five items were identified in
2013, and another five in 2014. One of the items identified in 2014 is "Avoid using
prescription appetite stimulants or high-calorie supplements for treatment of anorexia or
cachexia in older adults; instead, optimize social supports, provide feeding assistance and
clarify patient goals and expectations." Specifically, the AGS notes that megestrol acetate
has limited efficacy and can result in increased risks of thrombotic events, fluid retention,
and death. Mirtazapine is a tetracyclic antidepressant. In depression, it can result in
increased weight, similar to other antidepressants. Its use as an appetite stimulant cannot
be supported. Dronabinol is a cannabinoid. It has been shown to have some benefit in
acquired immunodeficiency syndrome (AIDS). It has not been well studied in geriatric
populations and cannot be recommended in geriatric anorexia. The AGS writes that highprotein, high-calorie oral nutritional supplements have limited evidence to support their use
and that many meaningful clinical outcomes (function and mood) have not been shown to
be positively impacted despite modest weight gain.
For further information, see the following:
• AGS Choosing Wisely Workgroup. American
Geriatrics Society identifies another five things
that healthcare providers and patients should
question. J Am Geriatr Soc. 2014;62:950–960.
Q30: Discharge Planning
• An 88-year-old woman who had been admitted for pneumonia is referred
for discharge planning. The patient has responded well to therapy, but the
hospitalist team has reservations about sending her home and has asked
for a geriatrics consultation.
• On admission, the patient was described as disheveled and dirty. Her BMI
is currently 20. The patient lives alone and has mild cognitive impairment.
Her daughter lives several hundred miles away and did come for a family
meeting. No other family live nearby. The daughter has reported that the
patient is a hoarder and that her home is cluttered and dirty, with piles of
various objects all around. The daughter fears that her mother will fall
because of the clutter. She says that the patient has always been eccentric,
but her hoarding has accelerated in the past several years. The patient
insists that her goal is to return home. A psychologist has seen the patient
and judges her to be decisional with regard to her desire to return home.
• You convene a family meeting with the hospitalist team, the patient's
daughter, and the patient's hospital social worker.
In the creation of a discharge plan, which of the following would
be a helpful adjunct in managing this patient?
A. Performing a home visit
B. Ensuring safety by insisting on a higher
standard for safety in the home
C. Avoiding negotiation that allows the patient
to "pick and choose" interventions
D. Avoiding worst-case scenario discussions
Rationale
•
Elder self-neglect is common in geriatric practice. Hospitalists are under
increasing pressure to reduce re-admissions, and self-neglect is associated with
re-admissions. With declining availability of persons to support the oldest old in
community settings, geriatricians will be more frequently called on to mediate
these discussions. Smith et al. provide a timely analysis of this topic. They
suggest four practical approaches to managing self-neglecting patients. A home
visit by the physician can be the means of allowing others to support the patient
in the home and, particularly, of introducing members of the home care team to
the patient. Although self-neglecting patients can be frail and lack resources,
there is no ethical justification to set a higher standard for safety for them than
one might in another population. Ageism and infantilization are to be avoided.
Persuasion and negotiation are useful in trying to help the patient and the
clinician meet shared goals. An uncompromising approach should be avoided.
Worst-case scenarios should be anticipated, and plans should be developed to
address these situations.
For further information, see the following:
• Smith AK, Lo B, Aronson L. Elder self-neglect—
how can a physician help? N Engl J Med.
2013;369:2476–2479. DOI:
10.1056/NEJMp1310684.