The answer is B. Exertional angina (chest pain) is the most common manifestation of myocardial ischemia in young and middle-age persons. Because of their more sedentary lifestyle or possibly a difference in pathophysiology, this may not be true in elderly patients. Instead of exertional chest pain, ischemia may be more commonly manifested as dyspnea in elderly patients. Other elderly patients with coronary artery disease (CAD) may be completely asymptomatic, although silent ischemia may be demonstrated by stress testing or Holter monitoring.

Additional Reading: Evaluation of the adult with dyspnea in the emergency department. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Cardiovascular system

The answer is D. Despite a wealth of evidence in favor of thrombolytic treatment for elderly MI patients, the therapy is commonly not used in this age group. The reasons for this are numerous and include delay in seeking medical assistance, misdiagnoses due to atypical presentation, increased contraindications, and higher prevalence of non-Q-wave MIs. Additionally, physicians are reluctant to use thrombolytics in the elderly population for fear of hemorrhage, although most studies show that intracerebral hemorrhage is not significantly increased in elderly MI patients who receive thrombolytics. Only approximately one-third of elderly patients presenting with acute MI have any contraindications to thrombolytic therapy, and less than 5% have absolute contraindications. In regard to patients with non-Q-wave infarction or unstable angina, repeated studies have demonstrated that thrombolytic therapy has no benefits in these patients regardless of age. In regard to choice of specific thrombolytic agent, initial studies comparing streptokinase to the much more expensive tissue-type plasminogen activator found that both drugs increased the survival rate equally. The Global Utilization of Streptokinase and Tissue Plasminogen Activator (tPA) for Occluded Coronary Arteries (GUSTO) trial, which was designed specifically to compare thrombolytic agents, reported a significant advantage with tPA for the overall study population. Patients above age 75, however, had a significantly higher risk of hemorrhagic stroke when treated with tPA than with streptokinase, and the incidence of death or nonfatal disabling stroke was not significantly different between the two therapies in this age group. Therefore, streptokinase may be appropriate in patients above the age of 75 years.

Additional Reading: Coronary reperfusion for acute myocardial infarction in older adults. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Cardiovascular system

The answer is B. The prevalence of aortic regurgitation increases with age. Unlike aortic valve stenosis, aortic valvular insufficiency is rarely caused by degenerative aortic valve disease. Acute aortic valvular insufficiency may be due to infective endocarditis, aortic dissection, trauma, or rupture of the sinus of Valsalva. Chronic aortic insufficiency may be caused by aortic root disease secondary to systemic hypertension, syphilitic aortitis, cystic medial necrosis, ankylosing spondylitis, rheumatoid arthritis, Reiter’s disease, systemic lupus erythematosus, Ehlers-Danlos syndrome, and pseudoxanthoma elasticum. Chronic aortic insufficiency can be caused by valve leaflet disease, including rheumatic heart disease, congenital heart disease, rheumatoid arthritis, ankylosing spondylitis, or myxomatous degeneration. Symptoms of aortic valvular insufficiency are the same in older persons as they are in younger ones. Usually, the main symptoms are related to heart failure, with exertional dyspnea and weakness being common symptoms. In some elderly patients, symptoms of dyspnea and palpitations may be more common at rest than with exertion. Nocturnal angina pectoris, often accompanied by flushing, diaphoresis, and palpitations, may occur; this is thought to be related to the slowing of the heart rate and the drop of arterial diastolic pressure. The classic findings of a high-pitched, blowing diastolic murmur and a wide pulse pressure with an abruptly rising and collapsing pulse should make the diagnosis of aortic valvular insufficiency easily recognized in elderly patients.

Additional Reading: Adult aortic regurgitation. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Cardiovascular system

The answer is B. Once symptoms develop in patients with critical aortic valve stenosis, the clinical course is rapidly downhill. Symptoms and left ventricular dysfunction are progressive, and the average survival is approximately 1 to 3 years. Aggressive treatment should be considered.

Additional Reading: Aortic stenosis. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Cardiovascular system

The answer is B. Due to the results of numerous studies showing that angiotensin-converting-enzyme (ACE) inhibitors are beneficial in relieving symptoms and preventing progressive ventricular deterioration, it is recommended that they should be the initial therapy utilized in patients with heart failure. In patients with moderate to severe heart failure due to systolic left ventricular dysfunction, the use of ACE inhibitors alone has not been found to be successful in relieving the signs and symptoms of volume overload. There is no question, however, that ACE inhibitors, digitalis, and diuretics are beneficial in improving the symptoms and prolonging survival in symptomatic patients with left ventricular systolic dysfunction. In the CONSENSUS trial, which demonstrated significant benefits in the use of ACE inhibitors in symptomatic patients, the mean age of the patients was above 70 years, and, at this age, ACE inhibitors were well tolerated. In asymptomatic elderly patients with depressed left ventricular systolic dysfunction, the use of ACE inhibitors is more controversial. The SOLVD trial demonstrated that asymptomatic patients with a depressed left ventricular ejection fraction of less than 35% demonstrated no benefit in survival, although a significant reduction in progression to clinical heart failure with a decrease in hospitalizations was noted. In the SAVE trial, ACE inhibitors were found to be beneficial in improving long-term survival and reducing the development of heart failure and recurrent MI in patients with reduced left ventricular systolic function following acute MI, regardless of the patient’s age.

Additional Reading: Ace inhibitors in heart failure due to systolic dysfunction: therapeutic use. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Cardiovascular system

The answer is C. NPH is a cause of dementia in the elderly. It may be caused by previous insult to the brain, usually as a result of a subarachnoid hemorrhage or diffuse meningitis that presumably results in scarring of the arachnoid villi over the brain convexities where cerebrospinal fluid (CSF) absorption usually occurs. However, elderly NPH patients seldom have a history of predisposing disease. NPH classically consists of dementia, apraxia of gait, and incontinence (“Wacky, wobbly, wet”), but many patients with these symptoms do not have NPH. Typically, motor weakness and staggering are absent, but initiation of
gait is hesitant—described as a “slipping clutch” or “feet stuck to the floor” gait—and walking eventually occurs. NPH has also been associated with various psychiatric manifestations that are not categorical. NPH should be considered in the differential diagnosis of any new mental status changes in the elderly. Computed tomography (CT) or magnetic resonance imaging (MRI) and a lumbar puncture are necessary for diagnosis. On CT or MRI, the ventricles are dilated. CSF pressure measured by a lumbar puncture is normal. A limited improvement after removing about 50 mL of CSF indicates a better prognosis with shunting. Radiographic or pressure measurements alone do not seem to predict response to shunting. Shunting CSF from the dilated ventricles sometimes results in clinical improvement, but the longer the disease has been present, the less likely shunting will be curative.

Additional Reading: Normal pressure hydrocephalus. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Neurologic

The answer is A. Although difficult to know for sure, Lewy body dementia may be the second most common dementia after AD. Lewy bodies are hallmark lesions of degenerating neurons in Parkinson’s disease and occur in dementia with or without features of Parkinson’s disease. In Lewy body dementia, Lewy bodies may predominate markedly or be intermixed with classic pathologic changes of AD. Symptoms, signs, and course of Lewy body dementia resemble those of AD, except that hallucinations (mainly visual) are more common and patients appear to have an exquisite sensitivity to antipsychoticinduced extrapyramidal adverse effects.

Additional Reading: Clinical features and diagnosis of dementia with Lewy bodies. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Neurologic

The answer is C. Pick’s disease is a less common form of dementia affecting predominantly the frontal and temporal lobes of the cortex. Patients have prominent apathy and memory disturbances. They may show increased carelessness, poor personal hygiene, and decreased attention span. Although the clinical presentation and CT findings in Pick’s disease can be quite distinctive, definitive diagnosis is possible only at autopsy. The Klüver-Bucy syndrome can occur early in the course of Pick’s disease, with emotional blunting, hypersexual activity, hyperorality (bulimia and sucking and smacking of lips), and visual agnosias. A variety of terms are also used to describe the clinical syndrome associated with Pick’s disease, including frontal lobe dementia, frontotemporal lobar degeneration, but the preferred terminology is frontotemporal dementia.

Additional Reading: Frontotemporal dementia: clinical features and diagnosis. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Neurologic

The answer is B. The true prevalence, etiology, and pathogenesis of polymyalgia rheumatica (PMR) are not entirely known. In some, the condition is a manifestation of underlying temporal arteritis. Although most patients are not at significant risk for the complications of temporal arteritis, they should be warned of the possibility and should immediately report such symptoms as headache, visual disturbance, and jaw muscle pain on chewing. PMR usually occurs in patients older than 60 years, and the female:male ratio is 2:1. Onset may be acute or subacute. PMR is characterized by severe pain and stiffness of the neck and shoulders and hips; morning stiffness; stiffness after inactivity; and systemic complaints, such as malaise, fever, depression, and weight loss. There is no selective muscle weakness or evidence of muscle disease on EMG or biopsy. Normochromic-normocytic anemia may be present. In most patients, the ESR is dramatically elevated, often >100 mm/h, usually >50 mm/h. C-reactive protein levels are usually elevated (>0.7 mg/dL) and may be a more sensitive marker of disease activity in certain patients than is ESR. PMR is distinguished from rheumatoid arthritis (RA) by the usual absence of small joint synovitis (although some joint swelling may be present), erosive or destructive disease, rheumatoid factor, or rheumatoid nodules. PMR is differentiated from polymyositis by usually normal muscle enzymes, EMG, and muscle biopsy, as well as by the prominence of pain over weakness. Hypothyroidism can present as myalgia, with abnormal thyroid function tests and elevated creatine kinase (CK). PMR is differentiated from myeloma by the absence of monoclonal gammopathy and from fibromyalgia by the systemic features and elevated ESR. PMR usually responds dramatically to prednisone initiated at doses of at least 15 mg/day. If temporal arteritis is suspected, treatment should be started immediately, with 60 mg/day to prevent blindness. As symptoms subside, corticosteroids are tapered to the lowest effective dose, regardless of ESR. Some patients are able to discontinue corticosteroids in less than 2 years, whereas others require small amounts for years. Rarely do patients respond adequately to salicylates or other NSAIDs.

Additional Reading: Polymyalgia rheumatica. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Musculoskeletal system

The answer is B. The family should be thoroughly informed of the changes that the patient’s body may exhibit directly before and after death. They should not be surprised by irregular breathing, cool extremities, confusion, a purplish skin color, or somnolence in the last hours. A discussion about autopsy can occur either before or just after death. Families may have strong feelings, either in favor of or against it. The discussion of autopsy should not be left to a covering physician or house officer who has not had previous contact with the family. Discussions about organ donation, if appropriate, should take place before death or immediately after death.

Additional Reading: Palliative care. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Patient/population-based care

The answer is D. Stiffened blood vessels also have an impact for blood pressure determination in later life. Systolic blood pressure rises throughout life in Western populations, whereas diastolic pressure peaks and plateaus in middle age and later life. “Normal” blood pressure has been defined by determining the cardiovascular risk associated with a given blood pressure. The presence of an isolated rise in the systolic pressure without a diastolic rise (isolated systolic hypertension) is fairly unique to older patients and, unlike younger patients, does not necessarily imply anemia, thyrotoxicosis, or aortic insufficiency, which can cause a bounding pulse and wide pulse pressure in the young.

Additional Reading: Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Cardiovascular system

The answer is E. Determination of orthostatic hypotension should be routinely performed in geriatric patients. Although a number of factors, such as declining baroreceptor sensitivity, diminished arterial compliance, increased venous tortuosity, decreased renal sodium conservation, and diminished plasma volume, could combine to cause a drop in orthostatic blood pressure among older patients, there is no clear evidence that the pressure drops solely as a function of age. However, a blood pressure drop when changing from the supine to the upright position is common among geriatric patients (possibly as many as 30% of unselected patients may experience a 20 mm Hg or more drop in systolic pressure). Diseases and medications that cause the problem are common offenders.

Additional Reading: Orthostatic hypotension. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014. Category: Cardiovascular system.

The answer is C. Temperature determination in the elderly is the same as it is in other patients. Norms for fever or hypothermia have not been adjusted for age. Elderly people do have a tendency toward disturbances of temperature regulation (hypothermia or hyperthermia). It is possible that some elderly patients, like others, may present with serious infections that do not produce much temperature rise.

Additional Reading: Evaluation of infection in the older adult. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Nonspecific system

The answer is C. Respiratory rate and patterns do not change significantly with age. An elevated respiratory rate may be a subtle clue to a serious medical illness (e.g., acidosis, hypoxia, central nervous system [CNS] disturbance) and should be detected and evaluated as in any other patient.

Additional Reading: The geriatric assessment. Am Fam Physician. 2011;83(1):48-56.

Category: Respiratory system

The answer is D. The presence of a palpable ovary in an elderly woman should raise a suspicion of some pathology, especially malignancy. Given the enlarged ovary, it is likely that she has an ovarian carcinoma, which often starts silently, not showing signs until later stages. The average age of diagnosis is about 63 years. Polycystic ovary syndrome would include other findings (e.g., acne, hirsutism, menstrual irregularities, and infertility) and is typically diagnosed at a much younger age. Fecaliths are often associated with acute illnesses such as appendicitis, intussusception, and diverticulitis.

Additional Reading: Ovarian cancer. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Reproductive system

The answer is C. From hospital admission to discharge, 25% to 35% of elderly patients lose independence in one or more of the basic activities of daily living. The loss of independent functioning during hospitalization is associated with important complications including prolonged length of hospital stay, greater risk of institutionalization, and higher mortality rates.

Additional Reading: The geriatric assessment. Am Fam Physician. 2011;83(1):48-56.

Category: Nonspecific system

The answer is B. Dementia is the single most important risk factor for the development of delirium or acute confused state. Delirium is found at admission or during hospitalization in about 25% of elderly patients admitted for acute medical illnesses. Patients with baseline dementia and severe systemic illness are predisposed to delirium. Factors known to precipitate delirium include the use of physical restraints, the addition of more than three medications to the regimen, the use of a bladder catheter, malnutrition, and any iatrogenic event.

Additional Reading: Delirium. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Neurologic

The answer is B. Essential tremor is the most common movement disorder. This postural tremor may have its onset anywhere between the second and sixth decades of life, and its prevalence increases with age. It is slowly progressive over a period of years. An essential tremor is characterized by a rapid, fine tremor that is made worse with sustained positions. The frequency of essential tremor is 4 to 11 Hz, depending on which body segment is affected. Proximal segments are affected at lower frequencies, and distal segments are affected at higher frequencies. Although typically a postural tremor, essential tremor may occur at rest in severe and very advanced cases. It most commonly affects the hands but can also affect the head, voice, tongue, and legs. It usually affects patients older than 50 years. The tremor may be intensified by stress, anxiety, excessive fatigue, drugs (e.g., caffeine, alcohol withdrawal, steroids), or thyroid disorders. In many cases, the patient may report relief with alcohol use and a positive family history for tremors. Senile tremors tend to increase with age. Parkinson’s disease is differentiated by the presence of a pill-rolling tremor at rest, masked face, bradykinesias, and rigidity. Parkinson’s also shows a favorable response to the administration of L-dopamine and does not improve with the use of alcohol. Treatment of essential tremors involves the treatment of the underlying disorder and the use of propranolol (Inderal), or primidone (Mysoline). Primidone may be preferred because of the exercise intolerance associated with the high-dose β-blockers. Some data suggest newer antiseizure agents (topirimate, gabepentin) have efficacy. Patients who have a very-low-amplitude rapid tremor are generally more responsive to these agents than those who have a slower tremor with greater amplitude. Patients who have a tremor of the head and voice may also be more resistant to treatment than do patients with an essential tremor of the hands. In severe cases, surgery may be considered.

Additional Reading: Differentiation and Diagnosis of Tremor. Am Fam Physician. 2011 Mar 15;83(6):697-702

Category: Neurologic

The answer is A. Urinary incontinence is often seen in the elderly. In most cases, the evaluation of urinary incontinence requires only a history (including frequency of urination and bowel movements, fluid and caffeine intake, and medication review), physical examination, urinalysis and culture, and, if no cause is easily identified, the measurement of postvoid residual urine volume. The initial purposes of the evaluation are to identify conditions requiring referral or specialized workup and to detect and treat reversible causes that may be present. Causes may include infection, atrophic urethritis, pelvic floor weakness (usually related to previous childbirth), medications (e.g., diuretics), altered mental status, or overflow incontinence related to obstruction (e.g., fecal impaction, prostatic hypertrophy). If the patient does not require referral and a reversible cause is not identified, the next step is to categorize the patient’s symptoms as typical of urge or stress incontinence and treat the patient accordingly. Urge incontinence results from bladder contractions that overwhelm the ability of the cerebral centers to inhibit them. These uncontrollable contractions can occur because of inflammation or irritation within the bladder resulting from calculi, malignancy, infection, or atrophic vaginitis-urethritis. They can also occur when the brain centers that inhibit bladder contractions are impaired by neurologic conditions such as stroke, Parkinson’s disease, or dementia; drugs such as hypnotics or narcotics; or metabolic disorders such as hypoxemia and encephalopathy. Stress incontinence is caused by a malfunction of the urethral sphincter that causes urine to leak from the bladder when intra-abdominal pressure increases, such as during coughing or sneezing. Classic or genuine stress incontinence is caused by pelvic prolapse, urethral hypermobility, or displacement of the urethra and bladder neck from their normal anatomic alignment. Stress incontinence can also occur as a result of intrinsic sphincter deficiency in which the sphincter is weak because of a congenital condition or denervation resulting from α-adrenergic-blocking drugs, surgical trauma, or radiation damage. Treatment involves the strengthening of pelvic floor muscles with Kegel exercises, voiding schedules, and biofeedback. Tolterodine (Detrol) and extended-release oxybutynin chloride (Ditropan XL) are used as a first-line treatment option for overactive bladder, which contributes to incontinence because of favorable sideeffect profiles. A trial of therapy may be attempted before formal urodynamic studies are ordered. If treatment fails or a presumptive diagnosis of urge or stress incontinence cannot be reached, the final step would be to perform more sophisticated tests or refer the patient for testing to define the cause and determine the best treatment.

Additional Reading: Incontinence, urinary adult female. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Nephrologic system

The answer is C. Many changes occur within the kidney as a result of increasing age. There is a gradual decrease in renal size; a decrease in renal blood flow; and, most importantly, a decrease in glomerular filtration rate, which can have a significant effect on drug metabolism. In most cases, serum creatinine remains essentially unchanged. In many cases, the doses of renal-metabolized medications need to be reduced in patients with decreased creatinine clearance. Additionally, the renal threshold for glucose increases with increasing age, and there is a decrease in maximal urinary concentration.

Additional Reading: Reducing the risk of adverse drug events in older adults. Am Fam Physician. 2013;87(5):331-336.

Category: Nephrologic system

The answer is C. The most common cause of hyperthyroidism in the elderly is Graves’ disease or toxic diffuse goiter. Graves’ disease is an autoimmune disorder resulting from the action of a thyroidstimulating antibody on thyroid-stimulating hormone receptors. Thyroid-stimulating hormone receptor antibodies are detectable in the serum of approximately 80% to 100% of untreated patients with Graves’ disease. Hyperthyroidism in the elderly is often more difficult to diagnose than in younger patients. Only 25% of those affected present with symptoms typical in younger patients, such as restlessness and hyperactive appearance. Elderly patients are more likely to show weight loss, new-onset atrial fibrillation, and withdrawal or depression. Other complications include cardiac failure, angina, MI, and osteoporosis with an increased risk of bone fractures. Older patients have a lower incidence of goiter. Behavioral changes in younger patients include anxiety, emotional lability, insomnia, lack of concentration, restlessness, and tremulousness. In contrast, elderly patients show apathy, lethargy, pseudodementia, and depressed moods.

Additional Reading: Atrial fibrillation and atrial flutter. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Endocrine system

The answer is E. Pressure ulcers occur more often in patients who have nonblanchable erythema, lymphopenia, immobility, dry skin,
and decreased body weight. Patients with these risk factors need aggressive mobilization to avoid developing pressure sores.

Additional Reading: Pressure ulcers. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Integumentary

The answer is B. In general, a patient should be able to void 80% of the total bladder volume and have a PVR of less than 50 mL immediately after emptying the bladder. High PVR volumes are suggestive of either detrusor weakness or obstruction.

Additional Reading: Urodynamic evaluation of women with incontinence. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Nephrologic system

The answer is B. Pick’s disease and other frontotemporal dementias (FTD) are a heterogeneous group of disorders that share several clinical features with AD such as rate of progression and duration. Many frontotemporal dementias patients are also aphasic and manifest preserved motor integrity. The language disturbance characteristic of Pick’s disease initially includes anomia, but there is a more stereotyped and perseverative verbal output than that found in AD. Unlike AD, in the early stages of frontotemporal dementias, memory, calculation, and visuospatial function are relatively well preserved. The most striking feature of this disorder is an extravagant change in the patient’s personality, including disinhibition, impulsivity, inappropriate jocularity, and intrusiveness. Patients with Parkinson’s disease with dementia typically show deficits on tests of executive function, visuospatial abilities, and verbal fluency. Symptoms in Wilson’s disease usually appear between 6 and 20 years of age, and although cases in older people have been described, psychiatric symptoms are accompanied by neurological symptoms. Lewy body dementia is often accompanied by delirium.

Additional Reading: Frontotemporal dementia: clinical features and diagnosis. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2013.

Category: Neurologic

The answer is A. BPH is a condition associated with enlargement of the prostate gland that gives rise to obstructive urinary symptoms. The condition affects men older than 50 years and is characterized as adenomatous hyperplasia. Enlargement of the gland is usually asymptomatic until bladder outlet obstruction occurs. Symptoms reported by patients include decreased force and caliber of the urinary stream, incomplete voiding, hesitancy, frequency, overflow incontinence, retention, nocturia, and dribbling after urination. Acute urinary retention may be precipitated by prolonged attempts to retain urine, immobilization, exposure to cold, anesthetics, anticholinergic and sympathomimetic drugs, or ingestion of alcohol. Physical examination consistent with BPH shows an enlarged bladder and an enlarged prostate, which is usually firm and symmetrical. The median furrow may be absent. Hard nodules found within the gland are more worrisome for cancer. Laboratory findings with BPH may show an elevated prostate-specific antigen (PSA), usually <10 ng/dL, and elevated creatine when there is obstruction severe enough to lead to renal impairment. Postvoid residuals are usually large and may predispose to infection. The most common cause of hematuria in older men is BPH. Medical treatment involves the use of 5-alpha reductase inhibitors finasteride or dutasteride, which may help to shrink the prostate by blocking the transformation of testosterone to dihydrotestosterone. The drawbacks of the 5-alpha reductase inhibitors are that they require 6 to 12 months to work and regrowth of the prostate occurs after the discontinuation of the medication. Other medications that help with voiding dysfunction are the α-adrenergic blockers prazosin, doxazosin, and terazosin, which are also used in the treatment of hypertension. Tamsulosin is a newer α-adrenergic blocker that does not significantly affect blood pressure. Definitive therapy is surgical. Although sexual potency and continence are usually retained, approximately 5% to 10% of patients experience some postsurgical problems. Transurethral resection of the prostate is preferred. Larger prostates (usually >75 g) may require open surgery using the suprapubic or retropubic approach, permitting enucleation of the adenomatous tissue from within the surgical capsule. The incidence of impotence and incontinence is much higher than after transurethral resection of the prostate. Alternative surgical approaches include intraurethral stents, microwave thermotherapy, high-intensity focused ultrasound thermotherapy, laser ablation, electrovaporization, and radiofrequency vaporization.

Additional Reading: Dutasteride (Avodart) with Tamsulosin (Flomax) for benign prostatic hyperplasia. Med Lett Drugs Ther. 2008;50(1296):79-80.

Category: Reproductive system

The answer is C. Osteoporosis afflicts 75 million persons in the United States, Europe, and Japan and results in more than 1.3 million fractures annually in the United States. Osteoporosis is defined as the loss of bone below the density for mechanical support. It occurs when there is a loss of bony matrix and mineral composition of the bone, which is defined as osteopenia. Those most commonly affected are white and Asian postmenopausal women. Bones typically affected include vertebrae, wrist, humerus, hip, and tibia. Risk factors include menopausal state, positive family history, small bone structure, decreased calcium intake, lack of exercise, smoking, excessive alcohol use, and chronic steroid use. Physicians should recommend bone mineral density testing to all women at age 65, postmenopausal women who present with fractures, and women 60 and older who have multiple risk factors. The most widely used techniques of assessing bone mineral density are DEXA and quantitative CT. Of these methods, DEXA is the most precise and the diagnostic measure of choice. Quantitative CT is the most sensitive method but results in substantially greater radiation exposure than DEXA. Bone densitometry reports provide a T score (the number of standard deviations above or below the mean bone mineral density for gender and race matched to young controls) or a Z score (comparing the patient with a population adjusted for age, gender, and race). Osteoporosis is the classification for a T score of more than 2.5 standard deviations below the gender-adjusted mean for normal young adults at peak bone mass. A T score of -1.0 to -2.5 represents osteopenia. Z scores are not used for the diagnosis. Medicare pays for bone-density examination at age 65 for initial diagnosis and for follow-up after 24 months. Other indications for screening at an earlier age include when estrogen deficiency is present in a woman at clinical risk for osteoporosis, vertebral abnormalities are present (e.g., osteopenia, vertebral fractures, osteoporosis), the patient has been exposed to long-term (more than 3 months’ duration) glucocorticoid therapy, the patient has primary hyperparathyroidism, or the patient requires monitoring to assess response to osteoporosis drug therapy. Plain X-rays are not adequate for the detection of osteoporosis because as much as 30% of bone mass can be lost before it becomes apparent on X-ray. More advanced cases may reveal decreased radiodensity of vertebrae, anterior wedging of vertebrae, and compression fractures. Prevention involves the use of vitamin D supplementation, exercise, and avoidance of smoking and heavy alcohol use. Thiazide diuretics may also help to decrease urinary excretion of calcium in patients with secondary hyperparathyroidism. In established cases, the bisphosphonates (alendronate [Fosamax] and risedronate [Actonel]) and a selective estrogen receptor modulator (SERM) (raloxifene [Evista]) are used for treatment. Monoclonal antibodies that inhibit osteoclast formation (Denosumab) are new to the market, effective, but very costly. Additionally, calcitonin (Calcimar) may also be used to prevent vertebral fractures; it does not appear to prevent nonvertebral fractures.

Additional Reading: Osteoporosis. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Endocrine system

The answer is B. Falls are a major cause of injury-related visits to emergency departments in the United States and the primary cause of accidental deaths in persons older than 65 years. The mortality rate for falls increases dramatically with age in both sexes and in all racial and ethnic groups. Falls can be an indication of poor health and declining function, and they are often associated with significant morbidity. More than 90% of hip fractures occur as a result of falls, with most of these fractures occurring in persons older than 70 years of age. Risk factors for falls in the elderly include increasing age, arthritis, medication use (more than four medications, including tricyclic antidepressants, neuroleptics, benzodiazepines, and type IA antiarrythmics), cognitive impairment (dementia and depression), and sensory deficits. Outpatient evaluation of a patient who has fallen includes a focused history with an emphasis on medications, a directed physical examination, and tests of postural control and overall physical function. Treatment is directed at the underlying cause of the fall, with the goal to return the patient to baseline function. Vitamin D deficiency has been associated with an increased risk of falls, and empiric supplementation can reduce the risk.

Additional Reading: Management of falls in older persons: a prescription for prevention. Am Fam Physician. 2011;84(11): 1267-1276.

Category: Nonspecific system

The answer is D. Presbycusis, a progressive, high-frequency hearing loss, is the most common cause of hearing impairment in geriatric patients. Exposure to loud noises and genetic factors play a role in the etiology. Men are more commonly affected with sensory neural hearing loss. It usually begins after 20 years of age and affects the high-frequency tones first (18 to 20 kHz). Patients often report trouble hearing normal conversations in crowds. This type of hearing loss decreases the ability to interpret speech, which can lead to a decreased ability to communicate and a subsequent increased risk for social isolation and depression. Hearing loss in the elderly can also adversely affect physical, emotional, and cognitive well-being. Questionnaires such as the Hearing Handicap Inventory for the Elderly-Screening Version have been shown to accurately identify persons with hearing impairment. The reference standard for establishing hearing impairment, however, remains pure tone audiometry, which can be performed in the physician’s office. Combining the Hearing Handicap Inventory for the Elderly-Screening Version questionnaire with pure tone audiometry has been shown to improve screening effectiveness. Appropriate interventions include periodic screening to provide early detection of hearing impairment, cautious use or avoidance of ototoxic drugs, and support for obtaining and continued use of the hearing aids.

Additional Reading: Presbycusis. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Special sensory

The answer is D. Ultrasound is the standard imaging tool for the detection of an AAA. In experienced hands, it has a sensitivity and specificity approaching 100% and 96%, respectively, for the detection of infrarenal AAA. The U.S. Preventive Services Task Force (USPSTF) recommends screening for AAA in patients who have a relatively high risk of dying from an aneurysm. Major risk factors include age 65 years or older, male sex, and smoking at least 100 cigarettes in a lifetime. The guideline recommends one-time screening with ultrasound for AAA in men 65 to 75 years of age who have ever smoked. No recommendation was made for or against screening in men 65 to 75 years of age who have never smoked, and it recommended against screening women. Men with a strong family history of AAA should be counseled about the risks and benefits of screening as they approach 65 years of age.

Additional Reading: Screening for abdominal aortic aneurysm. US Preventive Service Task Force, 2005 update. From: http://www.uspreventiveservicestaskforce.org/uspstf/uspsasco.htm.

Category: Cardiovascular system

The answer is B. Patients with aneurysms >5.5 cm should be considered for elective AAA repair. Because most clinically diagnosed AAAs are repaired, their long-term natural history is difficult to predict. The 1-year incidence of rupture is 9% for aneurysms 5.5 to 6.0 cm in diameter, 10% for 6.0 to 6.9 cm, and 33% for AAAs of 7.0 cm or more. Patients with an aneurysm <5.5 cm in diameter should have follow-up serial ultrasounds. Smoking is the biggest risk factor for the development of aneurysms.

Additional Reading: Abdominal aortic aneurysm. Am Fam Physician. 2006;73:1198-1206.

Category: Cardiovascular system

The answer is A. Treatment with cholinesterase inhibitors can provide mild improvement of symptoms, temporary stabilization of cognition, or reduction in the rate of cognitive decline in some patients with mild to moderate AD. Approximately 20% to 35% of patients treated with these agents exhibit a 7-point improvement on neuropsychologic tests (equivalent to 1 year’s decline and representing a 5% to 15% benefit over placebo). Before treatment is started, it is important to inform the family of the expected (modest) benefits of cholinesterase inhibitors. Some cholinesterase inhibitors include donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl), and tacrine (Cognex). These agents raise acetylcholine levels in the brain by inhibiting acetylcholinesterase.

Additional Reading: Drugs for cognitive loss and dementia. Treat Guidel Med Lett. 2010;8(91):19-24.

Category: Neurologic

The answer is B. Retinal detachment usually affects individuals older than 50 years. It does not cause pain or erythema of the eye. Bilateral spontaneous detachments are present in as much as 25% of those affected. Retinal detachment can be caused by retinal tears, retinal holes, or by other causes, including ocular melanoma and metastatic tumors. Warning symptoms include floaters, flashes of light (photopsia), or blurred vision. As detachment progresses, the patient may report a “curtain or shade coming down” phenomenon. Macular involvement leads to central visual loss and a worse prognosis. Patients suspected of retinal detachment should undergo emergent ophthalmologic evaluation. Prognosis is best if there is no macular involvement. Without treatment, total detachment usually occurs within 6 months. Treatment of retinal tears or holes is accomplished with laser photocoagulation, cryotherapy, or a scleral buckle. Uncomplicated retinal detachment can be repaired in up to 90% of cases.

Additional Reading: Retinal detachment. In: Domino F, ed. The 5-Minute Clinical Consult. Philadelphia, PA: Lippincott Williams and Wilkins; 2014.

Category: Special sensory

The answer is B. In the United States, approximately two-thirds of persons 65 years or older take prescription and nonprescription (over-the-counter) medications. Women take more drugs than men because they are, on average, older, and they use more psychoactive and antiarthritic drugs. At any given time, an average older person uses four to five prescription drugs, two over-the-counter drugs, and fills 12 to 17 prescriptions a year. The frail elderly use the most drugs. Drug use is greater in hospitals and nursing homes than in the community; typically, a nursing home resident receives seven or eight drugs. Changes that occur in the elderly often affect the medications that are administered to them. As patients age, they increase their body stores of fat. Because of this, fat-soluble medications have increased distribution and a longer half-life in the body. Although expression of drug-metabolizing enzymes in the cytochrome P450 systems does not appear to decline with age, the overall hepatic metabolism of many drugs by these enzymes is reduced. The glomerular filtration rate in the elderly is also reduced, which can lead to a decreased clearance of medications and an increased risk for toxicity. The volume of body water is also reduced in the elderly, and the administration of water-soluble medications can lead to toxicity with some medications. All these changes must be considered when administering medication to the elderly. Increased sensitivity with aging must be considered when drugs that can have serious adverse effects are used. These drugs include morphine, pentazocine, warfarin, ACE inhibitors, diazepam (especially given parenterally), and levodopa. Some drugs’ effects are reduced with aging (e.g., glyburide, β-blockers) and should also be used with caution because serious dose-related toxicity can still occur and signs of toxicity may be delayed. Many drugs produce active metabolites in clinically relevant concentrations. Examples are some benzodiazepines (e.g., diazepam, chlordiazepoxide), tertiary amine antidepressants (e.g., amitriptyline, imipramine), antipsychotics (e.g., chlorpromazine, thioridazine; not haloperidol), and opioid analgesics (e.g., morphine, meperidine, propoxyphene). The accumulation of active metabolites (e.g., N-acetylprocainamide, morphine-6-glucuronide) can cause toxicity in the elderly as a result of age-related decreases in renal clearance; toxicity is likely to be severe in those with renal disease.

Additional Reading: Reducing the risk of adverse drug events in older adults. Am Fam Physician. 2013;87(5):331-336.

Category: Nonspecific system

The answer is B.

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