1.

Urge incontinence (sudden onset of desire to urinate that results in incontinence before getting to restroom) results from which anatomic dysfunction?

Detrusor instability

2.

What classes of medications increase the risk of falls in the elderly?

Sedative hypnotics, tricyclic antidepressants, neuroleptics, benzodiazepines, and Type IA antiarrhythmics

3.

Lichen simplex chronicus in women is associated with what malignancy?

Vulvar carcinoma

4.

What medications are useful in the treatment of pain because of compression fractures?

Analgesics, recombinant parathyroid hormone, calcitonin (injectable or intranasal), bisphosphonates, selective estrogen receptor modulators (SERMs)

5.

What clinical findings are present in patients with Lewy body dementia?

Dementia Parkinsonism Visual hallucinations

6.

The USPSTF recommends initiation of screening for osteoporosis at what age?

65 if no risk factors; 60-64 if risk factors are present

7.

How is absorption altered in drug metabolism in elderly patients?

Absorption is slower, but generally as complete as in younger patients.

8.

What form of abuse is the most common in the elderly?

Neglect; women are more affected than men.

9.

What group of individuals are the most common perpetrators of abuse in the elderly?

Relatives of the abused (especially adult children)

10.

What is the classic clinical triad of symptoms for normal pressure hydrocephalus (NPH)?

Ataxia

Urinary incontinence

Dementia

(wet, wobbly, wacky)

11.

What is the most common etiology of seizures in geriatric patients?

Cerebrovascular disease (especially hemorrhagic strokes)

12.

In men with benign prostatic hyperplasia (BPH), how does finasteride and dutasteride affect prostate-specific antigen (PSA) levels?

They can reduce levels by half, making the detection of prostate cancer difficult; a baseline should be obtained before drug initiation, and follow-up testing should be interpreted recognizing this reduction

13.

In the geriatric population, what is the most common cause of blindness?

Age-related macular degeneration

14.

What are the clinical signs and symptoms of Parkinson disease?

Tremor at rest (“pill rolling”)

Bradykinesia (reduced arm swing when walking, micrographia)

Rigidity (lead pipe or cogwheeling)

Shuffling, festinating gait

15.

With what disease a positive Babinski (upgoing toes after stroking lateral heel to metatarsal pad) sign is associated with?

Upper motor neuron and central disease, including multiple sclerosis, pernicious anemia, cerebral tumors, subdural hematoma, and spinal cord disease. It is not associated with Parkinson disease.

16.

What is the initial drug of choice for treating Parkinson disease?

Levodopa

17.

To qualify for hospice benefits, the patient must be judged to have how long of a life expectancy?

Less than 6 months for any diagnosis

18.

Following breast cancer surgery, what routine surveillance is recommended?

Monthly breast self-examination

Annual mammography; history and physical examination every 6 months for the first 5 years and then annually

Routine surveillance with intensive laboratory and radiographic studies has not been shown to improve quality of life or survival

19.

What are the initial treatment recommendations for urge incontinence?

Behavioral therapy with bladder training and pelvic floor muscle (Kegel) exercises; these are more effective than anticholinergic medication.

20.

What class of medication is used for patients with excessive secretions at the end of life?

Anticholinergics (i.e., glycopyrrolate, scopolamine)

21.

What are the treatment options for initial Clostridium difficile infection?

Oral metronidazole; treatment failure can be treated with another course of metronidazole or oral vancomycin. For recurrent or resistant C. difficile, fidaxomicin and fecal transplants are options.

22.

Tuberculosis infection involving the bony spine is called:

Pott disease

23.

What type of incontinence is associated with a weak urinary sphincter and is associated with incontinence that occurs with coughing or sneezing?

Stress incontinence

24.

What vitamin supplementation may decrease the risk of falls?

Vitamin D

25.

What intervention can improve survival in patients with end-stage, severe COPD?

Oxygen

26.

Screening tests are considered not beneficial if the patient’s life expectancy is less than how many years?

10 years

27.

Which class of antihypertensive agents will help preserve bone density?

Thiazide diuretics

28.

In men, what are the risk factors for the development of osteoporosis?

Hypogonadism, corticosteroid use of >3 months, and vitamin D deficiency

29.

What PSA velocity is predictive of prostate cancer?

0.75 ng/mL/yr

30.

What is the risk of prostate cancer as the percentage of free PSA (unbound) goes up?

As the ratio of free (unbound) PSA goes up, the risk of prostate cancer goes down. When <10% of PSA is free, the positive predictive value for prostate cancer is 55%, when >25% of PSA is unbound, the risk is only 8%.

31.

What type of tremor may be reduced with the use of alcohol?

Essential tremor

32.

A sudden loss of vision that is without pain suggests what diagnosis?

Retinal detachment

33.

When a patient describes a “curtain or veil coming down” in their visual field suggests what diagnosis?

Retinal detachment

34.

What blood tests should be done as part of the evaluation of restless leg syndrome (RLS)?

Hemoglobin, hematocrit, serum ferritin, and transferrin saturation—low ferritin and transferrin levels are associated with RLS.

35.

What is the test used for assessing thyroid function in the elderly?

Thyroid-stimulating hormone

36.

What condition is the leading risk factor for the development of delirium?

Dementia

37.

What is the initial treatment of hypercalcemia associated with malignancy?

Aggressive rehydration and diuresis with furosemide; phosphorus replacement if hypophosphatemia is present, and administration of intravenous bisphosphonates.

38.

What are the primary services offered by hospice?

Dietary counseling; short-term hospital and respite care, medication, and supplies to treat symptoms of terminal illness (but not medication used to cure the illness); physical, occupational, and speech therapies

39.

Megestrol acetate (Megace) acting as progestin agonist to improve appetite in those with cachexia has what side effects?

Thrombophlebitis, pulmonary embolism, and adrenal suppression (in high doses for prolonged periods)

40.

When a patient has severe neuromuscular weakness, what procedure is used to prove myasthenia gravis?

The Tensilon test is used to diagnose myasthenia gravis.

41.

Which SSRI has been used for the treatment of hot flash symptoms?

Paroxetine

42.

What screening mammography testing interval does Medicare pay for?

Every 2 years

43.

What is the best time to do breast self-examination in a premenopausal woman?

During the first week following menses

44.

When treating Alzheimer dementia, what are the common side effects that result in the discontinuation of acetylcholinesterase inhibitors (tacrine, donepezil, rivastigmine, and galantamine)?

Gastrointestinal side effects including nausea, vomiting, and diarrhea

45.

What areas are often cultured in methicillin-resistant Staphylococcus aureus (MRSA) colonization?

Nasal mucosa and oropharynx

46.

How is MRSA colonization treated to reduce the shedding of MRSA organisms?

Mupirocin (Bactroban)

47.

Which flu symptom (fever, cough, sore throat, rhinorrhea, myalgias, headaches, fatigue) are less common in the elderly?

Fever

48.

What is the most worrisome complication in the elderly when they develop influenza?

Pneumonia and associated respiratory decompensation

49.

Unlike younger patients who develop chest pain, what symptoms do the elderly develop that represent their cardiac ischemia?

Dyspnea

50.

A high-pitched, blowing diastolic murmur and a wide pulse pressure are suggestive of what diagnosis?

Aortic valve insufficiency

51.

What is the life expectancy of symptomatic elderly patients with untreated aortic stenosis?

2-3 years

52.

What clinical features discern delirium from dementia?

Time of symptoms; delirium has an acute onset and fluctuating course; dementia has a gradual, worsening course.

53.

An acceleration-deceleration head injury can result in what sort of injury?

Subdural hematoma which results from tearing and rupture of the bridging veins beneath the dura

54.

A crescentic collection on CAT scan over one hemisphere of the brain that does not cross the midline is suggestive of what diagnosis?

Subdural hematoma

55.

What initially differentiates Pick dementia from Alzheimer dementia?

Pick disease (frontotemporal dementia) is an inherited disorder that does NOT initially present with memory loss; it affects the frontal lobes and causes aphasia and behavioral problems. Alzheimer often presents initially with shortterm memory loss.

56.

Pick disease is inherited by what genetic-type pattern?

Autosomal-dominant inherited disease

57.

What condition presents with loss of muscle strength and coordination, including difficulty opening and closing the jaw, drooling, voice change, hoarseness, muscle cramps, and stiffness and progresses to paralysis and death?

Amyotrophic lateral sclerosis, which affects both upper and lower motor neurons; sensory, cerebellar, and extraocular muscle functions are not affected.

58.

What is the document used in nursing care facilities that represents a comprehensive resident assessment?

Minimum data set; it is required to detail patients’ functional capacities.

59.

What is the likely cause of loss of central vision, but intact peripheral vision?

Macular degeneration causes central vision to be lost, but peripheral vision usually remains intact.

60.

An elderly male presents with yellowish spots on fundoscopic exam; what is the cause?

Drusen which are fatty desposits under the retina that does not cause macular degeneration, but does increase the risk of developing macular degeneration

61.

Which type of macular degeneration has the higher risk for loss of vision?

The exudative (or wet) form; the atrophic (or dry) form is usually less severe.

62.

What condition results from decreased function of dopamine-containing neurons in the substantia nigra?

Parkinson disease

63.

What are the clinical findings in a patient with Parkinson disease?

Bradykinesia; a pill-rolling tremor, cogwheel or lead pipe rigidity, infrequent blinking, blank stare, shuffling gait with a rapid initiation and the inability to stop once started (also called festinating gait), and increased salivation

64.

Levodopa-carbidopa (Sinemet) should be taken with what kind of meal?

Low-protein meal; high-protein meals will decrease the bioavailability.

65.

What is the rationale of using low dosages of levodopa and using short dosing intervals?

To prevent the “on-off effect” that is associated with fluctuations in the response to levodopa

66.

What is the pathologic process of multiple sclerosis?

Autoimmune T cells cause damage in the white matter of the motor strip, causing symptoms of visual disturbances (extraocular eye muscle dysfunction, optic neuritis-induced unilateral blindness), decreased sensation, and coordination dysfunction.

67.

An elderly patient complains of sudden-onset need to urinate and of loss of urine before being able to reach bathroom. What is the likely diagnosis?

Urge incontinence; because of detrusor hyperactivity

68.

Patients who state they loss their urine with cough or sneezing have what type of incontinence?

Stress incontinence; often due to pelvic floor relaxation

69.

Patients with loss of urine without warning or without feelings of fullness, leakage of urine while sleeping, and an intermittent urinary stream have what type of incontinence?

Overflow incontinence

70.

Which illnesses increase the risk of geriatric depression?

Stroke and cancer diagnoses are the two most highly correlated with the onset of depression.

71.

What patient training should be given to treat chronic urinary incontinence?

Kegel exercises (repeated tightening and relaxation of the pelvic floor muscles)

72.

What social condition increases the risk of geriatric depression?

Social isolation

73.

Vaginal pruritus, burning, discharge, and excessive dryness with dyspareunia are consistent with what diagnosis?

Atrophic vaginitis

74.

What topical agent is used first line to treat atrophic vaginitis?

Topical estrogen

75.

What is the likely diagnosis in someone with new-onset dementia, gait ataxia, and urinary incontinence?

Normal pressure hydrocephalus

76.

In men, what is the most common solid malignancy?

Prostate cancer

77.

Following a radical prostatectomy, what are the most common complications?

Urinary incontinence and erectile dysfunction

78.

What type of injury is associated with >10% risk of mortality in the geriatric population?

Hip fracture

79.

After a fall, a senior citizen is found to have a leg that appears shortened, abducted, and externally rotated. What is the most likely diagnosis?

Hip fracture

80.

With use of bisphosphonates, what is the most common adverse effect?

Gastrointestinal complaints including esophageal irritation

81.

After falls, what is the second most common cause of trauma in senior citizens?

Motor vehicle accidents

82.

What is the likely cause of a patient who presents with numbness of the hands and feet, decreased taste, and swelling or soreness of the tongue?

B₁₂ deficiency

83.

What diabetic medication is not associated with hypoglycemia and considered safe if GFR is ≥30?

Metformin

84.

What rare complication of metformin can occur if an elderly patient has a GFR <30 or acute renal failure?

Lactic acidosis

85.

What class of medications is considered first line in the treatment of dementia?

Acetylcholinesterase inhibitors

86.

Loss of short-term and recent memory and the presence of senile plaques, neurofibrillary tangles, and granulovacuolar degeneration of neurons is associated with what condition?

Alzheimer disease

87.

During what rehabilitation time frame will most improvement be found following a stroke?

The first 12 weeks

88.

In a geriatric patient, what test of mobility and function can be used to detect an increased risk for falls?

The “get up and go” test. Patient is instructed to stand from a sitting position without using their hands, walk 10 feet, turn, and return to the chair to sit. Greater than 16 seconds to complete the process suggests postural instability or gait impairment.

89.

Decreased visual acuity, noted primarily with reading and with decreased night vision and excessive glare in bright light or sunlight is associated with what diagnosis?

Cataracts

90.

What time frame is used to define menopause?

The absence of menses for 6 months

91.

What laboratory test can be used to detect menopause?

FSH ≥30 mIU/mL is consistent with ovarian failure.

92.

What is a written advance directive that assigns one person as a decision-maker called?

Health care proxy

93.

What is the term used for a written advance directive where a competent person indicates their medical preferences?

Living will

94.

How does aging effect fasting glucose levels?

Increasing fasting blood glucose (1 mg/dL for every 10 years), although most remain within normal limits.

95.

A geriatric patient presents with visual hallucinations, memory loss, and some symptoms of Parkinson but no tremor; what is the likely diagnosis?

Lewy body dementia presents with dementia, delirium, and visual hallucinations with parkinsonism (use the acronym DDaVP); tremor is often absent.

96.

What common drugs may induce a B₁₂ deficiency?

Metformin and proton pump inhibitors (omeprazole, others) can induce a B₁₂ deficiency; chronic alcohol use may as well.

97.

How does aging effect fat-soluble medications?

As people age, their creatinine clearance increases and as does their body stores of fat. This leads to increased volume of distribution and longer half-life of fat-soluble medications in the body.

98.

What are the indications for screening for an abdominal aortic aneurysm?

Men aged 65-75 who have ever smoked

99.

How does aging effect creatinine clearance?

It decreases; normally a 10% decrease in creatinine clearance per 10 years after 40 years of age.

100.

Hearing loss in the elderly is typically associated with loss of which frequencies?

High-frequency hearing loss, also called presbycusis

101.

How is osteoporosis defined using a bone mineral density test?

A “T-score” greater than 2.5 standard deviations below the gender-adjusted mean for normal young adults at peak bone mass

102.

How is osteopenia defined using a bone mineral density test?

A T score of -1.0 to-2.5

103.

At what age should an average risk woman be screened for osteoporosis?

At age 65 years; if she has multiple risk factors (low BMI, smoker, strong family history of early osteoporosis), at age 60 years

104.

On bone mineral testing, what does the Z score mean?

It compares the patient’s measurement with a population adjusted for age, gender, and race.

105.

How often will Medicare pay for bone density examinations?

At age 65 for screening and then every 2 years for those undergoing treatment

106.

How do thiazide diuretics affect bone density?

They decrease urinary excretion of calcium and improve bone density

107.

What is the mechanism of action of raloxifene (Evista)?

It is an SERM (selective estrogen receptor modulator); it is indicated for both osteoporosis prevention and treatment and for breast cancer prevention

108.

When used for BPH, why is tamsulosin (Flomax) preferred compared to other α-adrenergic antagonists?

It has a much lower risk of hypotension.

109.

Why does tamsulosin (Flomax) not induce hypotension?

It is an α1 selective adrenoreceptor inhibitor, which is only found in the prostate.

110.

What is the common cardiac concern in an elderly patient with hyperthyroidism?

Atrial fibrillation

111.

What agents are available to treat a healthy 70-year-old who has an essential tremor?

β-Blockers are first line; if intolerant, consider primidone (Mysoline), an antiseizure medication, topiramate or gabapentin.

112.

What brief test can be used to screen for dementia?

Mini-Cog, which as three steps: first, ask the patient to repeat three random words, then draw a clock face set to “10 minutes to 2,” and then recall the original three words. It is 99% sensitive and 93% specific for dementia.

113.

In a 65-year-old woman with lower abdominal pain and a palpable ovary, what diagnosis is most concerning?

Ovarian cancer

114.

What type of hypertension is more common and worrisome in elderly patients?

Systolic hypertension

115.

What is the most common cause of injury-related emergency room visits in geriatric patients?

Falls

116.

Geriatric men with untreated hypogonadism have a higher risk of what condition?

Osteoporosis

117.

What population should be vaccinated for herpes zoster?

Age 60 years and older

118.

What drugs are unsafe to use for chronic insomnia in the elderly?

Melatonin, benzodiazepines, and nonbenzodiazepine hypnotics are contraindicated as they are associated with an increased risk of falls, fractures, and death.

119.

What condition is the leading cause of disability in patients over age 65?

Osteoarthritis

120.

Clinical symptoms of osteoarthritis include what findings?

Dysfunction and distortion of the distal interphalangeal joints (DIP) and proximal interphalangeal joints (PIP) joints of the fingers (but not the metacarpophalangeal joint [MCP] or wrist), lack of systemic findings, and minimal joint inflammation

121.

A patient presents with “bumps” on the distal interphalangeal joints of her fingers associated with morning hand stiffness; what is the cause?

Heberden nodes form at the DIP joints in osteoarthritis.

122.

What nonpharmacologic treatment should be initiated whenever treating lower extremity osteoarthritis?

Physical therapy with the goal of strength training (decreases pain) and endurance (aerobics, which improves long-term functionality). Benefits are lost within 6 months of exercise cessation.

123.

How commonly do senior citizens live below the poverty level?

About 45% of US senior citizens live at or below the poverty level; seniors living alone or those over 80 have the greatest risk. Lack of adequate nutrition can be addressed by food stamps.

124.

What is the risk of developing varicella zoster?

Approximately one in three seniors over 60 will develop shingles; that number approaches 50% before age 80.

125.

What are the current pneumococcal vaccine recommendations for seniors?

Those 65 and older who have not received any pneumococcal vaccine should be given PCV 13 (Prevnar) first, followed by a dose of PPSV23 (Pneumovax) a year later.

126.

For what diseases should all seniors be counseled to receive vaccines?

Influenza, shingles (herpes zoster), diphtheria, tetanus, pertussis (whooping cough), pneumococcal disease (pneumonia)

127.

A senior presents with a painful vesicular rash on his chest that starts under his axilla and extends anteriorly to the midclavicular line; what is the likely diagnosis?

Varicella zoster (shingles)

128.

What rules can seniors follow to prevent (and initially treat) chronic constipation?

High-fiber diet, adequate fluids, exercise, and training to “obey the urge” to defecate (rectal distention initiates the defecation reflex; voluntarily overriding this reflex because of convenience or distraction is a common etiology)

129.

What two commonly used medications increase the risk of chronic constipation?

Antacids (calcium, aluminum) and calcium channel blockers

130.

In addition to increased exercise, increased fluid intake, and bowel training, what oral agents help treat chronic constipation?

Hydrophilic colloids (bulk-forming agents) like psyllium (konsyl, metamucil, perdiem fiber) and osmotic laxatives (polyethylene glycol, PEG) (MiraLax); all must be taken with adequate hydration or constipation may worsen

131.

An elderly patient complains of her rhinorrhea whenever she eats; what is the likely diagnosis?

Gustatory rhinitis. Other types of nonallergic rhinitis in seniors include vasomotor and α-adrenergic hyperactivity (because of antihypertensives). All three can be treated with topic anticholinergic nasal spray (ipratropium); narrow-angle glaucoma is a relative contraindication to this drug.

132.

A patient with history of smoking has worsening dyspnea; on spirometry, their forced expiratory velocity (FEV)₁/forced vital capacity (FVC) is <0.7; what is the likely diagnosis?

Chronic obstructive pulmonary disease