Welcome to the The Fastest 20 Minutes of the day!

1. Welcome to theThe Fastest 20 Minutes of the day! CaMDucky Derby!

2. the rules • Everyone in the infield can participate, but you’ll have to be quick. Grab an answer sheet right now! • In addition to prizes for our Thoroughbreds up front, I have prizes for the best scores from the audience. • While I’m giviny’all the rules, PUT YOUR NAME ON IT! (If you want a prize) • All questions (sort of) are from education or participation at this year’s CMDA Meetings and Vivage Geriatric Journal Club, so there will be a distinct advantage to those of you who took the time to participate!

3. the rules • When a question asks for the correct “letters”, list only the designated letters A, B, C, D and / or E (you won’t have time to write more!) • Legibility counts. If I can’t read it… no credit. • At the end of the race, I will yell pencils down! Entries must immediately be submitted in order for y’all to qualify for prizes.

4. the rules Finally, there is NO TALKING! DO NOT YELL OUT ANSWERS!!! This is a race… Questions will come fast and furious and will NOT be repeated

5. So… if you’re in your stirrups…here we go!!!

6. Question 1 [2 points each] Name the president, treasurer and administrative assistant for CMDA [1 point each] List the other 2 members of the Executive Board [1 point each] List any past presidents of CMDA [3 points each] Name any CMDA Member who has gone on to become the president of AMDA

7. Question 2 CMDA is fortunate to have a number of regular participants at monthly meetings from CDPHE, Telligen, CHCA and the state Ombudsman’s office. For 2 points each, name 3 of these persons. If you can name 5 with correct spelling, they will be worth 3 points each!

8. Question 3 [2 points] Give the time, date and location for CMDA Meetings* * Attendance via Zoom is appropriate

9. Question 4 [2 points] Give the time and date for the monthly Vivage Geriatric Journal Club* *Primary Attendance is via Zoom

10. We’re out of the Gates and ready to go!

11. Question 5 [3 points] When treating Parkinsons Disease in the elderly, typically the best ‘first’ choice of an agent would be (choose the correct letter): • Low Dose Sinemet 2 – 3 times daily with meals • Low Dose Sinemet 2 – 3 times daily separated from meals • Amantadine 100 mg bid • Mirapex 1 - 3 times daily • Sinemet plus another agent (eg, Mirapex, Amantadine, Entacapone) to keep doses low

12. Question 6 [2 points] An elderly Parkinsons patient who has been stable for 6 months begins developing dyskinetic movements. The best initial approach is (choose the correct letter): • Attempt a small increase in PD medication • Add Benztropine or a similar anticholinergic medication • Decrease the dose of PD agents • Add Propranolol • Note that it is an unavoidable step in the progression of PD that will eventually resolve with no intervention

13. Question 7 [3 points] Relative to when a provider is contacted by a facility, IMPACT Reviews require a documented action or response by what time?

14. Question 8 [2 points] For dialysis patients, Nepro & similar supplements are (choose the correct letter): • High carbohydrate, low protein • Low carbohydrate, high fat, low electrolyte • Low calorie, high protein, high electrolyte • High calorie, low protein, low electrolyte • High calorie, high protein, low electrolyte

15. Question 9 [1 point for each correct answer; -1for each wrong answer] From the following list, which bind phosphorous? (List ALL correct choices): • Calcium Carbonate • Calcium Acetate • Sevelamar • Velphoror • Lanthanum carbonate

16. Question 10 [3 points] When considering anemia in the elderly – as defined by the WHO – to within 5%, what percentage of anemic patients are due to nutritional deficiencies such as iron, B12 and/or folate?

17. Question 11 [3 points] In an elderly patient with anemia and iron deficiency, the best way to replace iron is (choose the correct letter): • Slow iron, once or twice daily • Iron supplement once daily with food + Vit C • Iron supplement twice daily with food + Vit C • Iron supplement once daily on an empty stomach + Vit C • Iron supplement twice daily on an empty stomach + Vit C

18. Question 12 [4 points] The Colorado Board of Medicine has adopted what maximum dosage of Morphine Milligram Equivalents as acceptable for chronic use (choose the correct letter): • No such recommendation has yet been made • Zero opiates – there is no level that is safe • 50 MME • 90 MME • 120 MME

19. Question 13 [2 points] True or False. Older adults with hearing loss are at greater risk of dementia than those with normal hearing.

20. Question 14 [3 points] For an Octogenarian, the most efficacious vaccine known to date is (choose the correct letter): • High Dose Influenza • Adjuvant Dose Influenza • Prevnar • Meningococcal • Shingrix

21. Question 15 [3 points] True or False. Dopaminergic medications relieve symptoms of restless leg syndrome, but may cause iatrogenic worsening of RLS at doses >0.25 mg q hs with long-term treatment.

22. Question 16 [1 point] True or False. Kratom supplements contain opiates.

23. Question 17 [3 points] A study in JAMA Neurology in April 2018 noted that there was only one vitamin with sufficient evidence to support routine supplementation for patients with Multiple Sclerosis. Name it.

24. Question 18 [1 point] True or False. There is not an FDA-approved, effective reversal agent available for Xa Inhibitors.

25. Question 19 [3 points] A BMJ review of 23 RCTs in 10/17 comparing DOACs (Direct Acting Oral Anticoagulants) to warfarin in patients with Atrial Fib found that compared to warfarin, DOACs (choose the correct letter): • Reduced risk of stroke or systemic embolic events • Provided the same risk reduction for stroke or systemic embolic events as warfarin • Had a higher risk of stroke or systemic embolic events

26. Question 20 [3 points] The same BMJ review found that compared to warfarin, DOACs (choose the correct letter): • Had the same risk for bleeding • May be safer with respect to risk of bleeding • Caused less minor bleeding, but more major hemorrhaging

27. Question 21 [3 points] The same review compared healthcare costs, finding that if drug costs, labs & treatment due to significant bleeding & intended preventable outcomes (e.g., DVTs, PEs, CVAs, deaths) were considered, DOACs(choose the correct letter): • Cost roughly the same overall as warfarin • Were more Expensive • Were more Affordable

28. Question 22 [2 points for each correct response] In 7/18, the FDA had a press release about use of fluoroquinolones. Previous FDA-required updates included an increased risk for disabling & potentially permanent side effects involving tendons, muscles, joints, nerves & the CNS as well as irreversible peripheral neuropathy. This press release was focused primarily on warnings about their risks for mental health side effects and serious blood sugar disturbances. In summary, they stated: “Because the risk of these serious side effects generally outweighs the benefits for patients with ____ , ____ and ____ , the FDA determined that fluoroquinolones should be reserved for use in patients with these conditions who have no alternative treatment options.” Name these 3 infectious conditions.

29. Question 23 [2 points] Calculation of the 10-year risk of atherosclerotic CV disease events includes all of the following except (choose the correct letter): • Gender • Age • Race • Frailty • Smoking status

30. Question 24 [3 points] Primary prevention using statins is indicated for the following older adults (choose the correct letter): • Females with a family history of CAD • Males with a family history of CAD • Everyone with a 10-year risk of a CV event >10% • All 3 of the above • None of the above

31. Question 25 [1 point] From JAMDA, in regard to communicating with elders, CHAT is (choose the correct letter): • CHAngingTalk to avoid babytalk or elderspeak • Caring Humans And Teachers • Choosing to Help Alzheimers without Treating with drugs • Cooperative Help for Alzheimers with Telemedicine

32. Question 26 [1 point] What are the 3 anchors of “A Fine Balance” in regard to prescribing antipsychotics (choose the correct letter): • Human Suffering, Power and Knowledge • Empathy, Training, Education • Qualitative Evaluation, Informed Application, Nonpharmacologic Alternatives • Patient, Family, Provider • Describe, investigate, create & evaluate (DICE)

33. Question 27 [3 points] In seniors, the dose of Melatonin necessary to promote sleep onset is (choose the correct letter): • 0.1 – 0.3 mg • 0.4 – 0.6 mg • 1 – 1.5 mg • 3 – 5 mg • 6 – 9 mg

34. Question 28 [1 point for each correct answer; -1for each wrong answer] A review of English-language trials >6 months in duration in patients without dementia found the following OTC agents were better than placebo in regard to cognitive outcomes (List ALL correct choices): • Omega-3 Fatty Acids • Ginkgo biloba • Vitamin D + Calcium • Vitamin E • Soy • Beta-Carotene

35. Question 29 [1 point for each correct answer; -1for each wrong answer] A review of English-language trials >6 months in duration in patients without dementia found the following pharmacologic treatments when the underlying condition was present were better than placebo in regard to cognitive outcomes(List ALL correct choices): • Antihypertensives • Diabetes Medications • Statins • Aspirin • NSAIDS • Estrogen • Testosterone

36. Question 30 [2 points] In regard to length of time to use oral bisphosphonates in older women at high risk for fractures, in order to reduce fractures of any kind, the Women’s Health Initiative found the ideal time to use these agents was (choose the correct letter): • Indefinitely • 5-10 years • 5 Years • 2 years

37. Question 31 [2 points for each correct answer] There are 4 main types or mechanisms of Drug-Induced Diarrhea. Name them.

38. Question 32 [2 points] When using TPN or PPN, an average adult should receive how much free water (choose the correct letter): • 10 - 20 ml / kg / day • 30 - 40 ml / kg / day • 50 - 75 ml / kg / day • >100 ml / kg / day

39. Question 33 [3 points] According to the GOLD Guidelines for COPD, long-term use of oral glucocorticoids has (choose the correct letter): • Limited side effects with no evidence of benefits • Limited side effects and is frequently beneficial in severe disease • Numerous side effects with no evidence of benefits • Numerous side effects but is frequently beneficial in severe disease

40. Question 34 [3 points] According to the 2018 IDSA Guidelines for C Diff (choose the correct letter): • Metronidazole or Oral Vanco are the initial drugs of choice • Vancomycin or Fidaxomicin are the initial drugs of choice • Metronidazole remains the best first option, followed sequentially by Vancomycin and then Fidaxomicin • Metronidazole, Vancomycin and Fidaxomicin have similar efficacy, so cost is the primary initial consideration

41. Question 35 [3 points] According to the 2018 IDSA Guidelines for C Diff, contact isolation (choose the correct letter): • Is not necessary • Should be implemented so long as the patient continues to have loose stools • Should be continued for 48 hours after resolution of loose stools • Should be continued for 1 week after resolution of loose stools • Should be continued until a follow-up C Diff toxin is negative

42. Question 36 [3 points] Studies in JAGS (2011), JAMA Internal Medicine (2015) and BMJ (2018) all noted that cumulative use of drugs with what type of side effect was associated with an increased risk for dementia.

43. Question 37 [1 point for each correct answer; -1for each wrong answer] A 2017 NEJM articled noted that the Gabapentinoid Pregabalin (Lyrica) has been approved for and found to be more effective than placebo for treating(list all correct letters): • Postherpetic Neuralgia • Sciatica • Osteoarthritis • Diabetic Neuropathy • Fibromyalgia

44. Question 38 [1 point for each correct answer; -1for each wrong answer] The same article found the Gabapentinoid Gabapentin (Neurontin) has been approved for and is more effective than placebo for treating (list all correct letters): • Postherpetic Neuralgia • Sciatica • Osteoarthritis • Diabetic Neuropathy • Fibromyalgia

45. Question 39 [3 points] A study in JAMA Internal Medicine in 2016 noted that Quetiapine was used in __ % of hospitalized, older patients, of which __ % was for sleep and __ % were discharged with a prescription for it.Choose the letter below correlating with the percentages they found. • 2%, 50%, 25% • 5%, 25%, 5% • 12%, 72%, 18% • 13%, 64%, 58% • 22%, 83%, 37%

46. here we go into the home stretch ! ! !

47. Question 40 [3 points] True or False (Both parts must be true for answer to be TRUE) Multiple NEJM articles in 10/18 reviewed use of aspirin vs placebo for primary prevention of certain endpoints, including CV events, dementia, death, persistent physical disability and major hemorrhage. By 4.5 years, there was a numerically higher rate of death from any cause in the ASA groups and there was not a statistically significant decrease in the primary endpoints listed.

48. Question 41 [1 point for each correct answer; -1for each wrong answer] A 4th study reviewed use of aspirin for primary prevention of cardiovascular events and major hemorrhage in diabetics. The primary findings were (list all correct letters): • Significantly fewer vascular events in ASA group • Significantly more major bleeds occurred in ASA patients • CV benefits of ASA outweighed a slight increase in major bleeding • Absolute benefits were largely counterbalanced by bleeding hazards, ie, all-cause mortality was neutral

49. Question 42 [1 point each] Name the ESCAPE Organisms, a group of clinically important, predominantly health care-associated organisms that have the potential for substantial antimicrobial resistance which have evolved largely as a result of overuse of antibiotics.

50. Question 43 [2 points] True or False According to a 2/19 article in Annals, none of the compounded pain creams reviewed (ketamine, gabapentin, clonidine, lidocaine, ketoprofen, baclofen, cyclobenzaprine) were better than placebo creams at relieving pain.