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A 70-year-old right-hand–dominant male has had a tremor in his righthand for 5 years. It is now getting worse, and he is also developing atremor in his left hand. He says his walking speed has become slower,and his wife thinks he is becoming more forgetful. There is no familyhistory of similar problems.On examination his facial expressions seem diminished. He has aresting tremor in both hands, but it is more prominent on the right. Hehas a slightly stooped posture and you note a decreased arm swingwhen he walks. There is some resistance when his arms are passivelyflexed and extended at the elbows. His Mini-Mental State Examinationscore is 27 out of 30.Appropriate treatment at this time would include which of the following?(Mark all that are true.)A. Carbidopa/levodopa (Sinemet)B. Donepezil (Aricept)C.Pramipexole (Mirapex)D. Primidone (Mysoline)E. Propranolol (Inderal)
Answer • A. Carbidopa/levodopa (Sinemet)C.Pramipexole (Mirapex)
Parkinson’s disease is a progressive neurodegenerative disorder with an estimated prevalence of 0.3% in the U.S. population. The cardinal signs and symptoms are bradykinesia (patients may describe this as weakness), resting tremor, and rigidity. Postural instability is considered by some to be the fourth cardinal sign. Essential tremor is generally a bilateral action tremor, and there are usually no extrapyramidal symptoms. An essential tremor may involve the head.Treatment for Parkinson’s disease includes levodopa, dopamine agonists, catechol O-methyltransferase (COMT) inhibitors such as tolcapone, MAO inhibitors, NMDA-receptor inhibitors such as amantadine, and surgery. Memantine has been shown in some studies to be effective in early Parkinson’s disease (SOR B).Carbidopa/levodopa has been the primary treatment for Parkinson’s disease with motor symptoms. It is effective for controlling bradykinesia and rigidity. When combined with levodopa, carbidopa increases cerebral levodopa bioavailability and decreases the peripheral side effects of dopamine, such as nausea and hypotension (SOR A). Dopamine agonists directly stimulate dopamine receptors and include bromocriptine, pergolide, pramipexole, and ropinirole. Double-blind controlled studies comparing dopamine agonists with levodopa have shown that levodopa is more effective at reducing symptom scores than dopamine agonists, but causes more motor complications (SOR A). Levodopa/carbidopa is also significantly less expensive. Primidone and propranolol can be used to treat essential tremor, but not Parkinson’s disease (SOR A).Dementia may occur, and the cholinesterase inhibitors donepezil and rivastigmine have shown modest efficacy in treating dementia associated with Parkinson’s disease. This patient’s mental status score is in the normal range so there is no need to treat with a cholinesterase inhibitor at this time (SOR B).
2. A 75-year-old male with a history of stable angina pectoris is found tohave persistently elevated blood pressure on three visits over a2-month period. There is no evidence of renovascular hypertension onphysical examination or laboratory testing.Which of the following would be appropriate at this point? (Mark all thatare true.)A Evaluation for excessive alcohol useB Counseling about NSAID useC Treatment with a Beta blockerD Treatment with an ACE inhibitorE Treatment with a diureticF Treatment with a calcium channel blocker
Answer • A Evaluation for excessive alcohol useB Counseling about NSAID useC Treatment with a beta blockerD Treatment with an ACE inhibitorE Treatment with a diuretic
Randomized, controlled trials (RCTs) have shown that consumption of more than two alcoholic drinks/day is associated with elevated blood pressure in elderly persons (SOR A). Multiple RCTs have shown that blood pressure is increased in patients using NSAIDs (SOR A). RCTs have also shown improved survival in hypertensive patients treated with β-blockers or diuretics (SOR A). ACE inhibitors and angiotensin receptor blockers have been shown in multiple RCTs to improve outcomes, if tolerated. JNC-7 does not list calcium channel blockers as first-line agents for hypertension (SOR A).
An 81-year-old male with New York Heart Association Class II heart failure complains of nocturia. He says he usually has to get up once during the night, and has also noticed mild hesitancy and an occasional decrease in the force of his urinary stream. He has not noted urinary frequency or dysuria, and does not feel the urge to void again shortly after urinating. He also denies hematuria. His American Urologic Association symptom score is 5.On examination there is no bladder distention, and he has a symmetrically enlarged, nontender prostate. Results of his urinalysis are normal.Which one of the following would be most appropriate at this time?A.Observation onlyB.A prostate-specific antigen (PSA) levelProstate ultrasonographyAn α-blocker such as tamsulosin (Flomax)Urologic referral
Answer • A.Observation only
This patient has a life expectancy of less than 10 years, so the potential harm from testing for prostate cancer outweighs the potential benefits (SOR C). The best management plan is to continue to observe and to take no further action unless the benefit clearly is greater than the potential for harm.If the patient had signs or symptoms of bladder stones, urinary retention, urinary tract infection, or renal failure, ultrasonography would be appropriate. An α-blocker would not be appropriate because of the potential side effects of the treatment.
An 82-year-old male has diabetes mellitus, heart failure, hypertension, and benign prostatic hyperplasia. His wife is 79 years old and has COPD, osteoarthritis, osteoporosis, and mild cognitive impairment. Their combined medication expenses are $5100 per year, and both are enrolled in a Medicare Part D plan.In order for them to qualify for the low-income subsidy under the federal rules for Medicare Part D, which of the following must be true? (Mark all that are true).Both must qualify for Medicare Part ABoth must be enrolled in a Medicare Part D planBoth must be eligible for both Medicare and MedicaidAt least one must be disabledTheir income level must fall below 150% of the federal poverty level for a couple
Answer • Both must qualify for Medicare Part A • Both must be enrolled in a Medicare Part D plan • Their income level must fall below 150% of the federal poverty level for a couple
Many older Americans who qualify for the low-income subsidy to Medicare Part D do not know it. Those who qualify have a reduced deductible ($50 instead of $250) and a markedly reduced co-pay (15% instead of 100%) for expenses incurred in the coverage gap ($2250–$5100).In order for a married couple to qualify, both must qualify for Medicare Part A, both must be enrolled in a Part D plan, and their income must fall below 150% of the federal poverty level for a couple. The Social Security Administration also looks at other resources to determine eligibility, including real property. Medicaid recipients are automatically deemed eligible, and are not required to file an application. It is not necessary for recipients to be eligible for Medicaid, however, or to be disabled. A social worker is often helpful in the application process.
An 83-year-old female nursing-home resident with moderate Alzheimer’s disease is having increasingly frequent frightening visual hallucinations at night, despite the nursing home staff’s efforts to create a comfortable routine.Reasonable first-line nightly medications would include which of the following? (Mark all that are true.)Buspirone (BuSpar)Carbamazepine (Tegretol)Lorazepam (Ativan)Olanzapine (Zyprexa)Risperidone (Risperdal)
Answer • Olanzapine (Zyprexa • Risperidone (Risperdal)
Atypical antipsychotics such as olanzapine and risperidone are the first-line drug of choice for managing psychotic symptoms of dementia (SOR A). The range of doses tolerated by demented patients is narrow, however, and the FDA has issued an alert for all drugs in this class noting that mortality is increased in patients taking these drugs, mostly from cardiovascular or infectious causes. There have been no trials of buspirone for this problem, and it is not recommended (SOR C). Side effects limit the use of carbamazepine to second-line therapy when antipsychotics fail (SOR B). Lorazepam is recommended only for acute agitation (SOR C).
A 73-year-old white male presents with palpable, slightly scaly areas on his face and the back of his hands. They are asymptomatic, except for being occasionally itchy. He isn’t worried about them, but his wife is.Appropriate management options include which of the following? (Mark all that are true.)Observation onlyCryosurgeryCurettageTopical fluorouracil (Carac, Efudex)Topical imiquimod (Aldara)Topical diclofenac (Solaraze)
Answer • CryosurgeryCurettageTopical fluorouracil (Carac, Efudex)Topical imiquimod (Aldara)Topical diclofenac (Solaraze)
This patient has multiple actinic keratoses (AK), which should be treated because they can progress to squamous cell carcinoma. Cryosurgery is effective for multiple AK, and curettage is effective for patients with a limited number of AK (SOR C). Topical treatment with 5-fluorouracil, imiquimod 5%, or diclofenac 3% gel should be considered for patients with multiple lesions (SOR C). Chemical peels are also effective, and may be preferred because of the convenience of a single application (SOR C).
An 80-year-old female complains of generalized weakness and increasing difficulty carrying groceries and walking up stairs. She has been widowed for 3 years, and has been sedentary since the death of her husband. Her only medical problems are osteoarthritis and hypertension controlled with medication. She has no history of heart disease.Which of the following would be appropriate components of an exercise prescription for this patient? (Mark all that are true.)Stress testing prior to exerciseWalking for a total of 30 minutes/day, 5 days a weekBalancing on one leg while holding on to the counterStrength training using 1- to 2-lb weights or soup cans, performing 10 repetitions 2–3 times per weekAquatic exercises
Answer • Walking for a total of 30 minutes/day, • 5 days a weekBalancing on one leg while holding on to the counter • Strength training using 1- to 2-lb weights or soup cans, • performing 10 repetitions 2–3 times per weekAquatic exercises
Regular exercise is associated with a decrease in all-cause morality and morbidity in middle-aged and older adults. Studies have shown that modest increases in life expectancy are possible even in patients who do not begin regular exercise until age 75. For elderly patients, the exercise prescription should include a combination of aerobic exercise, resistance exercise, and balance/flexibility training.The American College of Sports Medicine recommends exercise stress testing for all minimally active older adults who plan to begin exercising at a vigorous intensity. Most elderly patients, however, can safely begin a moderate aerobic and resistance training program without stress testing if they begin slowly and gradually increase their level of activity (SOR C).Aerobic exercise should consist of at least 30 minutes of moderate aerobic activity for most days of the week (SOR A). This can consist of walking briskly, leisurely cycling, or other activities such as mowing the lawn with a power mower, golfing using a pull cart, or swimming with moderate effort. The exercise can be broken into shorter periods of at least 10 minutes.Muscle strength declines by 15% per decade after age 50, and 30% per decade after age 70. Resistance training can result in strength gains of 25%–100% or more in older adults. Equipment need not be expensive, and the exercise can even consist of rising from a chair. Strength gains require that the effort be significant enough that the patient becomes fatigued after 10–15 repetitions per set (SOR A).Empiric evidence suggests that balance programs can improve stability and decrease the risk of falls (SOR B). Before beginning aerobic exercise, deconditioned and sedentary elderly patients should be encouraged to improve their functional ability with strength and balance training. This will reduce the risk of falling while performing aerobic exercise.Half of older adults cite musculoskeletal discomfort as the reason for not exercising. Exercising at a lower intensity and using a range of exercises can help prevent discomfort. Aquatic exercises limit weight-bearing, which can be helpful for patients with arthritis (SOR A).
A 78-year-old male with a previous history of hypertension and chronic atrial fibrillation has a transient ischemic attack (TIA). True statements regarding anticoagulation and antiplatelet therapy in this patient include which of the following? (Mark all that are true.)Treatment with warfarin (Coumadin) will reduce his risk of recurrent strokeAspirin will be as effective as warfarin for reducing his risk of strokeThe combination of aspirin and clopidogrel (Plavix) is better than aspirin alone in reducing his risk of stroke in this patientAspirin should be prescribed if there is a contraindication to anticoagulationThe target INR in this patient is 2.0–3.0
Answer • Treatment with warfarin (Coumadin) will reduce his risk of recurrent stroke • Aspirin should be prescribed if there is a contraindication to anticoagulation • The target INR in this patient is 2.0–3.0
Meta-analyses of randomized, controlled trials (RCTs) have shown that anticoagulants reduce the risk of stroke in patients at high risk of stroke who have atrial fibrillation (SOR A). Findings associated with a high risk of stroke include a history of previous stroke, TIA, or embolic event; a previous history of hypertension; poor left ventricular function; age >75; rheumatic heart valve disease; and a prosthetic heart valve. In persons without atrial fibrillation, anticoagulation with warfarin has not been shown to be more effective than aspirin therapy for secondary stroke prevention.Aspirin can be used in patients who have contraindications to anticoagulation, but it is not as effective (SOR A). An RCT has shown that the combination of aspirin and clopidogrel insignificantly reduces the risk of secondary stroke compared to aspirin alone, but significantly increases the risk of life-threatening bleeding (SOR A). A 2002 meta-analysis of 21 RCTs for antiplatelet therapy in secondary stroke prevention found that antiplatelet therapy reduces the risk of vascular events (17.8% vs 21.4%, RRR 135, P <.001). No differences in outcomes between different doses of aspirin were detected (SOR A).Several RCTs and observational studies suggest that an INR below 2.0 is not effective for stroke prevention and that an INR above 3.0 considerably raises the risk of hemorrhage (SOR A).
You are evaluating an 80-year-old female who has a history of recurrent falls in recent months. Her medical problems include hypertension, depression, chronic atrial fibrillation, heart failure, and insomnia. Her medications include sertraline (Zoloft), alprazolam (Xanax) as needed for sleep, digoxin, lisinopril (Prinivil, Zestril), and warfarin (Coumadin).Which of her medications may be contributing to her falls? (Mark all that are true.)BenzodiazepinesDigoxinLisinoprilSertralineWarfarin
Answer • BenzodiazepinesDigoxinSertraline
A meta-analysis of 29 trials (none were randomized, controlled studies) found a significant relationship between the risk of falls and the use of type IA antiarrhythmic agents, digoxin, and diuretics. There was no increased fall risk associated with ACE inhibitors, calcium channel blockers, β-blockers, centrally acting antihypertensive agents, or nitrates (SOR B).Studies have shown an increased risk of falling associated with the use of either short-acting or long-acting benzodiazepines (SOR A). One study done in a nursing-home population showed a 44% increased rate of falls in people currently using benzodiazepines. The rate of falls increased with longer elimination half-lives. A prospective, multicenter cohort study in community-dwelling women 65 years of age or older showed that the use of either short-acting or long-acting benzodiazepines was associated with frequent falls compared with the rate for those not taking these drugs.
An 80-year-old male consults you because he has become constipated. A routine screening was negative 8 months ago. He admits that he has been less active in the last month because of pain in his knees. He also has been using an over-the-counter antihistamine for “hay fever” symptoms.Appropriate initial measures include which of the following? (Mark all that are true.)Increased intake of fluid and dietary fiberIncreased physical activityBulking agents (e.g., Metamucil)Polyethylene glycol (MiraLax)Low-dose stimulant laxatives
Answer • Increased intake of fluid and dietary fiber • Increased physical activity
Fluid softens stool and counterbalances the effects of many medications that tend to dry the stool. Fiber also softens stool consistency by adding bulk (SOR C). Increased physical activity stimulates bowel motility, decreasing constipation (SOR B). Bulking agents should not be used until nonmedical therapy (SOR B) has been tried. Polyethylene glycol may cause electrolyte disturbances and cramping, and should not be used unless dietary changes and increased physical activity fail to resolve the problem (SOR B). Stimulant laxatives may also produce cramping and electrolyte disturbances (SOR B).
True statements regarding cataracts include which of the following? (Mark all that are true.)Family physicians should perform funduscopy, visual acuity testing, and pinhole testing on all patients suspected of having cataractsReferral to an ophthalmologist is not necessary for patients with suspected cataracts if their visual acuity is 20/40 or betterOtherwise healthy older adult patients scheduled for cataract surgery under local anesthesia do not require routine preoperative medical evaluationOutpatient surgery is recommended for cataract extraction
Answer • Family physicians should perform funduscopy, visual acuity testing, and pinhole testing on all patients suspected of having cataracts • Otherwise healthy older adult patients scheduled for cataract surgery under local anesthesia do not require routine preoperative medical evaluation • Outpatient surgery is recommended for cataract extraction
Funduscopy, visual acuity testing, and pinhole testing should be performed on all patients suspected of having cataracts, to determine the severity of visual impairment (SOR B). In patients with cataracts whose visual acuity is relatively preserved, glare sensitivity may adversely effect function, and must be tested by an ophthalmologist (SOR C). Local anesthesia for this brief procedure carries minimal risk in healthy older adults (SOR A). There is no benefit from inpatient stays after uncomplicated cataract extraction, and there is a possibility for harm (SOR B).
A 78-year-old female presents with diffuse abdominal pain, abdominal distention, diminished bowel sounds, and nausea with occasional vomiting. Her medical history includes type 2 diabetes mellitus, and well-controlled hypertension. She has a previous history of right upper-quadrant colicky pain, but no history of previous abdominal surgery.A CBC reveals a hematocrit of 38.0% (N 36.0–46.0) and a WBC count of 11,000/mm3(N 4300–10,800). Serum electrolytes, amylase, and lipase are within normal limits. A urinalysis is normal. Plain films of the abdomen show small bowel obstruction, air in the biliary tract, and a calculus.The most likely diagnosis isdiverticulitisacute cholecystitisgallstone ileusacute pancreatitis
Answer • gallstone ileus
This patient has the classic triad of gallstone ileus on the plain abdominal film. This condition occurs in patients with a past history of gallbladder disease, and is more common in females (SOR C). Diverticulitis pain is usually more localized and is not associated with calculous disease or with air in the biliary tract (SOR C). Air in the biliary tract is not found in cholecystitis, and unrelenting right-sided pain is more common than colicky pain (SOR C). The pain of acute pancreatitis often radiates to the back and is associated with elevated amylase and, more specifically, lipase (SOR C)
An 84-year-old male with Parkinson’s disease lives at home with his wife. At a routine follow-up visit she tells you that she is concerned because he likes to walk around inside the house but has fallen twice in the past 3 months.Which gait assistive device should you recommend?A standard four-point walkerA two-wheel walkerA four-wheel walkerA wheelchair
Answer • A four-wheel walker
Four-wheel walkers are the best choice for patients with Parkinson’s disease because walking is easier to initiate than with a standard four-point walker or a two-wheel walker (SOR C). Patients are also less likely to fall backward than with a four-point walker (SOR C), because they must lift a four-point walker before moving it forward. This often involves bending backward slightly in the process, and can result in falling backward in patients with Parkinson’s disease. A wheelchair would be too restrictive at this point (SOR C).
Consequences of polypharmacy in elderly patients can include which of the following? (Mark all that are true.)Medication nonadherenceAdverse drug eventsAge-related impairment of the immune systemDrug-drug interactionsDrug-disease interactions
Answer • Medication nonadherenceAdverse drug eventsDrug-drug interactionsDrug-disease interactions
While there is evidence that multi-drug therapy can be important in patients with certain conditions such as heart failure and diabetes mellitus, as well as in those with multiple chronic conditions, the elderly are at especially high risk for complications from these regimens. Underlying disease, physiologic changes due to aging, and poor physical and cognitive health increase the potential for drug-drug interactions, drug-disease interactions, and adverse drug events (SOR C). (Drug-disease interaction is the adverse effect of a drug on the management of a disease, e.g., elevation of blood pressure by NSAIDs or elevation of blood glucose by diuretics.)Physicians should prescribe medications with the lowest potential for adverse events, drug-drug interactions, and drug-disease interactions, at the lowest effective dosages. Medication use should be reviewed at regular intervals in patients taking multiple medications, and drugs that are no longer needed should be discontinued.There is no evidence that taking multiple medications adversely affects the immune system (SOR C).
An 87-year-old female has a 20-year history of type 2 diabetes mellitus. Her current medications include metformin (Glucophage), lisinopril (Prinivil, Zestril), and aspirin.True statements regarding the care of this patient include which of the following? (Mark all that are true.)Because of her age, her blood pressure targets are higher than those for younger patients with diabetesQuarterly hemoglobin A1c levels are indicatedAn LDL-cholesterol level of 140 mg/dL would suggest the need for interventionAspirin is no longer indicated because of the patient’s age
Answer • An LDL-cholesterol level of 140 mg/dL would suggest the need for intervention
This patient’s blood pressure target is the same as for younger patients with diabetes: 130/80 mm Hg (SOR B). There is no evidence that quarterly hemoglobin A1c levels are necessary. Experts recommend annual measurement (SOR C). Lifestyle intervention or medication would be indicated if the patient’s LDL-cholesterol level were above a threshold of 130 mg/dL (SOR B). Aspirin is still important for this patient (SOR B). Some authorities would recommend routine screening for proteinuria in patients on ACE inhibitors, but no studies have examined the effect on outcomes.
An 85-year-old female with Alzheimer’s disease of moderate severity lives alone. She is having increasing difficulty caring for herself, and her family is concerned about her safety. The family is considering care options and asks for your opinion.The patient has repeatedly stated that she wishes to remain in her home and refuses assistance other than family. When counseling the patient and family regarding appropriate placement, factors to consider include which of the following? (Mark all that are true.)The level and type of care requiredPatient and family financesThe patient’s ability to participate in decisionsThe progression rate of the Alzheimer’s diseaseThe amount and type of help that family can provide
Answer • The level and type of care requiredPatient and family finances • The patient’s ability to participate in decisions • The progression rate of the Alzheimer’s disease • The amount and type of help that family can provide
There are multiple options for care assistance to elders with impaired function. These options include home care, assisted living, nursing-home residential and skilled care, and hospice care. When choosing among options, it is important to consider many variables, including 1) the patient’s physical and cognitive health and related requirements for assistance with activities of daily living; 2) whether the patient’s condition is stable or rapidly changing; 3) the availability of rehabilitation services if appropriate; 4) the availability of skilled nursing services if appropriate; 5) the level of supervision required; 6) patient and family finances and insurance coverage; and 7) life expectancy (SOR C). While patient preference is important and should be honored when possible, patients with worsening dementia may lose their competence to make decisions about appropriate levels of care.Patients with moderate Alzheimer’s disease often require 24-hour supervision due to concerns about safety. This can be provided in the home, in some assisted-living facilities, or in nursing homes. When possible, a facility should be selected which optimizes the patient’s functional status and quality of life while also providing the required assistance.
A 72-year-old male with multiple myeloma presents with worsening pain in the back and ribs. He has tried both ibuprofen and acetaminophen with codeine, but neither has provided adequate pain relief.Which one of the following would be the best agent for pain control?AmitriptylineMeperidine (Demerol)MorphinePropoxyphene (Darvon)
