geriatrics exam #5

leading cause of death from unintentional injury in 64-75 yos

MVAs

a key component of the older driver assessment is

vision screening

3 multiple choice options

counseling regarding driving retirement plans should include

identifying alternative transportation options

3 multiple choice options

Mrs. C. is a 72-year-old woman with hypertension who was

recently involved in a driving incident, which she states was

caused by glare from oncoming traffic causing her to miss seeing a stop sign at night. The most likely cause of her vision

impairment is:

correctable surgically

3 multiple choice options

Mr. O. is a 66-year-old man coming in for his regular checkup on his hypertension, coronary artery disease, osteoarthritis, and diabetes. He reports no falls in the past year, no chest pain, and elevated blood sugars up to 200. His medications include metoprolol, celexicob, metformin, and glipizide. He is alert and cooperative, his blood pressure is 130/75 mmHg,

he has a grade 2 systolic murmur, and on range of motion he is unable to turn his head to the right. He takes 22 seconds to walk 10 feet, turn, and sit down again. The best option for primary prevention of driving impairment is:

PT referral

3 multiple choice options

Mr. S. is a 84-year-old man establishing care with you who presents with his wife because of poor sleep. He has no trouble with sleep onset on his current medications, gets up one to two times per night to urinate, and rises for the day

9 hours after going to bed. However, he is still tired on awakening and takes at least one nap per day, frequently falling asleep while watching TV. His medical history includes obesity, sinus headaches, and mild hypertension. Current

medications include hydrochlorothiazide in the morning, acetaminophen with diphenhydramine twice a day, zolpidem, and trazodone at night. His wife reports that he has occasionally needed to swerve to avoid going off the side of the road and insists on driving when they go out together. You should:

refer him to pulmonology

3 multiple choice options

Ms. M. is a 79-year-old woman whose daughter brings her in for concerns about her memory. She lives alone, appears to be in good health, and reports that she is independent in self-care activities of daily living. Her daughter states that she

began to handle her mother's major bills and to do the major housework about 6 months ago when her mother forgot to pay the utilities and take out the trash. Ms. M states that everything is fine and reports that she drives to church and

the grocery alone. She denies becoming lost or having any fender-benders. She does not like to drive to her daughter's home since her daughter moved to another area and thinks her daughter is making a big deal about nothing. You should:

refer her to driving rehab specialist for on road eval & counseling

3 multiple choice options

2 leading sources of funding facilitating ability of older pts to remain in community & in their homes as long as possible

older americans act & social services block grant

medicare

- 65+ that paid payroll tax at least 10 yrs or spouse did

- young pts w end stage renal dz, ALS, on social security disability insurance

- most 65+ qualify for Part A benefits w/o paying monthly premium

parts of medicare

- A: hospitalization, post acute rehab, home care, hospice, skilled care, DME

- B: physician services, outpt services, indepen labs, preventive, mental health

- C: allows voluntary participation in managed care programs

- D: prescription drug plan, voluntary outpt rx drug benefit, generic meds

medicaid

- medical assistance for individ all ages & families w low income & assets

- pt contributions much lower

- some medicare pts also eligible for this

long term care

- pts experience greatest coverage gaps

- medicare/traditional insurance do not fund custodial care, limited skill nursing benefits

- for >65 yo are >25% of total health care out of pocket expenses

are most veterans guaranteed basic health care coverage

no

which of the following statements about community based services is true

the majority of the administration on aging budget goes to nutrition programs and community based services

3 multiple choice options

all of the statements about medicare are true except

all of the funding for medicare comes from federal taxes

3 multiple choice options

all of the statements about medicaid are true except

the coverage provided under medicaid is the same in every state

3 multiple choice options

which sentence is false about the veterans health administration

provides care management only for individuals with disabilities that are service related

3 multiple choice options

when a medicare beneficiary with only traditional Part A and Part B coverage is admitted to the hospital, what will he or she have to pay out of pocket

more than 1000 deductible and 20% of all physician fees

3 multiple choice options

since the passage of the ACA in 2010, the following are true about payment changes except

providers in medicare advantage will be paid higher fees

3 multiple choice options

all of the following about the medicare part D prescription medication benefit plan are true except

beneficiaries have no out of pocket expense for each prescription filled

3 multiple choice options

frailty

- increased vuln to acute & chronic stressors as conseq of decrease physiologic reserve

- assoc w functional decline, loss of independence, mortality

- consider in ALL older pts admitted to hosp

- 10d in bed = similar loss of muscle mass at 10 yrs of normal aging

perioperative pulmonary complications

- atelectasis

- pneumonia

- resp failure

- exacerbation of underlying chronic lung dz

- hx of COPD & >60 increase risk

preop pulm eval

- PFTs for cardiothoracic surgery

- low albumin <3.5 predictor of periop mortality & PPCs

- pt w 1 or + RF for PPC or are having high risk surgery get preop albumin level

interventions to reduce PPCs

- deep breathing exercises or incentive spirometry perioperatively

- pts not to do breathing exercises -> CPAP

- smoking cessation, best 2 mos before

- monitor for delirium

american association of blood banks recommends transfusion cutoff of

8 g/dl hemoglobin

fall prevention in hospital

- begins with assessment at admission

- vit D 800 IU/d in deficient or high risk pts

skin care in hospital

- full thickness pressure ulcers can

develop in 2-3 hrs in elderly

- proactive care: adequate skin moisturizing & avoidance of maceration, shearing, tearing, or pressure damage

- ID skin lesions or breakdown on admission

- encourage activity

- pressure-reducing support products applied to cushion bony prominences (sacrum, heels)

- reposition at least every 2 hrs to ↓ risk of pressure ulcers

how to avoid c diff

- probiotics may ↓ risk in high-risk pts

- proper hand washing techniques🡪 soap rather than alcohol-based cleansers d/t spores

risks for unplanned readmission

- age >80

- depression

- poor pt education on d/c

ways in which a hospital physician design fails to meet the needs of older adults include all of the following except

easily graspable handrails on both sides of all hallways

3 multiple choice options

An 88-year-old woman was admitted to the hospital 1 week ago. The physiologic risk factors that contribute to the geriatric syndrome of frailty for this woman include all of the following except:

ongoing vit D supplementation during this hospital stay

3 multiple choice options

ways to prevent delirium in a hospitalized older adult include all of the following except

limiting time out of bed to prevent overstimulation

3 multiple choice options

the intervention most likely to maximize nutrition for hospitalized older adults in

providing assistance w all meals

3 multiple choice options

common infections in LTC

- UTI MC

- pneumonia MC infection leading to hospitalization

- norovirus MC cause of outbreaks of acute gastroenteritis

Mr. B is an 82-year-old enrolled in your primary care clinic panel. His medical history includes moderate dementia and probable Alzheimer's disease; his last MMSE score was 17/30. He requires cues to bathe and dress but is otherwise independent in his activities of daily living. He cannot

manage his medications and does not drive. His wife is his primary caregiver and has been providing 24-hour care supervision since he was found wandering outside by their neighbors. During your visit today, she admits that she is

"feeling stressed" and at times "overwhelmed" with her caregiving responsibilities. She wants to know what options are available to help support her taking care of him in their home. All of the following would be appropriate for Mr. B except:

skilled nursing facility

3 multiple choice options

which one of the following is the most true of the capacity to make medical decisions

it includes the ability to express a choice and to weigh options

3 multiple choice options

which one of the following is most true about the staffing of a typical nursing home

CNAs provide most of the direct patient care

3 multiple choice options

which of the following is true about the primary functions and duties of the skilled nursing facility medical director

participates in monitoring and improving the facility's medical care

3 multiple choice options

eligibility requirements for medicare certified agency

- pt must be homebound (leading home requires lot of absent, do not leave often)

- will not quality as skilled care if can safely be done by pt, nonmedical person w/o supervision

- unable to fxn w/o supportive devices, requires special transport or assis, skill needed

- if just needs assistance w ADLs, must find another way to get services

how is home care delivered

- physician certifies need & periodically reviews tx plan

- must have face to face visit at initial

- 90 d before or 30 d after date home care began, any setting. PA/NP can not sign

- PA/NP can sign orders for DME (canes, walkers, bedside commodes)

home care certification

- typical certification period = 60 days

- if pt progressing at end of period & still has signif rehab potential, physician can recert

- if skilled nursing needs remains active, nursing services can be reordered

reasons for skilled services to be long term

- chronic urinary catheters

- pernicious anemia requiring vit B12 injections

hospital at home appropriate diagnoses to treat

- community acquired pneumonia

- COPD & CHF exacerbation

- DVT, PE

- volume depletion, dehydration

- URI, urosepsis

which of the following is a true statement

"homebound" pts are those for whom leaving the home requires considerable and taxing effort

3 multiple choice options

a physician or other medical provider may receive medicare reimbursement for medical house calls if which of the following conditions is met

the provider documents the medical necessity of the home visit in lieu of an office visit

3 multiple choice options

which of the following is a true statement

for a Medicare-certified home health agency to receive payment for home care services, a face-to-face visit for home care order certification purposes must occur in the 90 days before or 30 days after the date on

which the home care agency begins to provide home care

3 multiple choice options

which of the following medicare pts has a skilled need

a 80 yo man with BPH & urinary retention for 2 yrs who requires a urinary catheter

3 multiple choice options

which one of the following medicare pts qualifies for skilled home care

an 86-year-old man who was ambulatory before he spent 4 days in bed during a recent episode of pneumonia and is now unable to

walk from his bed to the bathroom without assistance

3 multiple choice options

to receive payment from medicare for a home visit, a PA must

document the medical necessity of seeing the pt at home instead of in the office

3 multiple choice options

goal of rehab

- encourage physical activity to help pts achieve a higher level of baseline fxn

- regimens designed to help regain prior level of fxn

- directed at avoiding loss of fxn, promoting return of lost fxn, or both

- pts disabled by loss of fxn depends partly on what they consider normal & social support

your pt is a 75 yo man with a nondominant hemisphere stroke, leg weakness, & difficulty walking

of the following, which is the most effective strategy for rehabilitation

intensive inpatient therapy for 1 wk, starting 1 day after the stroke

3 multiple choice options

after a MI, a cardiac rehab program....

is generally appropriate

3 multiple choice options

an 85-year-old woman falls and is hospitalized for a pelvic fracture that is treated nonoperatively.

which of the following factors increases her chances of being discharged directly to home for rehabilitation?

availability of a caregiver who can provide assistance in the home 24hrs/day, 7 days/wk

3 multiple choice options

a 75 yo man develops severe right arm upper extremity spasticity after a left hemispheric stroke. which med is least likely to cause sedation & falls

botulinum toxin injections into affected spastic muscles

3 multiple choice options

a 72 yo woman with moderately advanced parkinson disease is having difficulty being understood because of her worsening hypophonia. speech therapy should encourage which of the following

think loud and think low

3 multiple choice options

a 65 yo man develops back pain and paraplegia because of a

pathologic T12 vertebral burst fracture that requires surgical

decompression and fixation. the patient desires intensive therapy to improve his mobility and self-care skills, requires training for his neurogenic bowel and bladder dysfunction, and needs evaluation for a wheelchair.

Which environment is most appropriate for his rehabilitation following hospitalization?

inpatient rehab facility

3 multiple choice options

what % of nursing home hospitalizations are potentially avoidable

67%

go to ED if

- you cannot exclude life threatening cause of sx

- you cannot stabilize an acute exacerbation of dz

the only guarantee that critical info regarding your elderly pt will be known to EMP

your direct report

programs being implemented to prevent avoidable transfers from NH to ED

- program of all inclusive care for the elderly (PACE): financing model created to decrease hosp in frail elders

- national transitions of care coalition (NTOCC): provides resources & tools for health care providers

which one of the following statements is false about trauma in the older pt

the expected neuro signs of head trauma are increased in the elderly due to the mobility of the brain within the skull

3 multiple choice options

a 71 yo female who lives alone is brought in by her neighbor who stopped in to visit her today. She asked for a ride to the doctor. The patient states she has felt a generalized weakness for the past 3 days and that she fell to the floor last night

after getting up to use the bathroom. She says that her legs gave out. There is no head trauma or loss of consciousness. She denies any pain. She denies dysuria or urinary frequency. Her vitals are normal. She has a normal neurologic exam except for generalized weakness. She requires support to walk. Her urine dip shows high specific gravity and leukocytes.

Which one of the following is the best management plan?

arrange for immediate, direct hospitalization for hydration & treatment of UTI

3 multiple choice options

an 88 yo man who is brought to the office by his daughter after sustaining a ground level fall at home. He reports he tripped over his grandson's toy and landed on a carpeted floor w/o striking his head. He denies any loss of consciousness but complains of left-sided chest wall pain, worse with deep breathing. Vital signs are notable for a BP of 124/86 mmHg, a HR of 84 beats per minute, a RR of 20 breaths per minute, with an O2 sat of 99% on room air. His PE is notable for a well-developed male, appearing his stated age

in mild discomfort taking shallow breaths. His pulmonary exam demonstrates diminished breath sounds at the bases bilaterally without focal findings. Bruising with assoc tenderness is appreciated along the left, midaxillary chest wall. You obtain a chest x-ray, which demonstrates nondisplaced seventh through ninth left-sided rib

fractures.

The next best step in management of this man is:

referral to the ED for full trauma eval & hospitalization

3 multiple choice options

a 77 yo man who reported to his primary care provider that he had 3 days of left-sided, sharp, pleuritic chest pain without associated shortness of breath. Other than with taking deep breaths, he denies any other exacerbating factors. He has been able to complete his daily tasks despite this discomfort. He denies any trauma, infectious complaints, or lower extremity swelling. The pain is not associated with eating. He denies any skin changes. His vital signs and physical examination are within normal limits. His electrocardiogram is suggestive of left ventricular hypertrophy only, a finding noted on his past ECGs. You decide to send a D-dimer as you consider pulmonary embolism (PE) as a possible cause.

Which of the following is true regarding the D-dimer test?

results of a d-dimer should be age adjusted to improve the specificity in older adults

3 multiple choice options

A 66 yo woman who is evaluated as an urgent visit in your clinic. She complains of new onset chest pain since this morning after waking up. She describes her pain as a

pressure with radiation to both the left and right shoulders. She vomited once after the pain started. Her history is remarkable for COPD for which she is on home oxygen, 2 L a minute, as well as hypertension and diabetes. Vital signs are notable for a BP of 92/56 mmHg, a HR of 110 beats per minute, a RR of 20 breaths per minute, with a O2 sat of 99% on her home oxygen. On examination, she appears moderately

uncomfortable, her examination is most notable for trace crackles in the lower lung fields bilaterally.

In addition to immediate referral to the emergency department (ED), what is the next most important step in caring for this patient assuming equipment availability in your office?

placing an IV line & starting fluids

3 multiple choice options

a 75-year-old woman who has been your primary care patient for 10 years comes to your office complaining of fatigue and weight loss. On further testing, she is found to have a colonic mass, which is biopsied. The results return as adenocarcinoma, and she returns to your office today. After bringing her into your examination room and explaining to your office manager that you are not to be disturbed for the next 20 minutes, what is the next step in the process of informing her that she has cancer?

ask her what she understands up to this point

3 multiple choice options

A 92-year-old woman with severe dementia and frailty is a

resident of a long-term care facility. She has been admitted

three times in the last 6 months for aspiration pneumonia. She is not enrolled in hospice. As a member of the palliative care team, which of the following services can you not offer her and her family?

insurance coverage of meds related to her underlying disease

3 multiple choice options

a 75-year-old man with lung cancer metastatic to the bones is receiving hospice care in his home. His predominant symptom is nociceptive and neuropathic right chest wall pain caused by a fourth rib metastasis. In recent days he has experienced a dramatic increase in his pain, and hospice staff have titrated his pain regimen to gabapentin 900 mg three times daily, extended-release morphine 100 mg three times daily, and

immediate release morphine 30 mg every 2 hours as needed. The hospice nurse calls you to ask about next steps, and reports that he is still in severe pain but is now nonverbal, and his family is struggling to administer his medication orally because of his somnolence. The patient's family is exhausted.

What is the best next step to assure the patient's comfort?

admit to an inpatient facility under the general inpatient hospice benefit

3 multiple choice options

An 85-year-old woman with congestive heart failure, end-stage COPD, chronic kidney disease stage 4, and

frailty is brought to your office for a routine appointment. She has preserved cognition, and her last Mini-Mental State Examination was 26. Affect is normal, and she has no history of depression. She has a loving and supportive family with whom she lives. During the visit, she shares that her quality of life is no longer acceptable and asks about options to hasten the end of her life.

Which of the following means of hastening death is legal throughout the United States?

voluntary stopping of eating and drinking

3 multiple choice options

A 78-year-old woman with ASCVD, peripheral vascular disease, and a history of transient ischemic attacks s/p carotid endarterectomy is seen as part of an annual wellness visit. She is advised to create an advance directive but declines, saying "I don't know who to pick" for a healthcare agent.

Which one of the following is a necessary characteristic of a healthcare agent?

knows how the patient defines quality of life

3 multiple choice options