Geriatrics PHARM III
Geriatric Pharmacology & Polypharmacy
50-Question Clinical Application Practice Exam
Didactic-Year Physician Assistant Students
Based on the uploaded Geriatric Pharmacology 2026 PowerPoint
Instructions: Select the single best answer for each clinical vignette. Questions emphasize clinical reasoning,
pharmacokinetics/pharmacodynamics, medication safety, Beers/STOPP-START application, deprescribing, polypharmacy,
and geriatric renal dosing.
Answer choices have been intentionally balanced across A–D. Complete the exam before reviewing the answer key.
1. An 82-year-old woman is prescribed a medication that is highly protein bound. Her serum albumin has fallen
substantially with age. Which pharmacokinetic change is most clinically relevant?
C. Increased gastric emptying
A. Increased active (unbound) drug concentration
D. Increased first-pass metabolism
B. Decreased renal blood flow only
2. An 80-year-old man takes diazepam nightly. Compared with a younger adult, which age-related change is most
likely to prolong the drug's effect?
C. Increased renal clearance
D. Increased phase I metabolism
A. Decreased volume of distribution of lipid-soluble drugs
B. Increased volume of distribution of lipid-soluble drugs
3. A 78-year-old patient is started on a medication that requires an acidic gastric environment for absorption. Which
age-related change could reduce its bioavailability?
A. Decreased body fat
B. Increased hepatic blood flow
D. Increased renal blood flow
C. Increased gastric pH
4. An older adult is prescribed atenolol. Which age-related distribution change is most relevant?
D. Decreased Vd of water-soluble drugs
C. No change in body composition
B. Increased Vd of lipid-soluble drugs
A. Increased Vd of water-soluble drugs
5. A 79-year-old patient is prescribed a prodrug. The clinician is concerned about decreased bioavailability due to
age-related changes in first-pass metabolism. Which example from the lecture is a prodrug?
B. Diazepam
A. Codeine
C. Atenolol
D. Amiodarone
6. An 84-year-old patient develops excessive sedation from a medication metabolized primarily by hepatic phase I
reactions. Which statement best explains the susceptibility?
D. Aging increases hepatic blood flow
B. Phase I metabolism is more affected by aging and liver disease
A. Phase II metabolism is more impaired than phase I
C. Aging increases overall hepatic metabolic capacity
7. A PA wants to choose a benzodiazepine for an older adult when a phase II glucuronidation pathway is preferred.
Which medication is listed in the lecture as undergoing glucuronidation?
B. Flurazepam
D. Clorazepate
A. Diazepam
C. Lorazepam
Page 18. A 77-year-old patient has a serum creatinine of 1.0 mg/dL, which appears normal. The clinician suspects reduced
kidney function because of low muscle mass. Why can serum creatinine be misleading in this patient?
A. Creatinine is produced primarily by the liver
C. Creatinine is unrelated to muscle mass
B. Creatinine rises dramatically with age regardless of renal function
D. Creatinine formation depends on muscle mass, so a normal value can occur despite reduced CrCl
9. A 90-year-old patient has declining renal function. Which medication is specifically identified as one requiring
consideration because it is substantially renally eliminated?
A. Digoxin
B. Diazepam
C. Verapamil
D. Lorazepam
10. An older adult with renal failure receives morphine and develops prolonged sedation and opioid effects. Which
mechanism best explains this?
D. Decreased morphine absorption
A. Accumulation of inactive M-3-glucuronide
B. Accumulation of active M-6-glucuronide
C. Increased hepatic first-pass metabolism
11. An 86-year-old patient becomes markedly confused and dizzy after receiving a standard adult dose of a
benzodiazepine. Which pharmacodynamic principle from the lecture best explains this?
D. Increased hepatic metabolism
C. Increased CNS sensitivity to benzodiazepines
A. Decreased CNS sensitivity to benzodiazepines
B. Increased receptor clearance
12. An older adult has recurrent lightheadedness when standing after starting antihypertensive therapy. Which
age-related cardiovascular change increases this risk?
D. Greater likelihood of orthostatic hypotension
C. Increased beta-blocker blood pressure response
A. Increased tolerance to hypotension
B. Reduced risk of orthostasis
13. A 79-year-old patient develops bradycardia and hypotension after starting a calcium channel blocker. Which
age-related pharmacodynamic change is described in the lecture?
B. Reduced sensitivity to calcium channel blockers
C. Increased blood pressure response to beta blockers
A. Increased hypotension and bradycardia with calcium channel blockers
D. Decreased cardiovascular sensitivity with age
14. A patient takes diphenhydramine nightly for sleep and subsequently develops dry mouth, urinary retention,
blurred vision, constipation, and confusion. Which syndrome is most consistent with this presentation?
D. Opioid withdrawal
B. Anticholinergic syndrome
C. Serotonin syndrome
A. Cholinergic syndrome
15. An 81-year-old patient is prescribed a first-generation antihistamine for insomnia. According to the 2023 Beers
material in the lecture, what is the best approach?
D. Use only if renal function is normal
B. Increase the dose at bedtime
C. Avoid because of strong anticholinergic effects
A. Use routinely because tolerance develops
Page 216. A 76-year-old woman has atrial fibrillation and is not currently anticoagulated. Which principle from the lecture
represents a START criterion?
A. Avoid all anticoagulants in older adults
D. Consider appropriate anticoagulation such as a vitamin K antagonist or factor Xa inhibitor
B. Avoid DOACs in atrial fibrillation
C. Start aspirin for primary prevention
17. A clinician uses STOPP/START criteria to review an older adult's medications. Which scenario is specifically
given as a STOPP example?
C. Renal dosing of a medication
A. Digoxin for heart failure with normal systolic ventricular function
D. Vitamin supplementation in deficiency
B. Anticoagulation for atrial fibrillation
18. A PA wants a structured tool that asks 10 questions about whether a medication has an indication, is effective,
has correct dosing, and has clinically important interactions. Which tool is being used?
C. START
D. Beers Criteria
B. Medication Appropriateness Index
A. STOPP
19. A clinician completes the Medication Appropriateness Index but still cannot determine which medication should
be changed first. Which limitation of the tool is relevant?
C. It does not address optimal prescribing or prioritize which drug to change
A. It cannot assess drug interactions
D. It only applies to antibiotics
B. It cannot assess duration
20. An older adult is taking a PPI, benzodiazepine, antipsychotic, and several chronic medications. The clinician
wants evidence-based guidance for safely tapering or stopping medications. Which resource is most appropriate?
C. Beers Criteria only
D. Deprescribing algorithm
B. Medication Appropriateness Index
A. START only
21. A clinician tells an older patient, 'This medication is on the Beers list, so you absolutely cannot take it.' Which
response best reflects the lecture's principle?
A. Beers medications are potentially inappropriate, not definitely inappropriate
D. Beers criteria apply only to renal dosing
C. Beers criteria replace clinical judgment
B. Every Beers medication is contraindicated
22. An older adult is taking a medication listed in Beers Criteria. The clinician reviews the rationale and finds that
the patient's clinical situation is a listed exception. What is the best interpretation?
A. The medication must still be stopped
D. Beers criteria no longer apply to any medications
C. The medication is automatically safe
B. The recommendation should be interpreted using the stated caveats and clinical context
23. The Beers Criteria recommendation for a medication states that harms, adverse events, and risks clearly
outweigh benefits. What strength of recommendation does this represent?
C. Strong
B. Moderate
A. Weak
D. Low
Page 324. A Beers Criteria entry is supported by evidence that is insufficient to assess harms because studies are limited
or inconsistent. How is this quality of evidence classified?
C. Strong
B. Moderate
A. High
D. Low
25. A 78-year-old patient with CrCl 25 mL/min is prescribed nitrofurantoin for a UTI. Based on the Beers table in the
lecture, what is the concern?
D. Nitrofurantoin is contraindicated only when CrCl is >60 mL/min
A. Avoid nitrofurantoin when CrCl is <30 mL/min
B. Nitrofurantoin is preferred regardless of renal function
C. Increase the dose because clearance is reduced
26. A 74-year-old patient asks whether aspirin should be started solely for primary prevention of cardiovascular
disease. Which recommendation is consistent with the Beers material presented?
D. Aspirin is always required after age 65
B. Avoid initiating aspirin for primary prevention in older adults
A. Initiate aspirin routinely
C. Use aspirin only with warfarin
27. An older adult has established cardiovascular disease and asks whether the aspirin recommendation for
primary prevention automatically applies to secondary prevention. Which response best matches the lecture?
B. Yes, aspirin is contraindicated in all older adults
A. Yes, aspirin should always be stopped
C. No; aspirin is generally indicated for secondary prevention in older adults with established cardiovascular disease
D. Aspirin has no role in cardiovascular disease
28. A 79-year-old patient with nonvalvular atrial fibrillation is being started on anticoagulation. Which option is
identified in the lecture as generally preferred over initiating warfarin?
C. Immediate-release nifedipine
B. Clonidine
D. A DOAC
A. Aspirin
29. A 78-year-old patient has been on warfarin for years with an INR therapeutic >70% of the time and no adverse
effects. What does the lecture suggest?
A. Continuing warfarin may be reasonable
C. Switch to aspirin
B. Warfarin must immediately be stopped
D. Double the warfarin dose
30. An older adult with nonvalvular atrial fibrillation is being considered for long-term rivaroxaban. Which concern
is highlighted in the lecture?
D. It is never appropriate in any circumstance
B. It may have higher major and GI bleeding risk than other DOACs, particularly apixaban
C. Rivaroxaban is more likely than warfarin to cause intracranial hemorrhage
A. Rivaroxaban has no bleeding risk
31. A 83-year-old patient takes alprazolam for insomnia. Which adverse outcome is a major reason benzodiazepines
are listed as medications to avoid in older adults?
D. Increased bone density
B. Renal stone formation
C. Cognitive impairment, delirium, falls, and fractures
A. Hyperthyroidism
Page 432. An older adult takes a benzodiazepine together with an opioid. Which complication is specifically emphasized in
the Beers rationale?
B. Severe diarrhea
A. Hyperglycemia
C. Hypertension
D. Profound sedation, respiratory depression, coma, and death
33. A 77-year-old patient requests zolpidem for chronic insomnia. Which is the most appropriate interpretation of
the lecture's Beers content?
D. Increase the dose until sleep duration doubles
B. Use routinely because zolpidem has no fall risk
C. Use because all hypnotics are preferred in older adults
A. Avoid because Z-drugs have adverse events similar to benzodiazepines with minimal sleep benefit
34. A 75-year-old patient with systolic heart failure is prescribed verapamil. Which concern is highlighted in the
lecture?
D. Verapamil prevents orthostatic hypotension
C. Verapamil is preferred to beta blockers
B. Nondihydropyridine calcium channel blockers should be avoided in systolic heart failure
A. Verapamil improves systolic function in all patients
35. A 73-year-old patient with heart failure takes ibuprofen daily for osteoarthritis. Which medication-related issue
should be recognized?
A. NSAIDs are always preferred in heart failure
D. NSAIDs have no cardiovascular effects
B. NSAIDs improve renal perfusion
C. NSAIDs are listed among medications to avoid in the CHF section
36. A 79-year-old patient with Parkinson disease presents with nausea. Which antiemetic from the lecture should
generally be avoided because it may worsen Parkinson symptoms?
D. Metoclopramide
A. Ondansetron
C. Famotidine
B. Acetaminophen
37. A patient with Parkinson disease requires an antipsychotic. Which drugs are listed as exceptions that appear
less likely to worsen Parkinson disease than other antipsychotics?
A. Clozapine, pimavanserin, and quetiapine
C. Metoclopramide, prochlorperazine, and promethazine
B. Haloperidol, risperidone, and olanzapine
D. Diazepam, alprazolam, and lorazepam
38. A 82-year-old patient has a documented history of recurrent falls. Which medication class is specifically listed
among drugs to avoid in this setting?
B. Benzodiazepines
C. Statins
A. ACE inhibitors
D. Proton pump inhibitors
39. A 76-year-old patient is prescribed immediate-release nifedipine for hypertension. Which adverse effect is the
lecture's reason for concern?
C. Hypotension
A. Hyperkalemia
D. Severe hypoglycemia
B. Bradycardia from beta blockade
Page 540. A 79-year-old patient with atrial fibrillation is being considered for first-line amiodarone. What is the concern
according to the lecture?
A. It is ineffective for atrial fibrillation
D. It has high toxicity potential and should not be first-line simply for atrial fibrillation
C. It is contraindicated solely because of age
B. It causes no toxicity
41. An 85-year-old patient takes digoxin and has reduced renal function. Which feature makes this medication
particularly concerning?
C. Very wide therapeutic index
B. No relationship to renal function
D. It is eliminated primarily through the lungs
A. High toxicity potential, renal dependence, and a narrow therapeutic range
42. A patient taking clonidine develops increasing confusion and sedation. Which explanation is most consistent
with the lecture?
C. Clonidine is a benzodiazepine
A. Clonidine causes peripheral anticholinergic toxicity
D. Clonidine primarily increases dopamine release
B. Clonidine is a central alpha-2 agonist with high risk for CNS adverse effects
43. An older adult takes 12 prescription medications, several OTC products, and two herbal supplements. Which
intervention is most important during medication review?
B. Stop all medications immediately
A. Review only prescription medications
C. Obtain a thorough drug history including OTCs, herbals, and dietary supplements
D. Ask only about medications prescribed by the current clinician
44. An 80-year-old patient develops dizziness after a medication was added to treat insomnia. The clinician realizes
the original medication may have caused the symptom. What prescribing phenomenon should be suspected?
D. Prescribing cascade
B. Medication adherence
C. Drug tolerance
A. Therapeutic substitution
45. An older adult taking amlodipine develops peripheral edema. Instead of reassessing the amlodipine, another
medication is added to treat the edema. Which concept does this illustrate?
D. START criterion
B. STOPP criterion
A. Prescribing cascade
C. Phase II metabolism
46. A clinician is initiating a new medication in a frail 84-year-old patient. Which prescribing strategy is most
consistent with the lecture?
A. Start at the maximum adult dose
D. Increase rapidly until symptoms disappear
C. Avoid titration
B. Start low and go slow
47. A 78-year-old patient has been taking a benzodiazepine chronically. The clinician decides it is no longer
necessary. Which approach is most appropriate?
B. Double the dose before stopping
A. Stop it abruptly
C. Taper the medication slowly
D. Add another benzodiazepine
Page 648. An older adult has a complex medication regimen with multiple daily doses and frequent confusion about
instructions. Which strategy can reduce adverse drug events?
A. Add more medications
C. Avoid medication review
D. Keep the medication regimen as simple as possible
B. Increase dosing frequency
49. A 92-year-old woman weighs 45.4 kg and has a serum creatinine of 1.0 mg/dL. Using Cockcroft-Gault as
presented in the lecture, which estimated creatinine clearance is closest?
A. 26 mL/min
D. 90 mL/min
B. 45 mL/min
C. 72 mL/min
50. The 92-year-old patient in the lecture has dysuria, urinary frequency, positive nitrites, moderate leukocyte
esterase, >60 WBCs, and bacteria. Which diagnosis is most consistent with the presentation?
D. Viral gastroenteritis
B. Uncomplicated urinary tract infection
C. Acute pancreatitis
A. Nephrotic syndrome
Page 7ANSWER KEY & HIGH-YIELD RATIONALES
1. B — The lecture notes that decreased albumin can increase the concentration of active, unbound drug for highly
protein-bound medications.
2. D — Older adults have increased body fat, producing an increased volume of distribution and potentially prolonged disposition
of lipid-soluble drugs such as diazepam.
3. D — The lecture notes that gastric pH generally increases with age, which can reduce the bioavailability of drugs requiring an
acidic pH.
4. A — The lecture identifies decreased Vd of water-soluble drugs, with atenolol given as an example.
5. B — Codeine is identified in the lecture as a prodrug whose bioavailability may decrease with age-related changes in
first-pass metabolism.
6. B — Phase I reactions (oxidation, reduction, hydrolysis) are described as being more affected by old age and liver disease.
7. D — Lorazepam, oxazepam, and temazepam are specifically listed as benzodiazepines undergoing phase II glucuronidation.
8. D — The lecture emphasizes that creatinine formation is a function of muscle mass; therefore, normal serum creatinine can
occur even when creatinine clearance is significantly reduced.
9. A — The lecture identifies digoxin, lithium, metformin, and morphine as key drugs to consider when renal function declines.
10. C — Morphine's active metabolite M-6-glucuronide is renally eliminated and can accumulate in renal failure, prolonging
effects and toxicity.
11. B — Older adults demonstrate increased sensitivity to several CNS drugs, including benzodiazepines.
12. A — The lecture specifically notes that older adults are more likely to experience orthostatic hypotension.
13. C — The lecture notes increased hypotension and bradycardia to calcium channel blockers in older adults.
14. B — The lecture's anticholinergic mnemonic includes dry mucous membranes, mydriasis/loss of accommodation, altered
mental status, and urinary retention.
15. C — The Beers table lists first-generation antihistamines as highly anticholinergic and recommends avoidance in older
adults.
16. B — START identifies potential prescribing omissions; the lecture gives anticoagulation in atrial fibrillation as an example.
17. B — The lecture gives digoxin for heart failure with normal systolic ventricular function as an example of a potentially
inappropriate prescription identified by STOPP.
18. C — The Medication Appropriateness Index uses 10 questions to evaluate the appropriateness of a medication regimen.
19. A — The lecture specifically identifies failure to address optimal prescribing and prioritize which drug to change as
limitations.
20. B — The lecture describes deprescribing algorithms as evidence-based guidelines for deciding when and how to safely taper
or stop medications.
21. A — The lecture emphasizes that Beers medications are potentially inappropriate, not definitely inappropriate, and that the
rationale and caveats should be reviewed.
22. D — The lecture stresses reading the rationale, recommendation statements, caveats, and guidance rather than applying
the list mechanically.
23. A — A strong recommendation is defined in the lecture as harms, adverse events, and risks clearly outweighing benefits.
24. D — Low-quality evidence is described as insufficient to assess harms or risks because of limited power, inconsistency,
flaws, or gaps in evidence.
25. B — The lecture's Beers table recommends avoiding nitrofurantoin in individuals with CrCl <30 mL/min.
26. B — The Beers table states to avoid initiating aspirin for primary prevention because major bleeding risk increases markedly
with age.
27. C — The lecture specifically notes that aspirin is generally indicated for secondary prevention in older adults with established
cardiovascular disease.
Page 828. C — The Beers table states that DOACs are generally preferred for nonvalvular atrial fibrillation or VTE because warfarin
has higher major bleeding risk and similar or lower effectiveness.
29. A — The Beers material notes that continuing long-term warfarin may be reasonable when INR control is good and there are
no adverse effects.
30. B — The Beers table notes higher major and GI bleeding risk with rivaroxaban compared with other DOACs, particularly
apixaban, while acknowledging special situations where once-daily dosing may aid adherence.
31. C — The Beers table lists increased cognitive impairment, delirium, falls, fractures, and motor vehicle crashes as important
benzodiazepine risks in older adults.
32. D — The Beers benzodiazepine table warns that concomitant opioid use can result in profound sedation, respiratory
depression, coma, and death.
33. D — Eszopiclone, zaleplon, and zolpidem are listed as Z-drugs to avoid because of delirium, falls, fractures, emergency
visits, and minimal improvement in sleep latency/duration.
34. C — The lecture specifically lists diltiazem and verapamil as nondihydropyridine CCBs to avoid in systolic heart failure.
35. D — The lecture's CHF section lists NSAIDs among medications to avoid.
36. A — The Parkinson disease Beers table identifies dopamine-receptor antagonists such as metoclopramide,
prochlorperazine, and promethazine as medications to avoid because they may worsen Parkinson symptoms.
37. A — The lecture lists clozapine, pimavanserin, and quetiapine as exceptions among antipsychotics in Parkinson disease.
38. A — For a history of falls, the lecture lists anticonvulsants, antipsychotics, benzodiazepines, Z-drugs, and TCAs as
medications to avoid.
39. A — Immediate-release nifedipine is listed because of its potential for hypotension.
40. B — The lecture lists amiodarone as a first-line therapy for atrial fibrillation among examples to avoid because of high toxicity
potential.
41. D — The lecture identifies digoxin as having high toxicity potential, especially with reduced renal function, and a narrow
therapeutic range of 0.5–2 ng/mL.
42. D — Clonidine is identified as a central alpha-2 agonist with high risk for CNS adverse effects.
43. C — The lecture recommends a thorough medication history at each visit, including OTCs, herbals, and dietary
supplements.
44. A — A prescribing cascade occurs when a drug's adverse effect is mistaken for a new condition and another drug is added
to treat it.
45. C — The lecture uses amlodipine → side effects → Lasix as an example of a prescribing cascade.
46. D — The lecture repeatedly emphasizes 'start low and go slow' when prescribing for older adults.
47. C — The lecture lists benzodiazepines among medications that should be tapered rather than abruptly discontinued.
48. C — Keeping medication regimens simple is specifically listed as a strategy to reduce ADRs in geriatric patients.
49. A — The lecture's worked example uses age 92, weight 45.4 kg, serum creatinine 1.0 mg/dL, and female sex to calculate an
estimated CrCl of approximately 26 mL/min.
50. B — The symptoms and urinalysis findings presented in the lecture are consistent with a urinary tract infection.
Source note: The exam was constructed from the uploaded lecture, including age-related PK/PD changes, prescribing
cascades, Beers 2023, STOPP/START, Medication Appropriate