Mr. Jones, an 89-year-old man, has recently relocated from the West Coast to be closer to his daughter who is also a patient in your office. He wants to establish a new PCP. His daughter reports that he has multiple comorbidities and is on seven prescribed medications. What medications should be assessed?
- His prescription drugs only
- Whatever he decides to bring to the office
- All of his medications, including prescription drugs, OTCs, and nutritional and herbal supplements
- Only his OTCs, because these can contribute to adverse events
3. All of his medications, including prescription drugs, OTCs, and nutritional and herbal supplements
Medication review of all OTC (e.g., nutritional supplements, herbals, vitamins, etc.) and prescription medications at each patient encounter is fundamental to health maintenance. In addition to the family nurse practitioner, older adults may see additional providers.
Mr. Jones, an 89-year-old man, has recently relocated from the West Coast to be closer to his daughter who is also a patient in your office. He wants to establish a new PCP. His daughter reports that he has multiple comorbidities and is on seven prescribed medications.His medication list includes Digoxin (Lanoxin) 0.25 mg by mouth daily, which was prescribed by his previous PCP for control of his CHF and atrial fibrillation. As the new PCP, what would you exclude from your plan?
- Measure a digoxin level.
- Do nothing because he looks fine.
- Consider decreasing his dose.
- Discuss with his previous HCP.
1. Measure a digoxin level.
The best response is to measure his digoxin level. All of the other responses should also be considered with the exception of doing nothing. Older adults are at increased risk for digoxin toxicity, with dosages of > 0.125 mg/day.
Mr. Jones, an 89-year-old man, has recently relocated from the West Coast to be closer to his daughter who is also a patient in your office. He wants to establish a new PCP. His daughter reports that he has multiple comorbidities and is on seven prescribed medications.His daughter, who was not present for the exam, calls at the end of the day to discuss his visit. She is concerned that her father did not provide her with all of the details. What should be the next step?
- Provide her with a summary of the visit.
- Ask her to come into your office to discuss it.
- Tell her that the information can only be discussed with the patient.
- Request a copy of his advanced directives.
3. Tell her that the information can only be discussed with the patient.
The Health Insurance Portability and Accountability Act (HIPPA) provides health care consumers with protection with respect to their private health information. A patient who has the mental capacity to make his/her medical decisions is not required to agree to sharing personal/medical information with family members.
When should the medication reconciliation be done?
- Upon request of the patient’s health care plan
- Upon discharge from the hospital or post-acute rehab center
- During each visit
3. During each visit
Medication reconciliation should be done at each visit. Older adults, on average, take six prescription drugs in addition to over-the-counter remedies. Also, older adults may have additional health care providers who prescribe medications. Therefore, it is essential that the family nurse practitioner reconcile medications at each visit.
All of the following are covered under Medicare Part A EXCEPT:
- Inpatient hospital care.
- Hospice services.
- Durable medical equipment.
- Short-term rehab.
3. Durable medical equipment.
Durable medical equipment is covered under Medicare Part B.
Delirium in the elderly is associated with functional decline, increased use of chemical and physical restraints, prolonged delirium post hospitalization, and increased mortality. Predisposing risk factors for delirium include older age, multiple comorbidities, a recent severe illness, past ETOH abuse, hearing or vision impairments, and a past history of delirium. Which of the following is the best tool to assess a patient for delirium?
- Geriatric Depression Scale
- MMSE (Mini Mental State Exam)
- CAGE Test
- CAM (Confusion Assessment Method)
4. CAM (Confusion Assessment Method)
The best way to assess for delirium is the CAM (Confusion Assessment Method). The CAGE is used to assess ETOH abuse. The MMSE is used to assess cognition in older adults.
Mrs. White is 85 years old and lives in her own house. Her husband died about 3 years ago. Mrs. White has two daughters who live about 30 minutes from her. Although she talks to them daily, she has not seen them in over 2 weeks. On her most recent visit to the office, she reports that she continues to experience considerable pain from her left hip and has been more and more disabled by this for the past 6 months. She states that she is on a waiting list for a hip replacement. In general, she states, "I feel miserable and I no longer enjoy reading or gardening. I have no energy and everything is an effort."
- Tell her that the symptoms she is experiencing are likely due to old age.
- Check a UA if positive C and S.
- Perform a Geriatric Depression Scale.
- Recommend that she move to an assisted living facility because there will be staff that can assist her with her ADLs.
3. Perform a Geriatric Depression Scale.
The Geriatric Depression Scale is a valid and reliable assessment tool to screen for depression in the clinical setting. It is available in a short and long form. It does not assess for suicide risk.
Mr. Sanchez is a 76-year-old Hispanic male hospitalized for a right total knee replacement. Prior to his discharge, he was diagnosed with a deep vein thrombosis (DVT) in his right lower extremity. His nurse reports increased confusion in the past 13 hours. Mr. Sanchez has been trying to climb out of bed, is agitated, tugging on his Foley catheter, pushing at the staff, calling out for his family, and has not responded to redirection. His labs are reported "within normal limits." His vital signs are stable. The most likely cause is:
- Mr. Sanchez is agitated that he can’t go home as promised.
- He developed an infection post-surgery.
- Depression, which he should be screened for.
- Hospital-acquired delirium.
4. Hospital-acquired delirium.
Hospital-acquired delirium is the most likely cause. Elderly patients who are hospitalized are at increased risk of delirium. Precipitating factors include medications, psychological stressors, sensory overload, nutritional deficiencies, etc.
Which of the following statements is the most accurate description of Alzheimer’s disease (AD)?
- The disease is reversible with pharmacological treatment modalities, including Aricept (donepezil) and Namenda.
- The disease is progressive.
- The disease is characterized by remissions and exacerbations.
- Over 50% of older adults will develop AD at some time.
2. The disease is progressive.
Alzheimer’s disease is a progressive disease. There is no cure available at this time.
The Geriatric Comprehensive Assessment (GCA) includes all of the following EXCEPT:
- Functional health.
- Physical health.
- Quality of life measures.
- Exercise regimen.
4. Exercise regimen.
The domains of the Geriatric Comprehensive Assessment include physical health, functional health, physiological health, socio-environmental supports, and quality of life measures.
The only acetyl cholinesterase inhibitor (ACHI) approved to treat moderate to severe dementia is:
- Exelon (rivastigmine).
- Aricept (donepezil).
- Namenda (memantine).
- Razadyne (galantamine).
2. Aricept (donepezil).
The only acetyl cholinesterase inhibitor approved to treat moderate to severe dementia is Aricept (donepezil).
JNC 8 recommends:
- lowering BP
- ETOH intake at 2 ounces/day.
- Anaerobic exercise of up to 30 minutes most days.
The JNC 8 recommends that older adults 60++ without chronic kidney disease or diabetes should have a SBP < 150 mmHg or DBP < 90 mmHg.
The FNP is preparing to do a round on hospital patients in the a.m., prior to going to your office. Which of these hospitalized patients should be checked on first?
- A 67-year-old male who had a Right BKA yesterday, following a motor vehicle accident who is complaining of phantom pain
- A 76-year-old female, who is less than 24 hours post, complaining of back pain with a new onset of urinary incontinence
- An 80-year-old male who received 2 units of packed red blood cells (PRBCs) the previous day for a suspected upper gastrointestinal bleed (GI)
- A 90-year-old nursing home patient who is scheduled for an endoscopy later in the day, who demands that she have her breakfast
2. A 76-year-old female, who is less than 24 hours post, complaining of back pain with a new onset of urinary incontinence
The patient that should be evaluated first is the 76-year-old female who is less than 24 hours post op, complaining of back pain with a new onset of urinary incontinence. This is a red flag and should be further evaluated. All of the other responses, although important, are secondary to this scenario.
The FNP has just seen Mr. Lyons, an elderly patient in the practice with suspected osteoarthritis of the hip. What is the most distinguishing characteristic of the physical examination?
- Gait abnormality
- Pain with external or internal rotation
- Joint instability
1. Gait abnormality
The most distinguishing characteristic of the physical examination for suspected osteoarthritis of the hip is gait abnormality. Patients with osteoarthritis of the hip routinely present with an antalgic gait to avoid pain in the affected hip.
Recommended immunizations for adults 65+ include:
- An annual influenza vaccine, TDAP vaccine every 5 years, shingles vaccination, pneumococcal vaccine(s) 13 and 23
- TDAP vaccine every 10 years, annual influenza vaccine, shingles vaccine after age 60, pneumococcal vaccine(s) 13 and 23
- An annual influenza vaccine, annual pneumococcal vaccines, TDAP every 10 years, and shingles vaccine after age 60
- Shingles vaccine—2 doses given 6 months apart, TDAP every 10 years, annual influenza vaccine, pneumococcal vaccines 13 and 23
2. TDAP vaccine every 10 years, annual influenza vaccine, shingles vaccine after age 60, pneumococcal vaccine(s) 13 and 23
Recommended immunizations for adults 65+ include TDAP every 10 years, an annual influenza vaccine, a shingles vaccine after the age of 60, and pneumococcal vaccines 13 and 23. The other responses are not correct.
A patient presents to the office who has multiple comorbidities and is taking multiple prescription medications to manage his chronic diseases. He is concerned about the rising cost of his medications. He will soon be enrolling in Medicare. Which Medicare Plan would help cover his prescription drugs?
- Medicare A
- Medicare B
- Medicare C
- Medicare D
4. Medicare D
Medicare Part D is referred to as the Medicare prescription drug benefit and helps to offset the costs associated with outpatient drug coverage. Medicare Part A covers hospitalization, skilled nursing services, and hospice care. There is no cost to enroll if the beneficiary has worked and paid Social Security taxes for a minimum of 40 calendar quarters. If the beneficiary has not contributed, there may be a monthly premium required. Medicare Part B covers outpatient services (e.g., diagnostics, visits to health care providers, etc.) and durable medical equipment. Medicare Part C allows private insurance companies to provide health benefits (e.g., Medicare Advantage plans).
The prevalence of elder abuse in this country is estimated to be approximately __________, according to epidemiological studies.
- less than 1%
The prevalence of elder abuse in this country is estimated to be 2 to 10%. Unfortunately, this is a fraction of the cases that should be reported to Protective Services for the elderly. The family nurse practitioner should be aware of mandated reporting of elder abuse in the state of practice.
Which of the following is NOT included in the definition of elder abuse, according to the National Center of Elder Abuse?
- Physical abuse
- Financial exploitation
- All of these can be considered in the definition.
4. All of these can be considered in the definition.
These are all included in the definition of elder abuse.
Therapeutic communication with older adults include:
- Talking to family members who are present to elicit a comprehensive health history.
- Speaking slowly in a deep tone and addressing your questions to the patient.
- Standing close to ensure they will hear you.
- Addressing the patient by their first name to create a "friendly atmosphere."
2. Speaking slowly in a deep tone and addressing your questions to the patient.
The most appropriate response is to speak slowly in a deep tone and address your questions to the patient. When interviewing the patient, the family nurse practitioner should be seated face to face with the patient. Do not assume that the patient wants to be called by his/her first name. It is important to ask how they wish to be addressed.
Goals of geriatric care include:
- Maintaining function and quality of life.
- Having a signed advance directive.
- An aggressive plan of care that is curative.
- Complying with the family’s requests.
1. Maintaining function and quality of life.
The goals of geriatric care are to provide safe, comprehensive, and cost-effective quality health care based on evidence-based practice to maintain and/or optimize function and improve the quality of life.
When prescribing for an older adult, all should be considered EXCEPT:
- Beer’s Criteria.
- McGeer’s Criteria.
3. McGeer’s Criteria.
McGeer’s criteria utilizes guiding principles that define infections (e.g., UTIs) in the long-term care setting using specific benchmarks. All of the other responses should be considered.
Anatomical and physiological changes occur as a result of the aging process. Which is a normal, non-pathological change related to the respiratory system?
- Improved coughing reflex
- Increase in A/P chest diameter
- Decreased residual volume
- Tissue elasticity increased
2. Increase in A/P chest diameter
Increase in A/P chest diameter is a normal, non-pathological change related to the respiratory system.
Screening instruments used to evaluate cognition include all of the following EXCEPT:
- Clock drawing test.
- MRI of brain.
2. MRI of brain.
The use of an MRI of the brain for screening is not supported. All of the other responses can be done by the family nurse practitioner and are considered to be an important part of the screening process.
According to the American Geriatrics Society, the hemoglobin A1C (HgbA1C) goal for an older adult with 3 multiple comorbidities or mild to moderate cognitive impairment should be:
- Individualized for each patient.
- HgbA1C between 6.5–7.0.
- HgbA1C between 7.5–8.0.
4. HgbA1C between 7.5–8.0.
The American Geriatric Society supports the HgbA1c recommendation of the American Diabetes Association for older adults with 3 or more multiple comorbidities or mild to moderate cognitive impairment. The final decision for each patient should involve patient and provider goals.
Which class of drug should be used cautiously in older adults with diabetes, due to the increased risk of hypoglycemia?
Sulfonyureas should not be used as a first choice for treating diabetes. The first-generation sulfonylureas have been shown to increase the risk of hypoglycemia in older adults. The second-generation sulfonylureas, which include glipizide, are a better choice, in addition to other treatment options.
The USPSTF recommends primary, secondary, and tertiary preventive services. Which of the following is not considered a primary preventive service?
- Smoking cessation
- Physical activity
A mammogram is a secondary form of prevention. The intent of primary prevention is to implement measures to avert the onset of disease or illness. Secondary preventive practices include those activities aimed at early detection to prevent or slow down the disease process, as well as disability.
Visible signs of intrinsic aging related to the integumentary system include all of the following EXCEPT:
- Increased melanin production.
- Decreased pigmentation.
- Ridging of nail.
- Loss or increase of subcutaneous fat deposition.
1. Increased melanin production.
Increased melanin production is an extrinsic cause of aging. Decreased pigmentation, ridging of nails, and the loss or increase of subcutaneous fat deposits are all related to intrinsic aging changes that occur in the integumentary system.
Older adults are at increased risk for abuse. Risk factors for elder abuse do NOT include:
- Substandard living arrangements to meet the needs of older adults.
- The education level of caregivers.
- Social isolation.
- Family stressors.
3. Social isolation.
The education level of caregivers is not considered. The family nurse practitioner must understand that elder abuse does not discriminate by level of education. The increased risk for elder abuse is multifactorial and includes societal, relational, community, as well as individual factors that lead to abuse.
Which of the following is the most common form of anemia diagnosed in older adults?
- Iron (Fe) deficiency anemia
- Cooley’s anemia
- Anemia of chronic kidney disease
- Vitamin B12 deficiency
3. Anemia of chronic kidney disease
Anemia of chronic disease is the most common anemia found in older adults. Cooley’s anemia is the most severe type of beta thalassemia, often requiring blood transfusions. Iron deficiency anemia can be found in older adults. It is a microcytic anemia which can be the result of acute blood loss due to malignancy or gastrointestinal pathology. Vitamin B12 deficiency is a macrocytic anemia. It is treatable and usually presents with another underlying medical illness.
Which of the following statements is true regarding suicide rates?
- Non-married women are more at risk.
- Caucasian men 85 and older are more at risk.
- Hispanic men of any age are more at risk.
- African American widowers are more at risk.
2. Caucasian men 85 and older are more at risk.
The greatest suicide rate occurs in Caucasian males 85+.