33-1Herbert, a 69-Year-Old Man, Comes to Youroffice Complaining of Nocturia. On

GeriatricsChapter 33December 21, 2014

33-1Herbert, a 69-year-old man, comes to youroffice complaining of nocturia. On questioningHerbert, you find that for the past 3 months hehas been getting up at least five times a night tovoid. He came in to seek help today because of hiswife’s insistence that he be checked out. Whenyou perform the digital rectal exam, you find thathis prostate protrudes 3–4 cm into the rectum.What grade would you assign to Herbert’s prostateenlargement?

A. Grade 1

B. Grade 2

C. Grade 3

D. Grade 4

33-1 Answer C: The degree of prostate enlargement is based onthe amount of projection of the prostate into therectum. The normal prostate protrudes less than1 cm into the rectum. Grade 1 enlargement is aprotrusion of 1–2 cm, grade 2 is 2–3 cm, grade 3 is3-4 cm, and grade 4 is greater than 4 cm.

33-2 Gerald, a 67-year-old male retiredmaintenance worker, comes to your office fora physical. On reviewing Gerald’s history, youdiscover that he has had pneumonia twice inthe past 5 years. When you question Geraldabout his immunization history, he revealsthat his last tetanus and diphtheria (Td)immunization was 6 years ago, and his lastflu shot was 8 months ago during the last fluseason. He denies ever having had a pneumoniavaccination. Which immunizations should youoffer to Gerald today?

A. Td

B. Pneumococcal vaccine

C. Influenza

D. Td and pneumococcal vaccine

33-2 Answer B: Prevention of pneumococcal disease in olderpeople is one of the health initiatives of the U.S.government report Healthy People 2020, NationalHealth Promotion and Disease Prevention Objectives.The goal for health-care providers is to have 90%of all clients older than 65 years immunized againstpneumococcal disease by the year 2020. Thepneumococcal vaccine is a one-time injection thatmay need to be repeated in 8 years. Gerald does not need a Td booster because his last injection was only 6 years ago, and the Centers for Disease Control and Prevention recommends a Td booster every 10 years. The influenza injection would notbe appropriate at this time. Influenza vaccine isadjusted yearly to address the type of influenza thatis thought to be prevalent in that year. Also, theinfluenza vaccine is given just before flu season.

33-3 Josephine, a 60-year-old woman,presents to your office with a history of elevatedtotal cholesterol, triglycerides, and low-densitylipoprotein (LDL) cholesterol. She was started ona statin medication 4 weeks ago and is concernedabout some muscle pains she has been experiencing.On questioning Josephine, you discover that she hashad pain in both her thighs for the past 2 weeks.What possible complication of statin therapy are youconcerned that Josephine might be experiencing?

A. Liver failure

B. Renal failure

C. Rhabdomyolysis

D. Rheumatoid arthritis

33-3 Answer C: Rhabdomyolysis is a syndrome that results fromdestruction of skeletal muscle. It is usually diagnosedfrom laboratory findings that are characteristicof myonecrosis. Although there are no standardcreatinekinase values that establish the diagnosisof rhabdomyolysis, elevations above 10,000 IU/Lare usually indicative of clinically significantrhabdomyolysis. The syndrome usually affectsmuscles used in exercise, but it may present asgeneralized muscle weakness. It usually resolves on stopping the statin medication, but severe cases may lead to renal failure and death.

33-4 Dennis, age 62, has benign prostatichyperplasia (BPH). He tells you that he voids atleast four times per night and that he has read abouta preventive drug called terazosin hydrochloride(Hytrin) that might help him. What do you tell him?

A. “It’s not a preventive drug, but it relaxes smooth muscle in the prostate and bladder neck.”

B. “It changes the pH of the urine and preventsinfections caused by urinary stasis.”

C. “It relaxes the urethra.”

D. “It shrinks the prostate tissue.”

33-4 Answer A: Terazosin (Hytrin) is an alpha-1 adrenergic blocker.It is not a preventive drug, but it does relax smoothmuscle in the prostate and bladder neck and allowscomplete emptying of the bladder, relieving frequentnocturnal urination. Terazosin is begun at 1 mg atbedtime initially and then titrated upward to 10 mgonce a day. Doxazosin (Cardura) is also effective asan alpha-1 adrenergic blocker. It is begun initially at1 mg at bedtime, with the dosage doubled every1–2 weeks to a maximum of 8 mg per day.Finasteride (Proscar), a 5-alpha reductase inhibitor,decreases the volume of the prostate within about3 months. At 12 months, it seems to have reachedits peak effectiveness. Finasteride is given 5 mg dailyfor at least 6 months; then the client is reevaluated.

33-5 Which of the following statements is trueabout the older adult?

A. Older adults are at an increased risk for depression.

B. Depression is a normal part of aging.

C. Depression may just be the emotion feltwhen a spouse is grieving the loss of a lovedone.

D. Most anti-depressive drugs do not work withoutpsychotherapy on older adults.

33-5 Answer A: Older adults are at an increased risk for depressionbecause of the associated chronic health conditionsthat may also exist. Older adults are oftenmisdiagnosed and undertreated. Depression is a trueand treatable medical condition, not a normal partof aging. Depression is not just having “the blues”or the emotions one feels when grieving the lossof a loved one. It is a true medical condition thatis treatable, like diabetes or hypertension.Most older adults see an improvement in theirsymptoms when treated with anti-depression drugsalone, with psychotherapy, or with a combinationof both.

33-6 Which federal insurance program went intoeffect in 1966 to provide funds for medical costsfor persons age 65 and older, as well as disabledpersons of any age?

A. Medicare

B. Title XIX of the Social Security Act

C. Medicaid

D. Omnibus Reconciliation Act

33-6 Answer A: Medicare was established in 1966 by the U.S.government as a federal insurance program toprovide funds for medical costs for persons age 65and older and disabled persons of any age. Medicaid,an amendment to Title XIX of the Social Security Act, went into effect in 1967 to provide basic healthservices to low-income persons. The Omnibus Budget Reconciliation Act was implemented in 1982, when

20 programs were combined into four block grants.

33-7 When can Pap smears be safely discontinued?

A. At age 80

B. At age 65 if the previous three Pap smears have been normal

C. Never; they should be continued throughout life

D. After menopause or hysterectomy

33-7 Answer B: Pap smears may be discontinued at age 65 if theprevious three Pap smears have been normal. Ator after the age of 30, women who have had threeconsecutive normal tests may have screening extendedto once every 2–3 years. An exception to this is forwomen who are at higher risk of cervical cancer, such aswomen exposed to DES in utero or those who are HIVpositive or immunocompromised for another reason.If a woman has had a hysterectomy, there is a need fora Pap smear only if the cervix has been left intact.

33-8 Which part of Medicare is basic hospitalinsurance?

A. Medicare Part A

B. Medicare Part B

C. Medicare Part C

D. Medicare Part D

33-8 Answer A: Medicare Part A is basic hospital insurance.Medicare Part B is supplementary voluntarymedical insurance supported by tax revenues andby additional monies paid by the insured to coverphysician services, laboratory services, home healthcare, and outpatient hospital treatments.

33-9 Mary, a 70-year-old woman with diabetes,is at your office for her 3-month diabetic checkup.Mary’s list of medications includes Glucophage XR1,000 mg daily, an angiotensin-converting enzyme(ACE) inhibitor daily, and one baby aspirin(ASA) daily. Mary’s blood work showed a fastingblood sugar of 112 and glycosylated hemoglobin (HgbA1c) of 6.5. You tell Mary that her bloodwork shows

A. that her diabetes is under good control and she should remain on the same medications.

B. that her diabetes is controlled and she needsto have her medications decreased.

C. that her diabetes is not controlled and hermedications need to be increased.

D. that her diabetes has resolved and she no longerneeds any medication.

33-9 Answer A: A person with diabetes mellitus type 2 should havea HgbA1c of 6.5 or less and a fasting blood sugar(fbs) less than 130 for optimal control. Becausethe clients lab results fall in those categories, she isunder good control and her medications should staythe same.

33-10 By 2030, the number of U.S. adults aged 65or older will more than double to about 71 million.What percentage of older adults have one chroniccondition?

A. 30%

B. 50%

C. 80%

D. almost 100%

33-10 Answer C: About 80% of older adults have one chroniccondition. Fifty percent of older adults have at leasttwo chronic conditions. Infectious diseases (such asinfluenza and pneumococcal disease) and injuriesalso take a disproportionate toll on older adults.Efforts to identify strategies to prevent or reducethese risks and to effectively intervene in theseconditions must be pursued.

33-11 Mildred, a 92-year-old independent woman,is moving into her daughter’s home. Her daughtercomes to see you seeking information to help keepher mother from falling. Which of the followinginterventions would you suggest she do to helpprevent Mildred from falling?

A. Install an intercom system in Mildred’sbedroom.

B. Limit the time Mildred is home alone.

C. Hire an aide to assist Mildred 24 hours a day.

D. Remove all loose rugs from floors and install hand grasps in bathtubs and near toilets.

33-11 Answer D: The correct answer is to allow Mildred herindependence but provide a safe environment byremoving loose rugs that she could easily trip overand installing handrails by the toilet and in thebathtub. The rails will provide support for her asshe goes from a sitting to a standing position. Hiringan aide 24 hours a day would decrease Mildred’sindependence. Leaving Mildred home, alone or not,will not change her chance of falling.

33-12Jan’s mother has Alzheimer’s disease.She tells you that her mother’s recent memory ispoor and that she is easily disoriented, incorrectlyidentifies people, and is lethargic. Jan asks you,“Is this as bad as it gets?” You tell her that hermother is in which stage of the disease?

A. Stage 1

B. Stage 2

C. Stage 3

D. Stage 4

33-12 Answer C: Families of persons with Alzheimer’s disease (AD)need to know that AD is a progressive disorder ofthe brain affecting memory, thought, and language.

Although the progression of the stages is individualand changes may occur rapidly or slowly overthe course of several years, knowing what stagea family member is in helps family members inplanning and knowing what to expect. Stage 1 isthe onset, which is insidious. Spontaneity, energy,and initiative are decreased; slowness is increased;word finding is difficult; the person angers moreeasily; and familiarity is sought and preferred. Instage 2, supervision with detailed activities suchas banking is needed, speech and understandingare much slower, and the train of thought is lost.In stage 3, personality change is marked anddepression may occur. Directions must be specificand repeated for safety, recent memory is poor,disorientation occurs easily, people are incorrectlyidentified, and the person may be lethargic. Instage 4, apathy is noticeable. Memory is poor orabsent, urinary incontinence is present, individualsare not recognized, and the person should not bealone.

33-13 The two main causes of death amongU.S. adults aged 65 years or older are

A. heart disease and stroke.

B. stroke and suicide.

C. heart disease and Alzheimer’s disease.

D. heart disease and cancer.

33-13 Answer D: The two main causes of death among U.S. adultsaged 65 years or older are heart disease (28.2%) andcancer (22.2%). Stroke accounts for 6.6%, chroniclower respiratory disease 6.2%, Alzheimer’s disease4.2%, and diabetes 2.9%.

33-14 A 68-year-old woman presents to your officefor screening for osteoporosis. Sandy states that hergrandmother and mother both lost inches in theirold age. Sandy has been postmenopausal for the past15 years and never took any hormone replacementmedications. She is Caucasian, weighs 108 lb, andis 5 ft 1 in. tall on today’s measurement. When dowomen lose the greatest amount of bone density?

A. During adolescence

B. The first year of menopause

C. The first 10 years after menopause

D. Bone loss occurs continuously at the same ratefrom menopause to death.

33-14 Answer C: Bone loss begins at a rate of 0.5% a year in awoman’s middle to late 40s. When menopauseoccurs, the rate increases up to 7% a year for thefirst decade after menopause. This increase in therate of bone loss is directly related to a decrease ina woman’s estrogen. After menopause, the boneloss decreases to 0.5%–1% a year until death. Thispatient should be encouraged to do weight-bearingexercises and have an adequate calcium intake of1,000–1,500 mg/day with sufficient amounts ofvitamin D.

33-15 A lab value that is commonly decreased inolder adults is

A. creatinine clearance.

B. serum cholesterol.

C. serum triglyceride.

D. blood urea nitrogen.

33-15 Answer A: The creatinine clearance value is commonly decreasedin older adults because of impaired renal function.Serum cholesterol, serum triglyceride, and blood ureanitrogen values are usually increased in older adults.

33-16 Marian’s husband, Stu, age 72, hastemporal arteritis. She tells you that his physicianwants to perform a biopsy of the temporal artery.She asks if there is a less invasive diagnostic test.What test do you tell her is less invasive?

A. Computed tomography (CT) scan

B. Magnetic resonance imaging (MRI)

C. Electroencephalogram (EEG)

D. Color duplex ultrasonography

33-16 Answer D: A biopsy of the temporal artery is usually requiredto confirm the diagnosis of temporal arteritis.Color duplex ultrasonography (a combination ofultrasonography and the flow-velocity determinationsof a Doppler system) has been shown to examine evensmall, such as vessels the superficial temporal artery,and show a halo around the inflamed arteries whentemporal arteritis is present. Therefore, it is a muchless invasive procedure than biopsy. A computed tomography (CT) scan and magnetic resonance imaging (MRI) are done to detect neurological damage from hemorrhage, tumor, cyst, edema, ormyocardial infarction. These tests may also identifydisplacement of the brain structures by expandinglesions. However, not all lesions can be detected byCT scan or MRI. An electroencephalogram is usedto evaluate the electrical activity of the brain. It canidentify seizure activity as well as certain infectiousand metabolic conditions.

33-17 Martha, age 82, has an asymptomatic carotidbruit on the left side. What do you recommend?

A. ASA therapy

B. Coumadin therapy

C. Surgery

D. No treatment at this time

33-17 Answer D: Clients with asymptomatic carotid bruits have a 2%incidence of cerebrovascular accidents (CVAs) peryear. Although ASA, anticoagulants, and surgeryare frequently ordered, there are not sufficient datato prove that these treatments reduce the risk ofCVA in clients with asymptomatic carotid bruits.Starting an asymptomatic older woman on ASAtherapy may produce more problems, such as skinbruising or gastrointestinal bleeding.

33-18 Harriet, a 76-year-old woman, comes toyour office every 3 months for follow-up on herhypertension. Harriet’s medications include onebaby aspirin daily, lisinopril 5 mg daily, and calcium1,500 mg daily. On today’s visit, Harriet’s bloodpressure is 168/88. According to the Joint NationalCommittee (JNC) VII guidelines, what should youdo next to control Harriet’s blood pressure?

A. Increase her dose of lisinopril to 20 mg daily.

B. Add a thiazide diuretic to the lisinopril 5 mg daily.

C. Discontinue the lisinopril and start acombination of ACE inhibitor and calciumchannel blocker.

D. Discontinue the lisinopril and start a diuretic.

33-18 Answer B: The eighth report of the Joint National Committeeon Prevention, Detection, and Treatment ofHypertension (JNC VIII) recommends that stage2 hypertension be treated with a combination ofa thiazide diuretic and an ACE inhibitor, ARB,calcium channel blocker, or beta blocker.

33-19 Oral health problems are common andpainful. Years ago, it was common to see almostall adults with complete dentures. Today, whatpercentage of U.S. adults aged 75 and older havelost all of their teeth?

A. 10%

B. 25%

C. 50%

D. 75%

33-19 Answer B: Twenty-five percent of U.S. adults aged 75 and olderhave lost all of their teeth. Advanced gum diseaseaffects 4%–12% of adults. Half of the cases of severegum disease in the United States are the result ofcigarette smoking. Three times as many smokershave gum disease as people who have never smoked.More than 7,600 people, mostly older Americans,die from oral and pharyngeal cancers each year.

33-20 Martin, an 83-year-old man, is at youroffice for his yearly physical exam. He has ahistory of hypertension, hyperlipidemia, cigarettesmoking, and chronic obstructive pulmonary disease(COPD). Martin states that he has been feelingincreased fatigue with minimal activity but deniesany chest pain or shortness of breath. Martin’slist of medications includes the following: one babyaspirin daily, one ACE inhibitor daily, diureticdaily, and statin medication daily. Martin’s physicalexam was normal. His blood pressure was 130/68,his heart rate was 88, and his respiratory rate was22. Observing Martin during your examination,you detect that he utilizes pursed-lip breathingthroughout the exam. What medication should hebe started on for his COPD?

A. Inhaled corticosteroid

B. Inhaled anticholinergic and inhaled beta-2 agonists

C. Oral steroids daily

D. Inhaled beta-2 agonists

33-20 Answer B: According to the Global Initiative for COPDguidelines, all symptomatic COPD clients shouldbe started on an inhaled anticholinergic drug anda beta-2 agonist. Both are well tolerated by olderadults and have few side effects.

33-21 Which statement about gender disparitiesand suicide is true?

A. Women take their own lives more often thanmen.

B. Men attempt suicide more often than women.

C. Suicide rates for males are highest among those aged 75 and older.

D. Poisoning is the most common method of suicidefor both sexes.

33-21 Answer C: Suicide rates for males are highest among those aged75 and older. Suicide rates for females are highestamong those aged 45–54. Males take their own livesat nearly four times the rate of females and represent78.8% of all U.S. suicides. During their lifetime,women attempt suicide about two to three times asoften as men. Firearms are the most commonly usedmethod of suicide among males (55.7%). Poisoningis the most common method of suicide for females(40.2%).

33-22 Answer A: White men are at a higher risk for testicular cancerthan nonwhite men. Testicular self-examination(TSE), along with early detection and treatment, hasdecreased the mortality rates appreciably. TSE shouldbe taught to all men ages 15–40. Testicular cancer is themost common solid tumor found in males ages 20–34.

33-22 Postmenopausal women who are not onhormone replacement therapy need how muchcalcium per day to help prevent osteoporosis?

A. 1,000 mg

B. 1,200 mg

C. 1,500 mg

D. 1,800 mg

33-22 Answer C: Postmenopausal women who are not takinghormone replacement therapy need 1,500 mg ofcalcium a day to help prevent osteoporosis. Becausetreatment for osteoporosis is limited, prevention isnecessary to reduce the occurrence.