Geriatrics Update via Board Review Questions From ABIM

Geriatrics Update via Board Review Questions From ABIM 2015 Copyright ABIM

Q 1: Insomnia Treatment • A 68 -year-old man who has insomnia is establishing care in your office because he recently moved to the area to live closer to his children. The patient is due for a refill of lorazepam, 2 mg orally at bedtime, prescribed by his previous physician for insomnia. According to the patient's medical records, the patient's physician prescribed lorazepam after a thorough evaluation for insomnia revealed no underlying medical or psychological disorder. Over the past year, the lorazepam dosage was gradually increased, and the patient states that the current dosage has been effective. He reports no adverse effects from the medication; he does not have any difficulties with cognition or gait and has had no falls.

Which of the following should you do now? A. Continue lorazepam B. Discontinue lorazepam and begin clonazepam C. Inform the patient that you will not prescribe a benzodiazepine because of the risk of cognitive deficits, falls, and hip fractures in older adults using this medication D. Provide educational material regarding the risks of benzodiazepine use, discuss a stepwise medication -tapering protocol, and review measures to improve sleep hygiene

Rationale • As part of The American Board of Internal Medicine Foundation Choosing Wisely Campaign, the American Geriatrics Society recommends against the use of benzodiazepine drugs for adults 65 years of age or older as first-line treatment for insomnia. This recommendation is based on studies that have demonstrated increased risk of cognitive deficits, falls, and hip fractures in older adults using benzodiazepines. Although the patient in this question has not had adverse events due to the medication, continuing to take it will continue to put him at risk. A trial of improved sleep habits (e. g. , sleep hygiene techniques) is usually the best first approach and may improve symptoms of insomnia. An attempt at nonpharmacologic management by improving sleep hygiene has not been documented in the patient's medical records and would be appropriate. A recent study demonstrated that providing patients with educational material about the risk of benzodiazepines and information on how to safely taper the medication effectively elicited shared decision making about the overuse of benzodiazepines and led to increased benzodiazepine discontinuation. An intervention that educates patients about inappropriate medication use and empowers them to share in the decision-making process to de-prescribe can be more effective than unilaterally stopping medication. This latter approach may harm the patient-provider relationship. In addition, patients may seek medications from another source if they are not provided adequate education regarding the harms of the medication. Abrupt discontinuation of benzodiazepines is not recommended because the patient can experience withdrawal symptoms. Clonazepam has not been found to be safer than lorazepam in geriatric patients.

Choosing Wisely: Don’t use benzodiazepines or other sedativehypnotics in older adults as first choice for insomnia, agitation, or delirium. Large-scale studies consistently show that the risk of motor vehicle accidents, falls, and hip fractures leading to hospitalization and death can more than double in older adults taking benzodiazepines and other sedative-hypnotics. Older patients, their caregivers, and their providers should recognize these potential harms when considering treatment strategies for insomnia, agitation, or delirium. Use of benzodiazepines should be reserved for alcohol withdrawal symptoms/delirium tremens or severe generalized anxiety disorder unresponsive to otherapies.

For further information, see the following: • Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: The EMPOWER Cluster Randomized Trial. JAMA Intern Med. 2014; 174(6): 890– 898. doi: 10. 1001/jamainternmed. 2014. 949. • Schutte-Rodin S, Broch L, Buysse D, et al. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008; 4: 487– 504. • AGS Choosing Wisely Workgroup. American Geriatrics Society identifies another five things that healthcare providers and patients should question. J Am Geriatr Soc. 2014; 62: 950– 960.

Q 2: Managing Hypertension • A 75 -year-old man comes to your office to establish primary care. The patient has hypertension but no known history of diabetes mellitus or chronic kidney disease. He smoked one pack of cigarettes daily for 20 years, but quit more than 20 years ago. His current daily medications are aspirin, 81 mg; lisinopril, 5 mg; and hydrochlorothiazide, 25 mg. Home blood pressures measured over the past week were 132/65 mm Hg, 146/78 mm Hg, 149/82 mm Hg, and 139/75 mm Hg. The review of systems is unremarkable. • On physical examination, the patient appears well. Sitting blood pressure is 149/85 mm Hg and sitting pulse rate is 80 per minute. Standing blood pressure is 135/80 mm Hg and standing pulse rate is 88 per minute. On standing, he does not become lightheaded. The lungs are clear; heart sounds are regular with no murmurs, rubs, or gallops. He has no carotid or abdominal bruits. Peripheral pulses are strong. There is no lowerextremity edema. • Lab: Creatinine = 1. 0 (0. 7 -1. 5), K+ = 3. 9 (3. 5 – 5. 0)

Which of the following should you recommend now for management of this patient's hypertension? A. Decrease hydrochlorothiazide to 12. 5 mg daily B. Increase lisinopril to 7. 5 mg daily C. Add amlodipine, 2. 5 mg daily D. Continue current regimen

Rationale • The prevalence of hypertension in adults older than age 65 years is approximately 70%. The best evidence supports pharmacologic treatment of elevated blood pressure in older adults to prevent stroke, heart failure, and coronary artery disease. The goal blood pressure, however, has been a point of debate, with some observational evidence indicating that lower blood pressure (possibly due to overtreatment) is associated with higher mortality and other adverse outcomes, such as injurious falls. The Eighth Joint National Committee recently recommended treatment of blood pressure in adults older than age 60 without diabetes mellitus or chronic kidney disease to a goal of less than 150 mm Hg systolic and less than 90 mm Hg diastolic. A corollary to this recommendation indicates that in older adults whose treated blood pressure is currently less than 140 mm Hg (the old goal) and who seem to tolerate this lower blood pressure, there is no need to decrease medication. In this case, the patient is at goal according to the current guidelines. Despite a few measures below 140 mm Hg, there is no indication to decrease his medication dosage, although continued monitoring for overtreatment is warranted, given his slight decrease in systolic blood pressure with orthostatic positioning.

For further information, see the following: • James PA, Oparil S, Carter BL, et al. 2014 evidencebased guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014; 311(5): 507– 520. • Tinetti ME, Han L, Lee DH, et al. Antihypertensive medications and serious fall injuries in a nationally representative sample of older adults. JAMA Intern Med. 2014; 174(4): 588– 595.

Q 3: Screening in the Elderly • You are seeing an 85 -year-old woman in your primary care practice at a continuing care retirement community. Two months ago, the patient had a non-ST-segment elevation myocardial infarction that was complicated by heart failure. She also has hypertension and hyperlipidemia. She says that she feels well and is participating in cardiac rehabilitation without symptoms. Her medications are metoprolol, lisinopril, atorvastatin, and aspirin. • On physical examination, heart rate is 68 beats per minute and blood pressure is 120/65 mm Hg. There is no jugular venous distention. Cardiopulmonary examination is normal. No peripheral edema is present. • At the end of the visit, the patient mentions that she is due for her annual mammogram. You recall that she has had them annually for more than 30 years, with biopsies of benign lesions on at least two occasions.

Which of the following represents the source of greatest harm from breast cancer screening for this patient? A. Diagnosis of cancer that is unlikely to benefit from treatment B. Stress from false-positive result C. Pain and discomfort of the procedure D. Cost of the procedure

Rationale • Important questions remain about how long to continue screening mammograms for older women. In part, the dilemma is related to the lack of inclusion of women older than age 75 in breast cancer screening trials. Current guidelines recommend that women should consider stopping annual screening mammography when their life expectancy is less than 10 years. In the case presented in this question, the previously healthy 85 -year-old woman now has coronary artery disease and congestive heart failure. While her recovery has progressed smoothly and her overall prognosis seems good, her level of health and life expectancy now predict that she has a median survival of 5 to 7 years (instead of 10 years). Initiating discussions about life expectancy and stopping screening can be difficult for patients and health care providers. A recent review recommends that the conversation focus on potential harms for a patient who has limited life expectancy. For this patient, who has endured mammograms for years (including false-positives and biopsies) and is willing to continue them, it is unlikely that psychological stress, discomfort, or cost will be the major limiting factor. For her, the greatest risk is diagnosis of a tumor that would not have otherwise shortened her life or adversely impacted her quality of life. Specifically, the potential harms of surgery, radiation, or chemotherapy and the stress of the diagnosis all present significant potential negative effects.

An ideal screening test would be a reasonably priced, noninvasive procedure. This screening test must identify a disease that is clinically significant and that, if left untreated, will cause significant morbidity and mortality. In addition, the ideal screening test must be for a disease that has a preclinical phase, a presymptomatic stage for which the disease is detectable. Finally, the disease must have an acceptable treatment course. The ideal screening test must also be sensitive and specific. We offer screening tests to those individuals who would consider initiating treatment of the disease.

For further information, see the following: • Walter LC, Schonberg MA. Screening mammography in older women: a review. JAMA. 2014; 311: 1336– 1347.

Q 4: Medications for Alzheimer’s Disease • • • A 70 -year-old man who has Alzheimer's disease has been treated with donepezil, 10 mg orally at bedtime, for the past six months covered by Medicare Part D. He returns to your office with his wife for a periodic follow-up visit. He has not had nausea, diarrhea, headache, weight loss, changes in sleep, falls, or syncope. Six months ago, the patient was unable to perform instrumental activities of daily living (IADLs) such as paying bills, managing medications, and driving a car. He was able to independently perform all ADLs and was able to recognize all his family members. The patient's wife states that she is uncertain if the donepezil is helping her husband's cognition and worries about the number of medicines he takes. The patient continues to be dependent in all IADLs. He now needs help choosing proper clothing for the season; otherwise he remains independent in ADLs. Findings on physical examination, including orientation, are normal. Laboratory studies are unremarkable. The patient's score on the Mini Mental State Examination is 20 of 30, which is unchanged from the same examination six months ago.

Which of the following should you recommend now? A. Increase the dosage of donepezil to 23 mg orally daily B. Discontinue the donepezil C. Continue the donepezil for an additional six months D. Taper off the donepezil for a trial period

Rationale • Acetylcholinesterase inhibitors (ACh. EIs) can improve short-term global function in patients who have moderate Alzheimer's disease, but the average effect of changes in cognition is small. Providers should determine cognitive, functional, and behavioral goals of treatment with patients and caregivers before initiating therapy, and should consider discontinuing ACh. EIs after a reasonable trial period on the medication (e. g. , 12 weeks) if goals of treatment are not met. A trial period off the medication can be helpful to determine whether cognitive decline continues at the same rate without medication or if such decline is accelerated. Six months of medication would be considered an adequate trial period on the medication, and an additional six months is not necessary to know whether the patient will experience notable benefit. Abrupt discontinuation of donepezil is not recommended in the absence of significant adverse effects, and there is no evidence in the question that the burden of the medication outweighs the benefit. Donepezil, 10 mg orally at bedtime, is an adequate dosage. A 23 -mg formulation of donepezil is available, and in the study by Farlow et al. , patients who took the 23 -mg formulation experienced a modest improvement in cognition compared with those who took the 10 -mg formulation. However, in this study comparing efficacy of the two medication regimens, more individuals in the higher dosage group withdrew from therapy because of adverse events. If after tapering the donepezil, the patient's family thinks his dementia has clearly worsened, the medication can be restarted.

Q 5: Management of Delirium • • • An 83 -year-old man who has mild dementia and chronic kidney disease stage 3 was admitted to the hospital for pyelonephritis, Escherichia coli bacteremia, and acute on chronic renal failure. Since the admission two days ago, his laboratory parameters have been improving, with a decrease in leukocytosis, repeat negative blood cultures, and slight decrease in his serum creatinine. Despite having mild dementia, at baseline the patient was conversant, recognized his family, could express his needs, and could process simple information. He also has peripheral arterial disease. Current medications are ceftriaxone, aspirin, amlodipine, and acetaminophen. Currently on hospital day 2, it is noted that he loses track of his ideas in mid-sentence while talking and starts picking at the bed sheets. His family says that he is more confused than previously, seems drowsy every time they visit, and now does not recognize his son. The patient has repeatedly been told that he is in the hospital with an infection, and each time he has been told this he has become upset. Last evening, he repeatedly tried to climb out of bed and removed his intravenous line. Today, he pulled out his intravenous line again even though staff had covered it up to hide it from sight. On physical examination, temperature is 38. 3 C (100. 9 F), heart rate is 96 per minute, and blood pressure is 148/70 mm Hg. The patient appears restless and is oriented only to person. His speech is mildly distorted, and he cannot repeat three numbers.

Which of the following should you recommend? A. B. C. D. Keeping the television on for distraction Initiating a bedside sitter Placing bilateral wrist restraints Administration of quetiapine, 25 mg once

Rationale • The best treatment for delirium is to take measures to prevent its occurrence. Once an older adult with medical illness has delirium, there are few proven effective treatments. In addition to treating the underlying causes of delirium, it is generally recommended that attention be paid to potential discomfort; the sleep-wake cycle; maximizing vision, hearing, and nutrition; family involvement; and providing a soothing and familiar environment. The American Geriatrics Society recently listed avoidance of physical restraints to manage the behavioral symptoms of the hospitalized older adult with delirium as a recommendation on their second list of 5 things patients and providers should question. This is part of the Choosing Wisely Campaign. Physical restraints may lead to increased agitation and injury in people who have dementia or delirium, or both, and should be used as a last resort. If attempts to protect and hide this patient's intravenous line do not work, the next step would be to provide a bedside sitter who could redirect the patient. While turning on the television is a common strategy used for medical inpatients who are restless, it could interfere with the sleep-wake cycle in delirious patients and potentially increase agitation through overstimulation. The television should be reserved for patients who request it. There are no placebocontrolled trials of pharmacologic therapy for delirium treatment in older medical inpatients (non-intensive care unit, non-surgical).

DSM-5 lists five criteria for delirium: A. There is a disturbance in attention and awareness. B. Delirium develops over a short period of time, typically hours to days. There is a change in baseline attention and awareness. It fluctuates throughout the day. C. There is also another disturbance in cognition, such as in memory, orientation, language, and perception. D. The disturbances in (A. ) and (C. ) are not better explained by another pre-existing, established, or evolving neurocognitive disorder. (Having a neurocognitive disorder, however, increases the risk of the development of delirium. ) E. There must also be evidence that the delirium is due to a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

For further information, see the following: • Moyer VA. Screening for cognitive impairment in older adults: U. S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014; 160: 791– 797. • Farlow MR, Salloway S, Tariot PN, et al. Effectiveness and tolerability of high-dose (23 mg/d) versus standard-dose (10 mg/d) donepezil in moderate to severe Alzheimer's disease: a 24 -week, randomized, double-blind study. Clin Ther. 2010; 32(7): 1234– 1251. • AGS Choosing Wisely Workgroup. American Geriatrics Society identifies another five things that healthcare providers and patients should question. J Am Geriatr Soc. 2014; 62: 950– 960.

For further information, see the following: • AGS Choosing Wisely Workgroup. American Geriatrics Society identifies another five things that healthcare providers and patients should question. J Am Geriatr Soc. 2014; 62: 950– 960. • Holroyd-Leduc JM, Khandwala F, Sink KM. How can delirium best be prevented and managed in older patients in hospital? CMAJ. 2010; 182: 265– 270.

Q 7: Inpatient DVT Prophylaxis • • • An 80 -year-old woman was admitted to the hospital for a heart failure exacerbation. On hospital day 3, the patient is making steady progress with diuresis but still must have more improvement in her condition to be discharged. At baseline, she could independently perform her activities of daily living but needed help with shopping, cleaning, and cooking because of shortness of breath with minimal exertion. She has ischemic cardiomyopathy, coronary artery disease, hypertension, and hyperlipidemia. Current medications are furosemide given intravenously, lisinopril, metoprolol, aspirin, atorvastatin, potassium chloride, and heparin given subcutaneously twice daily. Since admission, the patient has expressed her concern about receiving heparin injections. She has had a moderate amount of bruising on her abdomen, which is painful. She has asked her nurse several times if she really needs "those shots, " and the nurse has relayed her concerns to you. BMI at dry weight is 17. On physical examination, heart rate is 70 beats per minute, and blood pressure is 118/60 mm Hg. Jugular venous pressure is 11 cm at 45 degrees. An S 3 gallop is heard. Crackles are heard halfway up in both lung fields. Ecchymoses are seen on the abdomen, with no surrounding erythema. There is edema (2+) extending to the knees. She can walk slowly but safely with a walker or assistance.

Which of the following should you do now? A. Continue the heparin, and explain its necessity to the patient B. Stop the heparin, and start enoxaparin daily C. Stop the heparin, and encourage the patient to walk with her family D. Stop the heparin, and start venous foot pumps

Rationale • It is generally recommended that adults older than age 40 who are hospitalized for medical reasons and are expected to be less mobile for 3 days or more be given some form of deep venous thrombosis (DVT) prophylaxis. These data are based on several randomized controlled trials. However, whether these data apply to frail older adults is less clear. A systematic review and metaanalysis examined the evidence for harm and efficacy of pharmacologic prophylaxis of DVT in older adults. For the most part, frail older adults are excluded from these trials because cognitive impairment, renal insufficiency, and other comorbidities common among frail older adults are exclusion criteria. The data on which the recommendations are based typically report reduction in a composite endpoint. The majority of events prevented in these composite endpoints are asymptomatic DVTs. There is no consistent reduction in fatal pulmonary embolism or mortality. When data from the three trials that included a significant proportion of people older than age 75 are pooled, a similar reduction in composite endpoints to other trials is seen in the active treatment group (absolute risk reduction [ARR] range of 3. 8% to 14. 4%). However, two thirds of these events are asymptomatic DVTs. The bleeding risk was not reported for subgroups. In the general population, the authors report the absolute bleeding risk to be increased by 2% in the active treatment group. Older age, moderate-to-severe renal insufficiency, and low body weight increase the risk of bleeding over baseline in patients receiving these drugs. • Starting enoxaparin instead of twice-daily heparin could be considered; however, it is still an injection. Given that this patient's quality of life is significantly worsened by these injections, it is reasonable to stop injection therapy altogether. The current available data suggest that, at best, this patient would gain a very small absolute risk reduction for symptomatic DVTs and an even smaller ARR for pulmonary embolism. Patients like this one may not have been included in most studies. Venous foot pumps have not been shown to reduce the risk of DVT.

For further information, see the following: • Greig MF, Rochow SB, Crilly MA, Mangoni AA. Routine pharmacological venous thromboembolism prophylaxis in frail older hospitalised patients: where is the evidence? Ageing. 2013; 42: 428– 434.

Q 10: Dyspnea • A 76 -year-old woman comes to the emergency department for shortness of breath for one day. For the past several days, she has had malaise, nasal congestion, and a nonproductive cough and has needed to rest after walking a short distance, which is unusual for her. The patient has no other symptoms and specifically has not had fever, chest pain, palpitations, leg swelling, lightheadedness, sputum production, hemoptysis, or gastrointestinal symptoms. She has not traveled recently and has had no sick contacts. She has osteoporosis and had stage 1 breast cancer, which was treated 10 years ago. Since that time, she has regularly had normal mammograms. There is no known history of lung disease, coronary artery disease, or thromboembolism. Current outpatient medications are alendronate and a calcium and vitamin D supplement. • On physical examination the patient appears mildly tachypneic but there is no increased work of breathing or diaphoresis. Temperature is 36. 5 C (97. 7 F), heart rate is 98 beats per minute, respirations are 22 per minute, and blood pressure is 120/70 mm Hg. Arterial oxygen saturation is 97% on room air. Cardiopulmonary and abdominal examinations are normal. No edema is present. • Labs: normal CBC

Which of the following is most appropriate now? A. Observation and outpatient investigation of her symptoms B. Ultrasound study of the lower extremities C. CT angiogram D. Initiation of a heparin drip

Rationale • • By the two-level Wells score, this woman has an unlikely pretest probability of having a pulmonary embolism (PE). While there is not an immediate alternative explanation of her symptoms, it may be reasonable to observe her and have her follow up with her primary care physician in several days. While traditionally a D-dimer level of 600 µg/L (0. 6 µg/m. L) would be considered elevated, a recent prospective validation study found that age-adjusted D-dimer cutoffs may help eliminate the need for further testing among older people with non-high pretest probability of PE. The age-adjusted cutoff is equivalent to age x 10. When this age-adjusted cutoff was used prospectively with a group of older patients presenting to the emergency department with possible PE symptoms, almost no one with a true PE was missed. Among those with non-high pretest probability, 28. 2% of the sample had a D-dimer less than 500 µg/L (0. 5 µg/m. L) and 11. 6% had a D-dimer between 500 µg/L (0. 5 µg/m. L) and their age-adjusted cutoff. The 3 -month failure rate among the latter group was 1 in 331 (0. 3%), which is below the accepted 3% failure rate from prior angiography studies. Among those older than 75 years, the 3 -month failure rate was 0%. Given the fact that the patient in this question has no leg pain or swelling, and her pretest probability is unlikely for PE, ultrasound study of the lower extremities is likely to be normal and a CT angiogram could unnecessarily expose her to a dye load. Similarly, starting heparin with low clinical suspicion would not be indicated.

For further information, see the following: • Righini M, Van Es J, Den Exter PL, et al. Ageadjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study. JAMA. 2014; 311: 1117– 1124.

Q 11: Dementia with Behavioral Disorder • • • An 82 -year-old man who has moderately severe dementia comes into your clinic for routine follow-up accompanied by his wife. In the past several months, he has had frequent episodes of nocturnal awakening and wandering around the house. Several times per week, he has become agitated and verbally aggressive, but he was usually successfully redirected. Current medications are donepezil, 10 mg daily, and vitamin D, 800 IU daily. He lives at home with his wife, and she must perform all instrumental activities of daily living for him and assist with his bathing and dressing. An aide comes in twice per week to help with the patient's bathing and other chores. During the visit, you notice the patient's wife looks fatigued and unkempt. When you ask her how she has been coping, she admits that she feels very overwhelmed. She does not know how much longer she can provide nearly 24 hour per day care. She is tearful as she describes her desire to keep her husband at home. She and the patient have very limited financial resources. He is not hospice eligible. They have two children who live in the area. She says that she does not like to "bother them. "

In addition to encouraging increased family support, which of the following should you do to help decrease the patient's wife's distress? A. Encourage the patient's wife to join a longitudinal support group B. Encourage the patient's wife to switch to you for primary care C. Start the patient on zolpidem, 5 mg at bedtime D. Start the patient on quetiapine, 25 mg at bedtime

Rationale • • According to Zarit, caregiver burden is defined as "The extent to which caregivers perceive that caregiving has had an adverse effect on their emotional, social, financial, physical, and spiritual functioning. " Caregiver burden is a common occurrence among caregivers of older adults, particularly women who reside with the person they care for and provide a significant number of hours of direct care. It is important that the health care provider ask the caregiver about his or her own well-being, even if the health care provider does not provide care to the caregiver. A small number of randomized controlled trials have examined the effects of interventions aimed at patients and at caregivers and their impact on caregivers' perception of burden and psychological distress. Some interventions have shown a small positive effect. Support groups or psychoeducational interventions for caregivers of people who have dementia and pharmacologic interventions (anticholinergic and antipsychotic drugs) for patients had similar effects on caregiver burden, with effect sizes ranging from 0. 09 to 0. 27. However, many psychosocial interventions significantly improved symptoms of distress in caregivers, even if the degree of burden was not significantly impacted. During group meeting time, many caregiver support groups offer supervision of loved ones who have dementia. In this question, given the risks associated with antipsychotic agents, it is reasonable to recommend a support group before prescribing quetiapine to the patient. Zolpidem is of questionable benefit for sleep, in general, and has many adverse effects in older adults. It may make practical sense for the patient's wife to start seeing the same physician as her husband for care, but it has not been studied as an intervention for burnout and distress. A longitudinal support group provides the best ratio of safety and efficacy among interventions that have been studied.

For further information, see the following: • Adelman RD, Tmanova LL, Delgado D, et al. Caregiver burden: a clinical review. JAMA. 2014; 311(10): 1052 -1060. • Zarit SH, Todd PA, Zarit JM. Subjective burden of husbands and wives as caregivers: a longitudinal study. Gerontologist. 1986; 26: 260 – 266.

Q 12: End-of-Life Wishes • An 85 -year-old man who has stage IV congestive heart failure (CHF) is being discharged from a Veterans Administration hospital after treatment of an exacerbation of his condition. He has had several previous CHF exacerbation episodes. During the current hospitalization, he elects a do-not-resuscitate code status. The patient is not depressed, and he understands his medical condition and prognosis and the consequences of declining hospitalization and resuscitation. At the time of discharge, the patient states that he has strong preferences against any attempt at resuscitation and that he does not want to be hospitalized again. He lives alone in Oregon, is divorced, and is estranged from his only son. The patient does not wish to contact his son. He states that he has no friends or family that he trusts or can rely on and is concerned that if he collapses someone will call emergency medical services and bring him back to the hospital. He asks you what can be done to ensure that his preferences are followed.

Which of the following should you do now? A. Obtain an ethics consultation to determine who can serve as the patient's surrogate if he loses medical decision-making capacity B. Reach out to the patient's estranged son to see if he is willing to be a surrogate decision maker for the patient C. Help the patient complete a Physician Orders for Life-Sustaining Treatment (POLST) form outlining his preferences D. Give the patient an advance directive form to complete at a later date

Rationale • Patients who have a life-limiting illness and do not have a surrogate decision maker should be helped to complete a Physician Orders for Life-Sustaining Treatment (POLST) form in states that have POLST programs (e. g. , Oregon). POLST forms allow patients to give instructions that clearly address their preferences for life-sustaining treatment. The POLST form is a medical order outlining current treatment preferences that can be followed when a patient loses medical decision-making capacity. The patient did not give permission for the physician to reach out to his estranged son, and so doing this is not an appropriate option. Since the patient has decision-making capacity and has stated that he does not have anyone who can serve as a surrogate for him, it would be most appropriate to complete a Physician Orders for Life-Sustaining Treatment (POLST) form outlining his preferences. An ethics consultation may be helpful as a next step if the patient does not wish to complete a POLST form. The patient has indicated that he does not have anyone who can serve as a surrogate for him; therefore, giving him an advance directive form to complete at a later date puts him at risk for not identifying a surrogate and not having a valid means of communicating his wishes if he were to lose medical decision-making capacity.

For further information, see the following: • Thaddeus MP. Making medical decisions for patients without surrogates. N Engl J Med. 2013; 369: 1976– 1978. • National POLST Paradigm Task Force (NPPTF). About the National POLST Paradigm. http: //www. polst. org/about-the-national-polst -paradigm/. Accessed December 23, 2014.

Q 13: Man with Nocturia • A 65 -year-old man comes into your clinic for follow-up of lower urinary tract symptoms. For several years, the patient has had nocturia three times per night, daytime urinary frequency and urgency, occasional episodes of incontinence, and difficulty initiating urination. For the past year, he has been taking tamsulosin, 0. 4 mg daily, and has had some improvement in his symptoms. However, he still has symptoms that limit his activities. He wants to know what else can be done. He is going on a trip in four months and would like to have less worry about his urinary symptoms by the time that he departs. • Physical examination shows a smooth prostate, with no nodules, that has an approximate volume of 30 m. L. Postvoid residual volume is 100 m. L.

Which of the following should you recommend? A. B. C. D. Continue current therapy Add finasteride Add tolterodine Discontinue tamsulosin; begin terazosin

Rationale • • A recent meta-analysis demonstrated a clinically significant improvement in International Prostate Symptom Score (IPSS), storage subscale, and urinary frequency among men with benign prostatic hyperplasia and lower urinary tract symptoms who were treated with both an alpha-adrenergic blocker and an anticholinergic bladder agent compared with men who received alpha-adrenergic blockers alone. All the men included in the analysis had a postvoid residual volume of less than 200 m. L. There was a clinically insignificant increase in postvoid residual volume (average 11. 6 m. L), and the number needed to treat to cause 1 episode of acute urinary retention was 101 (95% confidence interval [CI], 60 to 267). In addition, 5 -alpha-reductase inhibitors have been shown to improve scores on the IPSS among men with moderate prostatic enlargement, but a separate systematic review found that benefit to occur primarily after one year of treatment. Prior to that time, alpha-adrenergic blockers alone provide similar symptom relief. Nonselective alphaadrenergic blockers are no more effective in improving symptoms than are selective alphaadrenergic blockers and may cause more side effects. Given the fact that the patient's trip is in 4 months, alpha-adrenergic blockers alone would not be appropriate. While the patient does have some mild urinary retention, a slight increase in postvoid residual is not likely to be harmful. He has significant storage symptoms and is asking for additional therapy; therefore, an anticholinergic agent, such as tolterodine, should be tried.

For further information, see the following: • Filson CP, Hollingsworth JM, Clemens JQ, et al. The efficacy and safety of combined therapy with alphablockers and anticholinergics for men with benign prostatic hyperplasia: a meta-analysis. J Urol. 2013; 190: 2153– 2160. • Fullhase C, Chapple C, Cornu JN, et al. Systematic review of combination drug therapy for nonneurogenic male lower urinary tract symptoms. Eur Urol. 2013; 64: 228– 243.

Q 14: Shoulder Injury • A previously healthy 80 -year-old woman comes into your office for a follow-up visit and reports worsening pain in her left shoulder since she tripped and fell more than one week ago. The pain sometimes makes it difficult for her to fall asleep. Shortly after she fell, the patient underwent evaluation in the emergency department. She was told to see her primary care physician if her symptoms persisted. She has been wearing a sling. Current medication is acetaminophen. • A radiograph of the shoulder from the emergency department shows no fracture, dislocation, or arthritis.

When examining this patient's shoulder, which of the following maneuvers should you perform to demonstrate the painful arc associated with a rotator cuff tear? A. Examiner passively rotates the patient's arm into full external rotation and assesses pain from 60 to 120 degrees. B. Examiner applies pressure proximal to the patient's wrist against external rotation by the patient and assesses pain from 60 to 120 degrees. C. Examiner brings the patient's arm into full abduction and assesses pain from 60 to 120 degrees.

Rationale • Shoulder pain and rotator cuff problems are very common in geriatric practice. Hermans et al. performed a systematic review in an attempt to determine the utility of physical examination maneuvers in assessing patients with shoulder pain. The authors note two types of examination maneuvers: pain-provocation tests and strength tests. For the pain-provocation tests, the painful arc (examiner passively brings the patient's arm into full abduction and assesses pain from 60 to 120 degrees) has the most helpful characteristics. The other tests listed as choices in this question are strength tests and have different utility. The authors suggest that generalist physicians develop proficiency in the findings that have the best likelihood ratios (LRs) with the narrowest confidence intervals (CIs), either independently or in combinations, as performed by specialists. The authors believe that all the tests listed as choices here fit these criteria.

For further information, see the following: • Hermans J, Luime JJ, Meuffels DE, et al. Does this patient with shoulder pain have rotator cuff disease? The Rational Clinical Examination systematic review. JAMA. 2013; 310: 837– 847.

Q 15: IPC Device • A 78 -year-old woman who had a hemorrhagic stroke was initially admitted to acute medicine. No anticoagulant was administered because of her central nervous system bleeding. Her outpatient medications included aspirin and this was withheld. She also has hypertension and low bone mass. Her other outpatient medications were hydrochlorothiazide, lisinopril, and a calcium and vitamin D supplement. • You are asked to see the patient on transfer to acute rehabilitation 72 hours after her stroke. The physiatrist wants your opinion about ordering an intermittent pneumatic compression (IPC) device for her. On physical examination, the patient cannot raise her affected arm or leg off the bed. Since having her stroke, she is incapable of walking to the toilet without the help of another person. She has a residual dense hemiplegia.

Which of the following should you tell your colleague will most likely result from the use of an IPC device in this patient? A. B. C. D. Reduced risk of deep venous thrombosis Reduced mortality risk Increased risk of falls Increased risk of lower leg ischemia or amputation

Rationale • Venous thromboembolism (VTE) is a common complication of stroke and can have lethal consequences. Intermittent pneumatic compression (IPC) devices have not been well studied in preventing VTE in the stroke population. The Clots in Legs Or s. Tockings after Stroke (CLOTS 3) trial, a multicentre randomized controlled trial, studied the efficacy and adverse effects of IPC devices in a stroke population. This large trial enrolled 2876 stroke patients within 3 days of their event and randomized them to an IPC device or no device. Patients were immobile (i. e. , could not walk to the toilet without the help of another person). The primary outcome was deep venous thrombosis (DVT). The mean duration of IPC use was 12. 5 days (standard deviation [SD], 10. 9), and the median duration was 9 days (interquartile range [IQR], 3 to 22). At 30 days, patients receiving IPCs had a significant reduction in any DVT (symptomatic or asymptomatic, proximal or calf) with 233 DVTs (16. 2%), compared to those who had no IPC with 304 DVTs (21. 1%). This protective effect was persistent through 6 months. The effect was similar whether anticoagulants were used or not. There was benefit to IPCs whether the stroke was hemorrhagic or not. Other outcomes (pulmonary emboli, death) did not reach significance at 30 days. Falls were not different between the groups. There was a slight increase in skin breaks in the IPC group with 44 (3. 1%), compared to those who had no IPC with 20 skin breaks (1. 4%). Despite this, the IPC group did not have a higher incidence of ischemia or limb amputation. In summary, IPC devices do appear to have a role in VTE prevention after stroke.

For further information, see the following: • Dennis M, Sandercock P, Reid J, et al. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet. 2013 Aug 10; 382(9891): 516– 524. doi: 10. 1016/S 01406736(13)61050 -8. Epub 2013 May 31.

Q 16: Screening for Alzheimer’s Disease • A healthy 75 -year-old man comes to your office for his annual wellness visit. The patient states that his neighbor was recently found to have Alzheimer's disease. He asks what the experts have found regarding screening for cognitive impairment in older adults. • Physical examination is unremarkable. Routine laboratory studies show no abnormalities.

The USPSTF has concluded which of the following regarding the evidence for screening for cognitive impairment in older adults? A. The evidence is lacking and the balance of benefits and harms cannot be determined. B. The evidence is sufficient to recommend for routine screening. C. The evidence is sufficient to recommend against routine screening.

Rationale • In 2011, Medicare began covering the detection of cognitive impairment as a part of the new annual wellness visit benefit. In March 2014, the United States Preventive Services Task Force (USPSTF) published a report in the Annals of Internal Medicine, "Screening for Cognitive Impairment in Older Adults. " According to the report, the USPSTF found no evidence of direct benefits and harms of screening for cognitive impairment. Although the task force found adequate evidence that some screening tools could accurately identify dementia, they found that drug therapies and nonpharmacologic interventions resulted in only small improvements in cognitive function and caregiver outcomes. They found no published evidence on the effect of screening on decision making or planning by patients, clinicians, or caregivers. Evidence of the harms of screening and nonpharmacologic interventions was also inadequate. Based on this aforementioned lack of evidence, The USPSTF concluded that the evidence on screening for cognitive impairment was lacking and that the balance of benefits and harms could not be determined.

For further information, see the following: • Moyer VA. Screening for cognitive impairment in older adults: U. S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014; 160: 791– 797.

Q 17: Pre-op Evaluation • As a geriatrics consultant in a large urban hospital, you receive a request for consultation on a 92 -year-old man who is undergoing resection of a colorectal cancer found on evaluation for anemia. The surgery resident explains that the patient had a hip replacement for osteoarthritis and also has hypertension, atrial fibrillation, and early dementia. You stop by the waiting room to speak with the patient's daughter. She explains that before the surgery the patient did well in managing his activities of daily living, but in the past three months he has lost 4. 5 kg (10 lb) and has reported low energy. • Review of the patient's preoperative visit in the Anesthesiology Department reveals that his outpatient medications are hydrochlorothiazide, 25 mg once daily; acetaminophen, 500 mg three times daily; donepezil, 10 mg at bedtime; and aspirin, 81 mg daily. • On physical examination, heart rate is 88 beats per minute and blood pressure is 134/62 mm Hg. • Labs: Hgb = 9. 8 (14 -18), Ferritin = 18 (20 -235)

Which of the following interventions would most likely reduce this patient's risk of becoming more frail in the postoperative period? A. B. C. D. Avoidance of narcotic medications Addition of metoprolol, 12. 5 mg twice daily Transfusion of 1 unit of packed red blood cells Providing access to a nursing assistant for mobility and orientation

Rationale • • Adults older than age 65 undergo more than 4 million major operations annually in the United States. Given their increased burden of comorbid illness and functional impairment, they are more likely to have significant postoperative complications. In addition to specific diagnoses, predictors of postoperative complications include poor nutrition, immobility, and cognitive impairment—all indicators of frailty among older adults. The Hospital Elder Life Program (HELP) was established to reduce the incidence of delirium and improve outcomes for older adults in the acute care setting. A recent trial applied a modified version of the HELP program (m. HELP) to reduce frailty in the postoperative period through a nurse-based intervention to improve mobility, mentation, and nutrition. The intervention appeared to reduce frailty rates compared with matched historical controls on the same surgical service. While frailty rates were improved at discharge, the advantage at three months after discharge did not reach statistical significance. Based on presentation, this patient does not appear to need beta-adrenergic blockade or transfusion. While judicious use of pain medicine is advised, undoubtedly some amount of low-dose opioid will be needed for adequate pain control.

For further information, see the following: • Chen CC, Chen CN, Lai IR, et al. Effects of a modified Hospital Elder Life Program on frailty in individuals undergoing major elective abdominal surgery. J Am Geriatr Soc. 2014; 62: 261– 268.

Q 18: Osteoporosis Risk • • • You see a 72 -year-old woman in your primary care clinic for a periodic health maintenance visit. The patient has felt well and is capable of a high level of function. She has knee osteoarthritis. One year ago, she fell without injury. Current medications are acetaminophen, 650 mg twice daily, and a calcium and vitamin D 3 supplement taken twice daily. She has never taken glucocorticoids or antiseizure medications. The patient does not use tobacco and drinks two glasses of red wine nightly. Her mother did have a hip fracture during the last year of life. On physical examination, the patient appears well but has moderate obesity. Height is 152 cm (5 ft) and weight is 82 kg (181 lb). BMI is 35. 3. Blood pressure is 135/80 mm/Hg, and heart rate is 80 beats per minute and regular. Heart and lung examinations are normal. Examination of the knees shows bilateral changes of osteoarthritis with crepitus and medial joint-line tenderness. She uses her arms to push up from a sitting position to stand. Her gait is slow (0. 8 meter per second) but steady. When offered a screening dual-energy x-ray absorptiometry (DEXA) scan, she politely states that she would like to avoid any unnecessary tests, particularly if her baseline risk of osteoporotic fracture is low.

In addition to age, which of the following screening information is most helpful to quickly determine whether the patient is at low risk for osteoporotic fracture? A. B. C. D. Family history Weight Gait speed Alcohol use

Rationale • Osteoporosis, a common and important medical problem, affects approximately 10% of women older than age 50 and leads to fractures that contribute to pain, limited mobility, and functional decline. A large number of older women, however, may be at relatively low risk for osteoporosis and may be able to forgo bone mineral density (BMD) screening. The Fracture Risk Assessment (FRAX) screening tool can provide a 10 -year estimate of probability of fracture but requires a collection of 11 different historical and health data points plus bone mineral density. The Osteoporosis Self-Assessment Tool (OST), on the other hand, utilizes two routinely available data points (age and weight) to calculate a score that was recently demonstrated to be as effective as the FRAX (without BMD) in identifying women at very low risk for osteoporosis. The formula is as follows: risk score equals weight (kg) minus age (yr) times 0. 2. A score of 0 or greater indicates very low risk of osteoporosis, equivalent to a 10 -year risk of hip fracture of 3% or less. These women may, in turn, be able to forgo BMD screening with a limited risk of failing to identify osteoporosis. However, it does not help risk-stratify women with a higher risk of fracture and the need for medical therapy; it simply identifies women who may not need radiologic screening.

For further information, see the following: • Pang WY, Inderjeeth CA. FRAX without bone mineral density versus osteoporosis selfassessment screening tool as predictors of osteoporosis in primary screening of individuals aged 70 and older. J Am Geriatr Soc. 2014; 62: 442– 446.

Q 19: Chest Pain Evaluation • A 72 -year-old woman comes to the emergency department and reports chest pain and dyspnea. The patient had the sudden onset of left inframammary pain, with mild radiation to the throat. She describes the pain as "a feeling of pressure" and says that she was experiencing stress when it occurred. She has noticed that the pain is worsened by exercise. The patient also has hypertension and hyperlipidemia, but does not have diabetes mellitus. Current outpatient medications are chlorthalidone, lisinopril, and atorvastatin. She has a 20 -pack-year smoking history but quit ten years ago. • On physical examination, the patient appears alert and uncomfortable. BMI is 26. Temperature is 36. 7 C (98. 0 F), pulse rate is 92 per minute and regular, respirations are 16 per minute and not labored, and blood pressure in both arms is equal, 155/75 mm Hg. The remainder of the examination is normal.

Which of the following is the strongest indication that this patient's chest pain is likely associated with a myocardial infarction? A. B. C. D. E. It is increased with exertion It is associated with dyspnea It is pressure-like It radiates to the throat It is induced by stress

Rationale • There is speculation that the presentation of a myocardial infarction differs by sex and possibly age. The large, prospective, international, multicenter study of men and women presenting to the emergency department with acute chest pain conducted by Rubini Gimenez et al. carefully collected presenting symptoms and compared results by sex. However, it could not be substantiated that there were differences that were clinically significant enough to differentiate myocardial infarction between the sexes. The median age of the women in the cohort was 70. Of the factors that were studied, one of the highest likelihood ratios (LRs) for a myocardial infarction among the women pertained to pain that was increased by exercise, with an LR of 1. 35 (95% confidence interval [CI], 1. 10 to 1. 65), and there was no difference between the sexes. The following were not helpful in predicting who was more or less likely to experience a myocardial infarction: pressurelike pain, LR of 1. 0 (CI, 0. 89 to 1. 12); attendant dyspnea, LR of 1. 01 (CI, 0. 85 to 1. 19); pain induced by emotional stress, LR of 0. 71 (CI, 0. 49 to 1. 02); and radiation of pain to the throat, LR of 0. 94 (CI, 0. 68 to 1. 31).

For further information, see the following: • Rubini Gimenez M, Reiter M, Twerenbold R, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014; 174: 241– 249

Q 20: End-of-Life Decision Making • A 75 -year-old man who has end-stage prostate cancer unresponsive to chemotherapy meets with you to discuss hospice care. His health status has been rapidly declining. The patient understands that his life expectancy is limited and so has considered hospice care as a treatment option. You have answered all his questions, and he will likely elect hospice care.

Which of the following should you say now? A. Do you have an advance directive that outlines your wishes? " B. "Whom would you want to make decisions for you if you were no longer able to make them yourself? " C. "If you were my father, I would recommend hospice care for you. " D. "Do you prefer to independently make this decision, or are there other people whom you would like to be involved in helping you make this decision? "

Rationale • It is important to determine how patients prefer to make decisions (e. g. , independently, in consultation with others, or even deferring to others). Older adults may value autonomy or shared decision making with family members or may prefer to defer decisions to surrogates. Therefore, it is important to investigate how patients prefer to make decisions. • Investigating how the patient in this question would like to make the decision at hand would precede asking the patient whom they would want as a surrogate decision maker when they lose decision-making capacity and asking them if they have an advance directive. Ensuring that the patient has a surrogate decision maker and an advance directive would be appropriate next steps. It is also important to investigate how the patient prefers to make decisions prior to making a care recommendation. It is beneficial to ask the patient whether they would like you to make a recommendation because some patients may prefer to independently make decisions.

For further information, see the following: • Schenker Y, Barnato A. Expanding support for "upstream" surrogate decision making in the hospital. JAMA Intern Med. 2014; 174(3): 377– 379. • Should Clinicians Give Recommendations? Geri. Pal - A Geriatrics and Palliative Care Blog. http: //www. geripal. org/2011/08/should-clinicansgive-recommendations. html. Accessed December 23, 2014.

Q 21: Weight Loss • An 80 -year-old man who was widowed one year ago undergoes evaluation for difficulty sleeping, decreased appetite, decreased energy, and trouble concentrating. The patient states that he has not felt depressed. He continues to enjoy visiting with his grandchildren and working in his garden. • Over the past six months, the patient has lost 4. 5 kg (10 lb). Physical examination shows no changes since his previous examination.

Which of the following should you recommend now? A. Investigate for an underlying medical cause of his symptoms B. Selective serotonin reuptake inhibitor C. Cognitive behavioral therapy D. Aerobic exercise

Rationale • It is important to exclude a medical cause of the symptoms the patient is experiencing (e. g. , renal disease, anemia, hypothyroidism). The patient says that he does not have depressed mood or anhedonia; therefore, his condition does not meet the criteria for diagnosis of major depressive disorder (MDD). Although symptoms of difficulty sleeping, decreased appetite, decreased energy, and trouble concentrating are 4 of the 9 screening items for diagnosis of MDD, the patient must also affirm that he has either depression or anhedonia for the diagnosis to be made. Although the patient lost his wife one year ago, it is important to exclude medical causes of the symptoms experienced by the patient before making a diagnosis. Medications and medical conditions can cause the symptoms experienced by the patient and should be excluded.

For further information, see the following: • Mojtabai R. Diagnosing depression in older adults in primary care. N Engl J Med. 2014; 370: 1180– 1182

Q 22: Dizziness • • • An 82 -year-old man is referred to you by his dentist for a possible stroke or transient ischemic attack. The patient was being seen by his dentist for a routine dental cleaning and examination and was not given any medication. After the patient had been recumbent in the dental chair for some time, he was repositioned and had the sudden onset of dizziness and extreme discomfort. The dentist was alarmed and terminated the examination. Since your office is in the same building as the dentist's, the patient was sent directly to you for an assessment. The patient tells you that in the dentist's office he had an uncomfortable vertiginous sensation and felt as if he would vomit. He was able to compose himself and is now feeling better. He has chronic mild hearing loss but does not have tinnitus. He said that he had no change in his hearing today. He has not had a headache. Occasionally, he has had slight dizziness, but these episodes have never been as severe as today's. He has otherwise been feeling well. He also has osteoarthritis and hypertension. Current medications are amlodipine, acetaminophen, and a multiple-vitamin supplement. At the time of the dental visit, blood pressure was 145/70 mm Hg in the left arm with the patient sitting; pulse rate was 80 per minute and regular. Repeat blood pressure and pulse rate measurements performed by you are similar, with no orthostatic changes. Neurologic examination is performed, including a Dix-Hallpike maneuver. Mixed vertical torsional nystagmus is noted with this maneuver. No nystagmus was noted on routine extra-ocular muscle testing.

Which of the following is the most likely diagnosis? A. B. C. D. Benign paroxysmal positional vertigo Meniere's disease Stroke Vestibular neuritis

Rationale • Dizziness is a geriatric syndrome. A common and important differential diagnosis is benign paroxysmal positional vertigo. These patients experience acute vertigo, and the prolonged recumbent position can be a trigger. Physical examination shows positional nystagmus in 70% of patients. The Dix -Hallpike maneuver is important to demonstrate this nystagmus with positional change. The nystagmus with the maneuver varies, depending on the vestibular semicircular canal affected by the offending canaliths. The posterior canal is most commonly affected, and with this maneuver one will see mixed vertical torsional nystagmus. If the horizontal canal is involved, horizontal nystagmus is seen with the positional maneuver. The differential diagnosis includes stroke. With a stroke, there is spontaneous nystagmus with beating in various or changing directions. Another consideration is vestibular neuritis. In this case, nystagmus is spontaneous and predominantly horizontal. The same is true for Meniere's disease. Vestibular migraine rarely has associated nystagmus, but it can be positional. Horizontal nystagmus with extreme lateral gaze can be seen in normal patients.

For further information, see the following: • Kim JS, Zee DS. Benign paroxysmal positional vertigo. N Engl J Med. 2014; 370: 1138– 1147. DOI: 10. 1056/NEJMcp 1309481.

Q 23: Significant Hearing Loss • • • An 84 -year-old man comes into your office for a periodic evaluation of his hearing accompanied by his son. For many years, the patient has been followed by otolaryngology and audiology for a sensorineural hearing loss. Over the years, he has had numerous hearing aids and adjustments. He has accommodated to this treatment, but over time the hearing aids have worked less well. The son says his father is struggling with his hearing, seems embarrassed about it, is becoming more withdrawn, and is socializing less. The patient seems to have memory loss but has otherwise been well and active. He also has well-controlled hypertension and osteoarthritis. Current medications are lisinopril, acetaminophen, and a multiple-vitamin supplement. On physical examination, the patient is wearing hearing aids and is having difficulty hearing. Mini Mental State Examination score is normal. Screening for depression is negative. The patient says that he does not want to go out and socialize and that other people are better off than he is. Audiology reports that on a standardized test of speech perception in which sentences were presented without visual cues while the patient was wearing hearing aids, his score was worse than 40%. Both audiology and otolaryngology recommend a cochlear implant (CI). The patient and his family are worried about surgery at his advanced age and want your opinion about this matter.

When compared to younger populations with CIs, older patients such as this with CIs are more likely to experience which of the following? A. B. C. D. Longer operative time Poorer hearing outcomes Longer hospital length of stay Greater likelihood of perioperative medical complications E. Greater likelihood of surgical complications

Rationale • In 2013, the Lasker-De. Bakey Clinical Medical Research Award recognized the pioneers of cochlear implantation. Profound deafness can impair function and cognition in elderly patients. The Centers for Medicare and Medicaid Services (CMS) does approve cochlear implants (CIs) when a score of worse than 40% is present on standardized testing of speech perception in which sentences are presented without visual cues while the patient is wearing hearing aids. Patients and families will confer with geriatricians and primary care providers when considering operative intervention. • The patient in this question meets the criteria for a CI. A systematic review of CIs in geriatric patients does show that compared with younger populations outcomes for geriatric patients are good, and operative times, hospital lengths of stay, and surgical complications are comparable. For those 80 years of age or older, nonsurgical complications, such as cardiac arrhythmia, delirium, and urinary retention (2% to 4%), that required hospitalization were more common.

For further information, see the following: • O'Donoghue G. Cochlear implants—science, serendipity, and success. N Engl J Med. 2013; 369: 1190– 1193. DOI: 10. 1056/NEJMp 1310111. • Clark JH, Yeagle J, Arbaje AI, et al. Cochlear implant rehabilitation in older adults: literature review and proposal of a conceptual framework. J Am Geriatr Soc. 2012; 60: 1936– 1945.

Q 24: Cost Management • You are on the planning committee of your hospital's new Medicare Shared Savings Program. The first data analysis of the program's 50, 000 beneficiaries reveals a sharp increase in the number of referrals for outpatient physical therapy immediately after discharge from inpatient rehabilitation for hip fracture. The Medical Director points to long-standing evidence that for these patients continued exercise after discharge from rehabilitation has improved function and mobility. The Chief Financial Officer (CFO) is not impressed and pushes the group to consider more affordable options without compromising the quality of care and health-related outcomes, specifically strength and endurance.

Which of the following should you recommend to satisfy the CFO's request? A. Home-based, functionally oriented exercise program B. Automated telephone or email prompts to exercise C. Six-month fitness center membership D. Inclusion of patient's partner or spouse in exercise program

Rationale • Prior evidence indicates that a continuation of outpatient physical therapy after discharge from inpatient rehabilitation after hip fracture can improve function. A recent randomized controlled trial (Latham et al. , 2014) examined the impact of an independent home-based exercise program on objective measures of physical function after discharge from rehabilitation for hip fracture. Exercises were customized and geared toward practical activities (e. g. , standing up from a chair and climbing steps). The intervention group had a 70% adherence rate by patient report and had significantly better physical function at six months than did the control subjects. No cost-effectiveness data are yet available for this intervention.

For further information, see the following: • Latham NK, Harris BA, Bean JF, et al. Effect of a home-based exercise program on functional recovery following rehabilitation after hip fracture: a randomized controlled trial. JAMA. 2014; 311: 700– 708. • Brown CJ, Flood KL. Mobility limitation in the older patient: a clinical review. JAMA. 2013; 310: 1168– 1177.

Q 25: Cataract Surgery • You evaluate your patient, a 78 -year-old retired pharmacist, in clinic. He has been in very good health except for mild chronic obstructive pulmonary disease, for which he takes fluticasone-salmeterol by discus, 2 puffs once daily, with good relief and normal function. During the visit, he states that his nighttime vision has worsened and his ophthalmologist has diagnosed cataracts in both his eyes. The patient is inclined to have cataract surgery on both eyes as offered by the ophthalmologist, but he wants your opinion. He will have the first surgery in one month and then the second surgery nine to ten months later. He is otherwise completely fine according to his self-report. • Physical examination is normal except for slightly decreased visual acuity. • From your perspective, the patient appears ready for cataract surgery. You reassure the patient, but discuss the risks related to surgery.

The risk of which of the following is highest between the first and second cataract surgeries? A. B. C. D. Decline in cognition Facial pain Injurious falls Vertigo

Rationale • • As many as 50% of adults older than age 80 have cataracts. More than 3, 000 adults have cataract removal surgery each year in the United States. Cataracts can cause important vision impairment among older adults that can limit key activities, such as driving, and increase the risk of falls. It is perhaps surprising that some studies indicate that fall rates among older adults can increase after cataract surgery. A recent analysis of 28, 396 adults older than 60 in Western Australia looked specifically at the rate of falls between first and second cataract surgeries. The study showed that the risk of an injurious fall resulting in hospitalization more than doubled (odds ratio [OR], 2. 14; 95% confidence interval, 1. 82 to 2. 51) between the first and second cataract surgeries. One explanation is that unequal vision and uncompensated refraction after the first surgery lead to increased problems with depth perception. While cataract surgery remains quite safe, with an overall complication rate of less than 2%, anticipation of these problems, better correction of refraction, and more prompt performance of the second surgery may reduce risk. Decline in cognition is an uncommon complication in healthy patients. Facial pain and vertigo are also uncommon complications.

For further information, see the following: • Meuleners LB, Fraser ML, Ng J, Morlet N. The impact of first- and second-eye cataract surgery on injurious falls that require hospitalization: a whole-population study. Age and Ageing. 2014; 43: 341– 346.

Q 26: Which of the following instruments has the best evidence supporting its use for screening for cognitive impairment? A. B. C. D. Mini Mental State Examination (MMSE) Memory Impairment Screen Mini-COG Test Montreal Cognitive Assessment (MOCA)

Rationale • The Mini Mental State Examination (MMSE) is the most rigorously studied instrument for cognitive impairment screening, with 25 published studies, and has been studied in various populations. Pooled estimates across 14 studies (n = 10, 185) yielded a sensitivity of 88. 3% (95% confidence interval [CI], 81. 3 to 92. 9) and a specificity of 86. 2% (95% CI, 81. 8 to 89. 7) for a cut-point of 23/24 or 24/25 in the detection of dementia. • The other instruments have been studied in far fewer studies (4 to 7 studies each), had limited reproducibility in primary carerelevant populations, and had unknown optimum cut-points. Sensitivity and specificity ranged widely in these studies of the other instruments.

For further information, see the following: • Moyer VA. Screening for cognitive impairment in older adults: U. S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014; 160: 791– 797. • Lin JS, O'Connor E, Rossom RC, et al. Screening for cognitive impairment in older adults: an evidence update for the U. S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2013 Nov. Report No. : 1405198 -EF-1. U. S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. http: //www. ncbi. nlm. nih. gov/pubmed? term=Lin+JS%5 Bauthor%5 D +AND+Screening+for+cognitive+impairment+in+older+adults%3 A++ an+evidence+update+for+the+U. S. +Preventive+Services+Task+Force +&Trans. Schema=title&cmd=detailssearch. Accessed December 23, 2014.

Q 27: Observation Status • An 88 -year-old woman who has mild dementia is brought to the emergency department (ED) after having sustained a fall with no loss of consciousness. The patient recently had symptoms of an upper respiratory tract infection, with rhinorrhea, cough, and achiness. • The patient was assessed in the ED and found to be volume depleted with mild hyperkalemia. She was febrile and had a leukocytosis. She was referred to an inpatient bed by the ED for "SIRS, rule out sepsis. " The hospital utilization review physician placed the patient on observation ("obs") status. • The patient and her family were not specifically informed about the patient's status, but they did receive a Medicare patient-oriented brochure on observation status. After three days, she was judged to likely have had an influenza-like illness. Her family members thought that she was too weak to return home, and she was discharged to a skilled nursing home for a subacute stay and reconditioning.

The patient's being placed and maintained on observation status will most likely be the cause of which of the following? A. Medicare Part A covering the patient's hospital charges B. The hospital incurring penalties because the patient was not specifically informed of her observation status C. Administrative costs to determine the patient's status being billed to the patient D. The hospital recovering the costs for this patient E. Medicare Part A not covering the patient's skilled nursing home stay

Rationale • Observation ("obs") status has been used for years to help emergency department physicians clarify diagnosis, monitor patients, and determine if admission was required. Over time, Medicare has codified and refined its position on observation status. Sheehy et al. note that nationally, in 2011, hospitals in the United States placed 8% of their patients— 1. 6 million patients per year—on observation status, compared with 3% five years earlier. Given this frequent use, geriatricians need to know the ramifications of this status. Medicare requires a minimum 3 -day inpatient stay as a bridge to coverage for a subsequent skilled nursing facility stay. This means that patients who go from a prolonged "obs" stay (in this case 3 days) to a nursing facility will not be eligible for Medicare reimbursement. Sheehy et al. write "In April 2013, CMS proposed rule changes that, if implemented, would confer inpatient status to some longer stay observation patients. " Observation patients are, in essence, outpatients. As a result, observation stays are not covered under Medicare Part A, which means these patients are subject to substantial co-payments and are liable for the costs of their hospital medications. Sheehy et al. found that reimbursement for observation patients fell far below the hospital's costs, particularly for general medical patients and those with longer stays. The administrative costs to hospitals for determining each patient's status are not factored into reimbursement and are not recoverable. Hospitals are under no obligation to inform patients of their observation status, and most do not. In this question, the patient on observation status will be responsible for significant hospital-associated costs, and her skilled nursing stay cannot be considered for Medicare reimbursement.

For further information, see the following: • Sheehy AM, Graf B, Gangireddy S, et al. Hospitalized but not admitted. JAMA Intern Med. 2013; 173(21): 1991– 1998. • Wachter RM. Observation status for hospitalized patients: a maddening policy begging for revision. JAMA Intern Med. 2013; 173(21): 1999– 2000. doi: 10. 1001/jamainternmed. 2013. 7306.

Q 28: Mental Status Changes Post-Hospitalization • • A 67 -year-old man who has diabetes mellitus is found to be comatose and is admitted to the intensive care unit (ICU) for a hyperosmolar nonketotic state and sepsis from necrotizing fasciitis of the leg. He responds well to fluids, antibiotics, and surgery, but after 24 hours of coma he becomes delirious. His delirium lasts for 5 days. While in the ICU, he has episodes of extreme agitation and receives propofol (aggregate dose of 800 mg) while receiving mechanical ventilation and lorazepam (8 mg) for agitation. He also receives opioids for pain associated with his necrotizing fasciitis. After a 10 -day stay, he is discharged to a skilled nursing facility for wound care and rehabilitation. He returns home 2 months after his initial admission. Current outpatient medications are NPH insulin/regular insulin 70%/30%, aspirin, levothyroxine, atorvastatin, lisinopril, and acetaminophen. He has been followed by you in your office, and both he and his family feel that he is "just not himself. " He seems slower cognitively. You have asked a neuropsychologist to follow the patient with you. Serial administrations of the Trail Making Test Part B of executive function have yielded abnormal results. One year after his admission, the patient continues to show deficits in his Trail Making Test Part B score. The patient and his family want to know what happened to him. They are convinced that he is different since his illness 12 months ago.

Which of the following is most strongly associated with this patient's persistent cognitive deficits? A. B. C. D. E. Total propofol dose Total benzodiazepine dose Opioid dose Duration of delirium episode Duration of coma

Rationale • It has been known for some time that critical illness creates neurocognitive and functional disabilities that can be long lasting. Pandharipande et al. examined this issue in some depth with careful prospective neuropsychological follow-up among patients admitted to intensive care units (ICUs) with medical and surgical illnesses. Many variables as well as ICU drug exposure were carefully inventoried analyzed. These authors determined that the duration of delirium was associated with poorer executive cognitive function, as measured by the Trail Making Test Part B as long as 12 months after the illness. Duration of coma did not affect the resultant scores, nor did doses of benzodiazepine, propofol, and opioids.

For further information, see the following: • Pandharipande PP, Girard TD, Jackson JC, et al. ; BRAIN-ICU Study Investigators. Long-term cognitive impairment after critical illness. N Engl J Med. 2013; 369: 1306– 1316. DOI: 10. 1056/NEJMoa 1301372. • Herridge M, Cameron JI. Disability after critical illness. N Engl J Med. 2013; 369: 1367– 1369. DOI: 10. 1056.

Q 29: Treatment for Weight Loss • • A 93 -year-old man is admitted to the hospital for monarticular arthritis. Calcium pyrophosphate deposition disease is diagnosed. He lacks an appetite and has been losing weight for months. He has no difficulty with chewing, swallowing, or feeding himself. He has a remote history of a gastrectomy for a malignancy. The patient also has progressive dementia of moderate severity and is cared for by his family. He has benign prostatic hyperplasia, hypertension, chronic kidney disease, and diastolic dysfunction with heart failure. Current outpatient medications are finasteride, tamsulosin, furosemide, and multiple-vitamin, vitamin B 12, and iron supplements. On physical examination, the patient appears thin and cachectic. He is pleasant, but not well oriented. He weighs 47 kg (103 lb). BMI is 17. Physical examination does not reveal a source of his weight loss. Benign prostatic hyperplasia is noted on rectal examination. His affect is flat, but he says that he is not depressed. Laboratory studies show that the patient's chronic anemia is unchanged, as well as the findings below: Lab studies: Creatinine = 1. 5 (0. 7 -1. 5), Albumin = 2. 6 (3. 5 -5. 5), Fecal occult blood = negative. CXR negative After the examination, you meet with the patient's daughter, who is concerned about his anorexia and weight. She requests some sort of therapy.

Which of the following should you recommend for this patient? A. B. C. D. E. Provision of feeding assistance High-calorie supplements Megestrol acetate Mirtazapine Dronabinol

Rationale • In concert with the American Board of Internal Medicine, the American Geriatrics Society (AGS) has participated in the Choosing Wisely Campaign. This effort seeks to identify key things that health care providers and patients should question. Five items were identified in 2013, and another five in 2014. One of the items identified in 2014 is "Avoid using prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia in older adults; instead, optimize social supports, provide feeding assistance and clarify patient goals and expectations. " Specifically, the AGS notes that megestrol acetate has limited efficacy and can result in increased risks of thrombotic events, fluid retention, and death. Mirtazapine is a tetracyclic antidepressant. In depression, it can result in increased weight, similar to other antidepressants. Its use as an appetite stimulant cannot be supported. Dronabinol is a cannabinoid. It has been shown to have some benefit in acquired immunodeficiency syndrome (AIDS). It has not been well studied in geriatric populations and cannot be recommended in geriatric anorexia. The AGS writes that highprotein, high-calorie oral nutritional supplements have limited evidence to support their use and that many meaningful clinical outcomes (function and mood) have not been shown to be positively impacted despite modest weight gain.

For further information, see the following: • AGS Choosing Wisely Workgroup. American Geriatrics Society identifies another five things that healthcare providers and patients should question. J Am Geriatr Soc. 2014; 62: 950– 960.

Q 30: Discharge Planning • An 88 -year-old woman who had been admitted for pneumonia is referred for discharge planning. The patient has responded well to therapy, but the hospitalist team has reservations about sending her home and has asked for a geriatrics consultation. • On admission, the patient was described as disheveled and dirty. Her BMI is currently 20. The patient lives alone and has mild cognitive impairment. Her daughter lives several hundred miles away and did come for a family meeting. No other family live nearby. The daughter has reported that the patient is a hoarder and that her home is cluttered and dirty, with piles of various objects all around. The daughter fears that her mother will fall because of the clutter. She says that the patient has always been eccentric, but her hoarding has accelerated in the past several years. The patient insists that her goal is to return home. A psychologist has seen the patient and judges her to be decisional with regard to her desire to return home. • You convene a family meeting with the hospitalist team, the patient's daughter, and the patient's hospital social worker.

In the creation of a discharge plan, which of the following would be a helpful adjunct in managing this patient? A. Performing a home visit B. Ensuring safety by insisting on a higher standard for safety in the home C. Avoiding negotiation that allows the patient to "pick and choose" interventions D. Avoiding worst-case scenario discussions

Rationale • Elder self-neglect is common in geriatric practice. Hospitalists are under increasing pressure to reduce re-admissions, and self-neglect is associated with re -admissions. With declining availability of persons to support the oldest old in community settings, geriatricians will be more frequently called on to mediate these discussions. Smith et al. provide a timely analysis of this topic. They suggest four practical approaches to managing self-neglecting patients. A home visit by the physician can be the means of allowing others to support the patient in the home and, particularly, of introducing members of the home care team to the patient. Although self-neglecting patients can be frail and lack resources, there is no ethical justification to set a higher standard for safety for them than one might in another population. Ageism and infantilization are to be avoided. Persuasion and negotiation are useful in trying to help the patient and the clinician meet shared goals. An uncompromising approach should be avoided. Worst-case scenarios should be anticipated, and plans should be developed to address these situations.

For further information, see the following: • Smith AK, Lo B, Aronson L. Elder self-neglect— how can a physician help? N Engl J Med. 2013; 369: 2476– 2479. DOI: 10. 1056/NEJMp 1310684.