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ABIM Geriatric Medicine study materials
ABIM Geriatric Medicine study resources

ABIM Geriatric Medicine practice questions

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First 50 of 199 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

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Question 1Normal aging and age-related physiology

Which change in kidney function is characteristic of normal aging in a healthy adult?

  1. Increased maximal urine osmolality
  2. Reduced renal reserve Correct answer.
  3. Increased renal blood flow
  4. Increased glomerular filtration rate

Explanation

Nephron loss and sclerosis reduce the kidney's ability to increase filtration under stress, so renal reserve falls. Renal blood flow and maximal concentrating ability also decline with age, while baseline creatinine may remain normal because muscle mass is lower.

Question 2Normal aging and age-related physiology

Which cardiovascular finding is most typical of normal aging?

  1. Higher resting heart rate
  2. Arterial stiffening Correct answer.
  3. Higher left ventricular compliance
  4. Higher maximal heart rate

Explanation

Age-related elastin loss and collagen deposition stiffen the aorta and large arteries, raising systolic pressure and pulse pressure. Resting heart rate is usually unchanged, maximal heart rate falls, and ventricular compliance decreases.

Question 3Normal aging and age-related physiology

Which lung volume change is expected with normal aging?

  1. Increased vital capacity
  2. Increased residual volume Correct answer.
  3. Increased diffusing capacity
  4. Increased elastic recoil

Explanation

Loss of elastic recoil and stiffening of the chest wall raise residual volume and functional residual capacity. Vital capacity and diffusing capacity tend to decline rather than increase.

Question 4Normal aging and age-related physiology

Which body composition change is expected in healthy older adults?

  1. Increased lean body mass
  2. Increased total body water
  3. Decreased total body water Correct answer.
  4. Decreased body fat

Explanation

Lean mass and total body water decrease, while fat mass and the proportion of body fat increase. This shift affects drug distribution and increases vulnerability to dehydration.

Question 5Normal aging and age-related physiology

Why are older adults at higher risk of heat-related illness during a heat wave?

  1. Enhanced cardiovascular reserve
  2. Reduced sweating capacity Correct answer.
  3. Increased sweat gland density
  4. Increased thirst perception

Explanation

Aging reduces sweat gland output and blunts the thirst response, limiting heat dissipation and fluid replacement. Reduced cardiovascular reserve further impairs the ability to redirect blood flow to the skin.

Question 6Normal aging and age-related physiology

Which pattern of hearing loss is most characteristic of normal aging?

  1. Low-frequency conductive loss
  2. Improved speech discrimination
  3. High-frequency sensorineural loss Correct answer.
  4. Unilateral conductive loss

Explanation

Presbycusis typically causes bilateral, symmetric high-frequency sensorineural hearing loss. Speech discrimination often becomes harder in background noise, and conductive loss suggests another process such as cerumen or middle-ear disease.

Question 7Normal aging and age-related physiology

Which pharmacokinetic change most prolongs the effect of a highly lipid-soluble sedative in an older adult?

  1. Increased body fat proportion Correct answer.
  2. Decreased volume of distribution
  3. Increased hepatic blood flow
  4. Increased renal clearance

Explanation

Lipid-soluble drugs distribute into adipose tissue, and higher body fat increases the volume of distribution and prolongs elimination half-life. Renal clearance and hepatic blood flow tend to decline with age, further slowing drug removal.

Question 8Normal aging and age-related physiology

Which change in glucose metabolism is most consistent with normal aging?

  1. Higher insulin sensitivity
  2. Lower HbA1c
  3. Higher postprandial glucose Correct answer.
  4. Fasting glucose above 140 mg/dL

Explanation

Aging is associated with increased insulin resistance and impaired early insulin secretion, so postprandial glucose rises more than in younger adults. Fasting glucose rises only modestly, and HbA1c tends to be slightly higher rather than lower.

Question 9Normal aging and age-related physiology

Which sleep pattern change is typical of healthy aging?

  1. Increased total sleep time
  2. Frequent nighttime awakenings Correct answer.
  3. Delayed sleep phase
  4. Increased slow-wave sleep

Explanation

Older adults spend less time in slow-wave sleep and awaken more often during the night. Sleep timing often shifts earlier, and total sleep time tends to decrease slightly.

Question 10Normal aging and age-related physiology

Which age-related change contributes to bone loss in older adults?

  1. Increased osteoblast activity
  2. Reduced vitamin D synthesis Correct answer.
  3. Increased renal calcium reabsorption
  4. Increased intestinal calcium absorption

Explanation

Cutaneous synthesis of vitamin D declines with age and with reduced sun exposure, lowering calcium absorption and contributing to bone loss. Osteoblast activity and intestinal calcium absorption also decline, while renal calcium reabsorption is not increased.

Question 11Normal aging and age-related physiology

Which immune system change is most characteristic of aging?

  1. Decreased autoantibody prevalence
  2. Decreased T-cell-mediated immunity Correct answer.
  3. Increased naive T-cell production
  4. Enhanced vaccine response

Explanation

Thymic involution reduces naive T-cell output and impairs T-cell-mediated immunity, contributing to higher susceptibility to infections and poorer vaccine responses. Autoantibody prevalence tends to increase with age.

Question 12Normal aging and age-related physiology

Which hormonal change is expected in a healthy older man?

  1. Increased testosterone
  2. Increased DHEA
  3. Increased thyroid-stimulating hormone in all cases
  4. Gradual decline in total testosterone Correct answer.

Explanation

Total and free testosterone decline gradually with age, although not all men develop symptomatic hypogonadism. DHEA also declines, and TSH may rise modestly in some individuals but not universally.

Question 13Normal aging and age-related physiology

Which gastrointestinal change is most typical of normal aging?

  1. Increased esophageal peristalsis
  2. Increased intrinsic factor production
  3. Reduced gastric acid secretion Correct answer.
  4. Accelerated colonic transit

Explanation

Atrophic gastritis and reduced parietal cell function lower gastric acid secretion and can reduce intrinsic factor production. Esophageal motility and colonic transit tend to slow rather than accelerate.

Question 14Normal aging and age-related physiology

Which visual change is expected with normal aging?

  1. Increased tear production
  2. Improved night vision
  3. Reduced accommodation Correct answer.
  4. Increased pupil diameter

Explanation

Lens stiffening reduces accommodation, producing presbyopia, and the pupil becomes smaller with age. Tear production often decreases, and night vision worsens because of reduced light transmission and pupillary miosis.

Question 15Normal aging and age-related physiology

Which change in maximal exercise capacity is expected with normal aging?

  1. Increased maximal heart rate
  2. Increased maximal cardiac output
  3. Decreased maximal oxygen consumption Correct answer.
  4. Increased muscle mitochondrial density

Explanation

Maximal oxygen consumption (VO2max) declines with age because of reduced maximal heart rate, lower stroke volume, and loss of skeletal muscle mass. Mitochondrial density and oxidative capacity in muscle also tend to decline.

Question 16Normal aging and age-related physiology

Which hematologic statement is most consistent with normal aging?

  1. Anemia is an expected consequence of aging
  2. Platelet count doubles
  3. Normal hemoglobin in most older adults Correct answer.
  4. Lymphocyte count rises steadily

Explanation

Most healthy older adults maintain a normal hemoglobin concentration; anemia should be evaluated for a cause rather than attributed to aging. Bone marrow reserve declines modestly, but blood counts usually remain within reference ranges.

Question 17Normal aging and age-related physiology

An 82-year-old woman with a normal serum creatinine is prescribed a renally cleared drug. Why can creatinine-based GFR estimation overestimate her kidney function?

  1. Serum creatinine parallels GFR
  2. Aging increases creatinine production
  3. Low muscle mass masks low GFR Correct answer.
  4. Tubular secretion of creatinine declines before GFR

Explanation

Creatinine generation depends on muscle mass, which is often reduced in older adults; a normal creatinine can therefore coexist with a substantially reduced GFR. Drug doses should be adjusted using an estimate that accounts for age, sex, and body size, or measured clearance when critical.

Question 18Normal aging and age-related physiology

Which mechanism best explains the increased left ventricular afterload commonly seen in older adults with a normal ejection fraction?

  1. Reduced systemic vascular resistance
  2. Increased myocardial contractility
  3. Increased venous capacitance
  4. Aortic and large-artery stiffening Correct answer.

Explanation

Central arterial stiffening raises systolic pressure and pulse-wave velocity, increasing the load against which the left ventricle ejects. This contributes to concentric remodeling and diastolic dysfunction even when ejection fraction is preserved.

Question 19Normal aging and age-related physiology

Which autonomic change predisposes older adults to orthostatic hypotension?

  1. Increased heart rate response to standing
  2. Blunted baroreflex-mediated vasoconstriction Correct answer.
  3. Increased baroreceptor sensitivity
  4. Increased renin release

Explanation

Aging reduces baroreceptor sensitivity and the vasoconstrictor response to standing, so blood pressure falls when posture changes. The heart rate response to standing is also blunted, and renin release tends to decrease.

Question 20Normal aging and age-related physiology

Which cognitive change is most consistent with normal aging?

  1. Rapid loss of semantic memory
  2. Slowed processing speed with preserved vocabulary Correct answer.
  3. Impaired procedural memory
  4. Global decline in all cognitive domains

Explanation

Normal aging typically slows processing speed and reduces divided attention while vocabulary and semantic knowledge remain stable or improve. Procedural memory and language are relatively preserved, and global decline suggests a pathologic process.

Question 21Geriatric assessment, function and disability

An 82-year-old man is being assessed for functional status. Which of the following is classified as an instrumental activity of daily living?

  1. Bathing without assistance
  2. Managing personal finances Correct answer.
  3. Using the toilet independently
  4. Transferring from bed to chair

Explanation

Instrumental activities of daily living are higher-order tasks needed to live independently in the community, such as managing money, shopping, cooking, and using transportation. Basic activities of daily living include bathing, dressing, toileting, transferring, continence, and feeding. Screening instrumental activities helps detect early functional decline, especially in patients with cognitive impairment.

Question 22Geriatric assessment, function and disability

The Katz Index of Independence in Activities of Daily Living primarily assesses which of the following?

  1. Walking speed, stair climbing, and balance performance
  2. Bathing, dressing, toileting, and feeding Correct answer.
  3. Memory, orientation, executive function, and language
  4. Shopping, cooking, telephone use, and managing medications

Explanation

The Katz index rates independence in six basic self-care activities: bathing, dressing, toileting, transferring, continence, and feeding. It is used to describe functional dependence and to track changes over time. Instrumental tasks and cognitive testing are outside its scope.

Question 23Geriatric assessment, function and disability

A 79-year-old woman completes the Timed Up and Go test in 15 seconds. What is the most appropriate interpretation?

  1. It suggests increased fall risk and warrants further assessment Correct answer.
  2. The result mandates immediate emergency department referral for possible stroke
  3. The result is normal for her age and needs no follow-up
  4. The result confirms a diagnosis of dementia

Explanation

A Timed Up and Go time of 12 seconds or more is generally considered abnormal and identifies older adults at increased risk for falls. It should prompt a multifactorial falls assessment, including gait, balance, vision, medications, and home hazards. The test is a screening tool, not a diagnostic test for dementia or an emergency indication by itself.

Question 24Geriatric assessment, function and disability

A 78-year-old man walks 4 meters at his usual pace in 5.5 seconds. How should this gait speed be interpreted?

  1. 0.73 m/s, below the 0.8 m/s threshold Correct answer.
  2. 0.73 m/s, which exceeds the threshold for frailty
  3. 1.10 m/s, indicating excellent mobility
  4. 0.55 m/s, which is within the normal range

Explanation

Gait speed is calculated as distance divided by time, so 4 meters divided by 5.5 seconds is approximately 0.73 m/s. A usual gait speed below 0.8 m/s is associated with frailty, functional decline, falls, and mortality. Gait speed is a practical single-item measure of physical performance in older adults.

Question 25Geriatric assessment, function and disability

A 74-year-old woman is screened for depression with the 15-item Geriatric Depression Scale. Which score is generally considered suggestive of clinically significant depressive symptoms?

  1. 5 or more Correct answer.
  2. 15 or more
  3. 10 or more
  4. 12 or more

Explanation

On the 15-item Geriatric Depression Scale, a score of 5 or more is commonly used as the threshold for possible depression, with higher scores indicating greater severity. The scale uses yes-or-no questions and avoids somatic symptoms that can confound depression assessment in older adults. Positive screens require clinical confirmation.

Question 26Geriatric assessment, function and disability

Which set of five components defines the Fried frailty phenotype?

  1. Weakness, depression, hearing loss, vision loss, and insomnia
  2. Weight loss, exhaustion, low physical activity, weakness, and slow gait Correct answer.
  3. Slow gait, delirium, pressure injury, malnutrition, and pain
  4. Weight loss, cognitive impairment, recurrent falls, incontinence, and polypharmacy

Explanation

The Fried phenotype defines frailty by five physical components: unintentional weight loss, self-reported exhaustion, low physical activity, weak grip strength, and slow walking speed. Meeting three or more criteria classifies a person as frail, while one or two criteria indicate prefrailty. It is distinct from deficit-accumulation frailty indices.

Question 27Geriatric assessment, function and disability

An 84-year-old stroke survivor has a Barthel Index score of 40 out of 100. What does this score most likely indicate?

  1. Complete independence in basic activities
  2. A score that cannot be interpreted without cognitive testing
  3. Severe dependency requiring substantial assistance Correct answer.
  4. Mild dependency needing only occasional supervision

Explanation

The Barthel Index ranges from 0 to 100, with lower scores indicating greater dependence in basic activities of daily living. A score around 40 generally reflects severe dependency and need for substantial assistance. Serial scores can be used to track functional recovery or decline.

Question 28Geriatric assessment, function and disability

Which statement about the Short Physical Performance Battery is correct?

  1. It measures only upper-extremity strength and fine motor dexterity
  2. It combines balance, gait speed, and chair stands, scored 0 to 12 Correct answer.
  3. A score of 12 indicates severe frailty and high fall risk
  4. It combines the MMSE, GDS, and Barthel Index into a 30-point score

Explanation

The Short Physical Performance Battery is a performance-based measure with three components: standing balance, a 4-meter usual-pace walk, and five repeated chair stands. Each component is scored from 0 to 4, yielding a total of 0 to 12, where higher scores indicate better performance. Lower scores predict disability, falls, and mortality.

Question 29Geriatric assessment, function and disability

A 70-year-old lawyer reports mild word-finding difficulty but scores 28/30 on the MMSE. Which statement about cognitive screening instruments is most accurate?

  1. The MMSE and MoCA have identical sensitivity across all education levels
  2. The MMSE is preferred because it is unaffected by educational attainment
  3. The MoCA is generally more sensitive than the MMSE for mild cognitive impairment Correct answer.
  4. The MMSE is generally more sensitive than the MoCA for detecting mild cognitive impairment in all settings

Explanation

The Montreal Cognitive Assessment was designed to detect mild cognitive impairment and generally has higher sensitivity for subtle deficits than the MMSE. The MMSE is less sensitive to executive dysfunction and can show ceiling effects in highly educated patients. Both instruments require interpretation in the context of education, language, and sensory ability.

Question 30Geriatric assessment, function and disability

Which finding is required for a positive Confusion Assessment Method diagnosis of delirium?

  1. A stable, chronic confusional state lasting more than six months
  2. Disorganized thinking alone
  3. Acute fluctuating course plus inattention Correct answer.
  4. An altered level of consciousness alone

Explanation

The Confusion Assessment Method requires two core features: acute onset with a fluctuating course and inattention. A positive diagnosis also requires either disorganized thinking or an altered level of consciousness. Delirium is distinguished from dementia by its acute onset and fluctuating course.

Question 31Geriatric assessment, function and disability

A 76-year-old woman reports urinary frequency and urgency. A bladder scan shows a post-void residual of 250 mL. What is the most appropriate interpretation?

  1. A residual of 250 mL rules out bladder outlet obstruction
  2. The elevated residual suggests incomplete emptying and needs evaluation Correct answer.
  3. This residual volume is normal and requires no further action
  4. The residual confirms detrusor overactivity as the sole diagnosis and needs no further testing

Explanation

A post-void residual of 250 mL is abnormally elevated and suggests incomplete bladder emptying, which may result from obstruction, detrusor underactivity, or medications. Elevated residuals increase the risk of urinary retention and infection and require further evaluation. A bladder diary and medication review are useful adjuncts.

Question 32Geriatric assessment, function and disability

Which statement about hearing screening in older adults is most accurate?

  1. A whispered voice test at arm's length is a reasonable bedside screen for hearing loss Correct answer.
  2. A normal whisper test completely excludes mild presbycusis and does not require retesting
  3. Hearing screening is not recommended for older adults unless they report obvious difficulty
  4. Rinne and Weber tuning fork tests are the preferred screening method for age-related hearing loss in primary care

Explanation

The whispered voice test is a simple, validated bedside screening method for hearing impairment in older adults. It is performed at arm's length and followed by formal audiometry if abnormal. Screening is important because hearing loss is common, underreported, and associated with isolation and cognitive decline.

Question 33Geriatric assessment, function and disability

Which statement best summarizes the evidence for inpatient comprehensive geriatric assessment?

  1. Inpatient comprehensive geriatric assessment has no effect on functional outcomes or quality of life
  2. Inpatient comprehensive geriatric assessment reduces mortality and institutionalization Correct answer.
  3. Comprehensive geriatric assessment is equivalent to a single-domain fall assessment in most trials
  4. Comprehensive geriatric assessment should be restricted to patients younger than 70 years

Explanation

Randomized trials show that inpatient comprehensive geriatric assessment, delivered by a multidisciplinary team, reduces mortality and nursing home admission and improves the chance of remaining at home. It addresses medical, functional, cognitive, and social domains rather than a single problem. The benefit is greatest for frail older adults.

Question 34Geriatric assessment, function and disability

What does the Zarit Burden Interview primarily measure?

  1. A caregiver's physical lifting technique
  2. The subjective burden experienced by family caregivers Correct answer.
  3. The likelihood of nursing home placement within 30 days
  4. The care recipient's stage of cognitive impairment

Explanation

The Zarit Burden Interview is a validated questionnaire that quantifies the perceived emotional, physical, and financial burden experienced by caregivers. High scores identify caregivers at risk for burnout and depression. It supports caregiver-focused intervention planning.

Question 35Geriatric assessment, function and disability

Which statement about the Mini Nutritional Assessment-Short Form is correct?

  1. It is used only in hospitalized patients with dementia
  2. It replaces the need for weight measurement in all older adults
  3. It screens for malnutrition using weight loss and appetite Correct answer.
  4. It is a 30-item tool that requires a dietitian to administer

Explanation

The Mini Nutritional Assessment-Short Form is a six-item screening tool that includes food intake, weight loss, mobility, acute illness, neuropsychological problems, and body mass index or calf circumference. It identifies older adults at risk for malnutrition and triggers a fuller assessment. It can be administered by various clinicians in multiple care settings.

Question 36Geriatric assessment, function and disability

Which statement best distinguishes the frailty phenotype from the frailty index?

  1. The two tools are identical and interchangeable in all clinical settings
  2. The frailty index requires gait speed measurement, whereas the phenotype does not
  3. The frailty phenotype is a ratio of accumulated deficits, while the frailty index is a five-item physical test
  4. The phenotype counts five physical deficits; the index uses accumulated deficits Correct answer.

Explanation

The frailty phenotype operationalizes frailty as five physical components, with frailty defined by meeting three or more. The frailty index uses a comprehensive list of health deficits and expresses the proportion present, which can capture psychosocial and cognitive domains. They are related but not interchangeable.

Question 37Geriatric assessment, function and disability

An 80-year-old man presents after a fall. How should orthostatic vital signs be assessed?

  1. Measure blood pressure only while seated in the clinic
  2. Measure supine blood pressure, then standing at 1 and 3 minutes Correct answer.
  3. Skip orthostatic vitals if the patient denies dizziness or lightheadedness
  4. Use a systolic drop of 10 mm Hg as the diagnostic threshold

Explanation

Orthostatic hypotension is assessed by measuring blood pressure after at least 5 minutes of rest in the supine position and again after standing at 1 and 3 minutes. A systolic drop of at least 20 mm Hg or a diastolic drop of at least 10 mm Hg is diagnostic. Many older adults with orthostasis do not report dizziness.

Question 38Geriatric assessment, function and disability

A 70-year-old woman has a grip strength of 14 kg. Using European consensus cutoffs for low muscle strength, how should this be interpreted?

  1. Normal, because the threshold for women is 10 kg
  2. Normal, because grip strength is not part of sarcopenia assessment
  3. Low, because the threshold for women is 16 kg Correct answer.
  4. Low, because the threshold for women is 20 kg

Explanation

The European Working Group on Sarcopenia in Older People defines low grip strength as less than 27 kg in men and less than 16 kg in women. A value of 14 kg is therefore low and supports further assessment for sarcopenia. Grip strength is a practical measure of overall muscle strength.

Question 39Geriatric assessment, function and disability

What is the primary purpose of the Braden Scale in geriatric assessment?

  1. To measure fall risk in hospitalized older adults during acute illness
  2. To assess nutritional status and swallowing function in long-term care
  3. To screen for cognitive impairment in older adults with memory complaints
  4. To estimate pressure injury risk using six subscales Correct answer.

Explanation

The Braden Scale assesses six risk domains-sensory perception, moisture, activity, mobility, nutrition, and friction or shear-to estimate pressure injury risk. Lower scores indicate higher risk and guide preventive interventions such as repositioning and support surfaces. It is not a falls or cognitive screening tool.

Question 40Geriatric assessment, function and disability

A 75-year-old woman with mild cognitive impairment insists she manages all household affairs independently, but her son reports unpaid bills and spoiled food. What is the most appropriate next step in functional assessment?

  1. Perform a single chair-stand test to determine driving safety
  2. Use the MMSE score alone to estimate her functional capacity
  3. Obtain collateral history from a reliable informant Correct answer.
  4. Accept the patient's self-report as accurate and document independence

Explanation

Patients with cognitive impairment often underestimate their functional difficulties, so collateral information from a reliable informant is essential. Informant-based reports of instrumental activities such as finances, medication management, and cooking improve the accuracy of functional assessment. Performance-based measures can supplement but not replace this history.

Question 41Falls, gait disorders and immobility

Which Timed Up and Go (TUG) result is the threshold most commonly used to identify increased fall risk in community-dwelling older adults?

  1. 30 seconds or longer
  2. 20 seconds or longer
  3. 8 seconds or longer
  4. 12 seconds or longer Correct answer.

Explanation

The TUG measures the time to rise from a chair, walk 3 meters, turn, and return. A score of 12 seconds or longer is the threshold used by CDC STEADI to flag increased fall risk. A 10-second cutoff is sometimes cited for general mobility screening but is not the standard falls threshold.

Question 42Falls, gait disorders and immobility

Orthostatic hypotension is defined as a sustained fall in blood pressure within 3 minutes of standing of at least which amount?

  1. 30 mm Hg systolic or 15 mm Hg diastolic
  2. 40 mm Hg systolic or 20 mm Hg diastolic
  3. 20 mm Hg systolic or 10 mm Hg diastolic Correct answer.
  4. 10 mm Hg systolic or 5 mm Hg diastolic

Explanation

Orthostatic hypotension is a sustained reduction of at least 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing or head-up tilt. Measuring after 1 and 3 minutes improves detection, especially in older adults with blunted baroreflexes.

Question 43Falls, gait disorders and immobility

Which set of questions is used in the CDC STEADI three-question screening for fall risk?

  1. Fallen in the past year, takes five or more medications, has vision trouble
  2. Fallen in the past year, has arthritis pain, lives alone
  3. Fallen in the past year, feels unsteady, worries about falling Correct answer.
  4. Fallen in the past year, has urinary incontinence, uses a walker or cane

Explanation

STEADI uses three questions: falls in the past year, feeling unsteady, and worry about falling. A yes to any question triggers multifactorial assessment. Medication count, vision, and incontinence are relevant to falls but are not part of the three screening questions.

Question 44Falls, gait disorders and immobility

An older adult with right knee osteoarthritis and no other cause of gait instability needs a single-point cane. In which hand should the cane be held?

  1. Right hand, on the same side as the painful knee
  2. Left hand only if the left leg is stronger
  3. Either hand, because cane side does not affect loading
  4. Left hand, opposite the painful knee Correct answer.

Explanation

A cane is held in the hand opposite the affected lower limb, which widens the base and reduces joint reaction force across the painful hip or knee. The cane and the affected leg should move together.

Question 45Falls, gait disorders and immobility

Which exercise approach has the strongest evidence for reducing falls in community-dwelling older adults?

  1. Walking only, without balance training
  2. Seated chair aerobics without balance work
  3. Stretching alone three times weekly
  4. Otago exercise program or tai chi Correct answer.

Explanation

Programs that combine balance, strength, and gait training, such as Otago or tai chi, have the strongest evidence for reducing falls in community-dwelling older adults. Stretching or walking alone does not provide the same balance challenge.

Question 46Falls, gait disorders and immobility

An 82-year-old woman has had two falls in six months and takes lorazepam nightly for insomnia. Which action is most appropriate?

  1. Add zolpidem on nights when sleep is poor
  2. Taper lorazepam and start cognitive behavioral therapy Correct answer.
  3. Continue lorazepam because sleep deprivation also causes falls
  4. Switch to diphenhydramine nightly

Explanation

Benzodiazepines raise fall and fracture risk, and short-acting agents are not safer in older adults. Gradual tapering prevents withdrawal, and cognitive behavioral therapy for insomnia is first-line treatment.

Question 47Falls, gait disorders and immobility

An 80-year-old reports brief vertigo when rolling over in bed. Dix-Hallpike testing on the right reproduces torsional nystagmus. What is the best next step?

  1. Perform the Epley repositioning maneuver Correct answer.
  2. Start a prolonged course of oral corticosteroids
  3. Prescribe meclizine and advise strict bed rest
  4. Order MRI of the brain before any treatment

Explanation

Brief positional vertigo with torsional nystagmus on Dix-Hallpike is posterior canal benign paroxysmal positional vertigo, and canalith repositioning with the Epley maneuver is first-line. Vestibular suppressants are not recommended because they promote immobility and do not remove the canaliths.

Question 48Falls, gait disorders and immobility

Which gait feature is most characteristic of Parkinson disease?

  1. Scissoring gait with adductor spasticity
  2. Steppage gait with foot drop
  3. Wide-based gait with a positive Romberg sign
  4. Shuffling, festination, reduced arm swing Correct answer.

Explanation

Parkinson disease produces a hypokinetic gait with shuffling steps, reduced arm swing, stooped posture, and festination. Steppage, wide-based sensory ataxia, and scissoring spasticity point to other causes.

Question 49Falls, gait disorders and immobility

An older adult has three months of magnetic gait, urinary urgency, and mild cognitive slowing. Imaging shows enlarged ventricles. Which diagnosis best fits?

  1. Vitamin B12 deficiency
  2. Normal pressure hydrocephalus Correct answer.
  3. Cervical spondylotic myelopathy
  4. Parkinson disease

Explanation

The triad of gait disturbance, urinary incontinence, and cognitive impairment with ventriculomegaly suggests normal pressure hydrocephalus. Gait is usually the earliest and most treatable feature, and a large-volume lumbar puncture can predict response to shunting.

Question 50Falls, gait disorders and immobility

An older adult with long-standing diabetes walks with a wide base and slaps his feet; symptoms worsen with eyes closed. Which finding best supports sensory ataxia?

  1. Improvement of gait when the patient runs
  2. Spasticity with hyperreflexia and clonus
  3. Positive Romberg sign, strength preserved Correct answer.
  4. Festinating gait with a stooped posture

Explanation

Sensory ataxia from peripheral neuropathy causes a wide-based, stomping gait that worsens in the dark or with eyes closed, and Romberg sign is positive with preserved motor strength. Parkinsonism and spasticity produce different patterns.