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NCCPA CAQ Geriatrics study materials
NCCPA CAQ Geriatrics study resources

NCCPA CAQ Geriatrics practice questions

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Question 1Geriatric Medicine

An 82-year-old with mild cognitive impairment has a blood pressure consistently around 158/88 mm Hg in clinic. According to current hypertension guidance for community-dwelling older adults, which initial pharmacologic approach is most appropriate?

  1. Defer treatment until systolic pressure exceeds 170 mm Hg
  2. Begin two agents at full dose simultaneously to reach target quickly
  3. Restrict treatment to lifestyle measures regardless of pressure
  4. Start a single agent at a low dose and titrate while monitoring orthostatic symptoms Correct answer.

Explanation

Older adults benefit from treating systolic pressures above target, but start-low-go-slow dosing limits orthostatic hypotension and falls. Combination therapy at full dose up front raises the risk of syncope and electrolyte disturbance in this population.

Question 2Geriatric Medicine

Which finding is most characteristic of delirium rather than dementia in an 85-year-old hospital inpatient?

  1. Progressive word-finding difficulty over months
  2. Acute onset with fluctuating attention and altered awareness Correct answer.
  3. Stable, preserved level of alertness across the day
  4. Insidious decline in memory over several years

Explanation

Delirium is defined by acute onset, fluctuating course, and inattention with altered awareness, typically triggered by illness, medication, or environment. Dementia instead shows chronic, progressive cognitive decline with preserved arousal until late stages.

Question 3Geriatric Medicine

A 78-year-old woman has a DXA T-score of -2.7 at the femoral neck and no prior fracture. Which intervention is best supported?

  1. Reassurance and repeat DXA in five years
  2. Pharmacologic therapy plus adequate calcium and vitamin D Correct answer.
  3. Calcium and vitamin D alone without pharmacotherapy
  4. Estrogen therapy as first-line treatment

Explanation

A T-score of -2.5 or lower defines osteoporosis and warrants pharmacologic treatment alongside calcium and vitamin D repletion. Antiresorptive or anabolic agents reduce fracture risk in this group.

Question 4Geriatric Medicine

Which screening approach is recommended for cognitive impairment in an older adult presenting with new memory complaints?

  1. Use a brief validated instrument such as the Mini-Cog plus functional assessment Correct answer.
  2. Obtain a head CT before any cognitive screening
  3. Order routine APOE genotyping as the initial test
  4. Rely on family report alone without objective testing

Explanation

Brief validated tools such as the Mini-Cog combined with assessment of function efficiently detect cognitive impairment in primary care. APOE genotyping is not a diagnostic test and imaging is reserved for specific indications.

Question 5Geriatric Medicine

An 80-year-old taking warfarin for atrial fibrillation has an INR of 5.8 and no bleeding. What is the most appropriate immediate management?

  1. Continue the same warfarin dose and recheck in one week
  2. Transfuse platelets to correct the coagulopathy
  3. Hold warfarin and give oral vitamin K Correct answer.
  4. Give fresh frozen plasma immediately

Explanation

For an INR above 4.5 to 10 without bleeding, guidelines advise withholding warfarin and giving low-dose oral vitamin K, then monitoring. Plasma is reserved for serious bleeding, and platelets do not correct a warfarin effect.

Question 6Geriatric Medicine

Which statement about normal aging changes in renal function is most accurate for prescribing decisions?

  1. Creatinine clearance declines while serum creatinine may remain normal Correct answer.
  2. Serum creatinine rises proportionally with age in all adults
  3. Tubular secretion increases with age
  4. Glomerular filtration rate is preserved until age 90

Explanation

Glomerular filtration declines with age, but reduced muscle mass lowers creatinine production so serum creatinine can look normal despite impaired clearance. Dose adjustments should be based on estimated clearance, not creatinine alone.

Question 7Geriatric Medicine

Which intervention has the strongest evidence for preventing falls in community-dwelling older adults with gait and balance impairment?

  1. Routine use of hip protectors in all older adults
  2. Bed rest to reduce exposure to falls
  3. A structured exercise program targeting balance and strength Correct answer.
  4. Sedative hypnotics to improve sleep quality

Explanation

Exercise programs emphasizing balance, strength, and gait training reduce falls in community-dwelling older adults with identified impairment. Sedatives and bed rest increase fall risk and deconditioning.

Question 8Geriatric Medicine

An older adult with advanced dementia has poor oral intake and recurrent aspiration. Which statement best reflects appropriate feeding decisions?

  1. Tube feeding should be initiated routinely whenever intake declines
  2. Percutaneous feeding tubes reliably prevent aspiration pneumonia
  3. Intravenous fluids should be continued indefinitely regardless of goals
  4. Hand feeding with careful positioning is preferred over tube feeding for comfort Correct answer.

Explanation

In advanced dementia, hand feeding with attention to positioning and food preferences supports comfort and dignity, and tube feeding has not been shown to prevent aspiration pneumonia or prolong meaningful survival. Decisions should follow the patient's goals of care.

Question 9Geriatric Medicine

A 76-year-old man with heart failure and chronic kidney disease takes ibuprofen daily for knee pain. Which concern is most important to address?

  1. Daily NSAID use has no interaction with chronic kidney disease
  2. Ibuprofen reliably improves heart failure outcomes
  3. NSAIDs are preferred over acetaminophen in older adults
  4. NSAIDs worsen renal function and fluid retention in this patient Correct answer.

Explanation

NSAIDs reduce renal prostaglandin synthesis, causing sodium and water retention and worsening kidney function, particularly with heart failure and CKD. Acetaminophen or topical agents are safer first-line options.

Question 10Geriatric Medicine

Which immunization is recommended annually for adults aged 65 and older?

  1. Yellow fever vaccine
  2. Typhoid vaccine
  3. Inactivated influenza vaccine Correct answer.
  4. Hepatitis B series

Explanation

Annual influenza vaccination is recommended for all adults aged 65 and older, with high-dose or adjuvanted formulations preferred in this group. Hepatitis B, yellow fever, and typhoid vaccines are given for specific risk indications rather than routine annual use.

Question 11Geriatric Medicine

An 84-year-old woman with atrial fibrillation has a CHA2DS2-VASc score of 5 and a HAS-BLED score of 3. What is the most appropriate anticoagulation decision?

  1. Start anticoagulation and address modifiable bleeding risk factors Correct answer.
  2. Use aspirin alone as equivalent stroke prevention
  3. Recommend left atrial appendage occlusion as first-line therapy
  4. Withhold anticoagulation because of the elevated bleeding score

Explanation

A high CHA2DS2-VASc score strongly favors anticoagulation for stroke prevention, and an elevated HAS-BLED score should prompt correction of modifiable bleeding risks rather than withholding therapy. Aspirin is inferior to anticoagulation for stroke prevention in atrial fibrillation.

Question 12Geriatric Medicine

A 79-year-old presents with 3 days of confusion, urinary frequency, and suprapubic discomfort. Which step best reflects appropriate evaluation of suspected delirium?

  1. Identify and treat precipitating causes such as infection, medications, and metabolic derangement Correct answer.
  2. Order restraints to prevent agitation
  3. Assume dementia and arrange outpatient follow-up
  4. Prescribe an antipsychotic as first-line therapy

Explanation

Delirium management centers on finding and correcting precipitants, including infection, medications, pain, and metabolic abnormalities. Antipsychotics are reserved for severe distress and do not treat the underlying cause.

Question 13Geriatric Medicine

Which medication class is most strongly associated with anticholinergic burden and cognitive impairment in older adults?

  1. Topical emollients
  2. Angiotensin-converting enzyme inhibitors
  3. Strong anticholinergics such as diphenhydramine and oxybutynin Correct answer.
  4. Inhaled corticosteroids

Explanation

Strongly anticholinergic drugs, including first-generation antihistamines and some bladder antimuscarinics, are linked to confusion, falls, and cognitive decline in older adults. Deprescribing or substituting safer alternatives is recommended.

Question 14Geriatric Medicine

An older adult with type 2 diabetes and multiple comorbidities has an HbA1c of 7.9% and experiences hypoglycemia. What is the most appropriate approach?

  1. Relax glycemic targets and simplify the regimen to reduce hypoglycemia risk Correct answer.
  2. Add a sulfonylurea to achieve tighter control
  3. Tighten control to an HbA1c below 6.5%
  4. Intensify insulin dosing to reach a lower target

Explanation

For older adults with comorbidities and hypoglycemia, less stringent glycemic goals are appropriate, with regimens simplified to avoid dangerous lows. Sulfonylureas and intensified insulin raise hypoglycemia risk.

Question 15Geriatric Medicine

Which feature most strongly suggests a diagnosis of frailty in an older adult?

  1. Unintentional weight loss, exhaustion, weakness, slow gait, and low activity Correct answer.
  2. Stable weight with normal gait speed
  3. A single episode of acute bronchitis
  4. Isolated mild hypertension

Explanation

The frailty phenotype is defined by unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity. Three or more criteria indicate frailty and predict adverse outcomes.

Question 16Geriatric Medicine

An 86-year-old with advanced COPD and a life expectancy of months reports dyspnea despite optimal inhalers. Which approach best reflects palliative care principles?

  1. Avoid addressing goals of care until the terminal phase
  2. Limit discussion to disease-modifying therapy alone
  3. Use low-dose opioids titrated for dyspnea relief alongside nonpharmacologic measures Correct answer.
  4. Withhold opioids because of respiratory depression fears

Explanation

Low-dose opioids titrated carefully relieve refractory dyspnea in advanced disease, combined with fans, positioning, and pulmonary rehabilitation. Goals-of-care discussions should occur early and iteratively.

Question 17Geriatric Medicine

Which finding on geriatric assessment most strongly predicts future functional decline and mortality?

  1. A single normal Mini-Cog score
  2. Presbycusis alone
  3. Mild seborrheic keratosis
  4. Slow gait speed on a timed walk Correct answer.

Explanation

Gait speed is a validated marker of overall health and predicts disability, hospitalization, and mortality in older adults. Skin findings, isolated hearing loss, and a normal cognitive screen carry far less prognostic weight.

Question 18Geriatric Medicine

An older adult on multiple antihypertensives and a diuretic reports dizziness on standing. Which assessment best evaluates the cause?

  1. Order an echocardiogram before any positional measurement
  2. Check blood pressure only while seated
  3. Discontinue all medications immediately without measurement
  4. Measure blood pressure and heart rate after lying, then sitting, then standing Correct answer.

Explanation

Orthostatic vital signs measured after supine rest and then on standing identify orthostatic hypotension, defined as a drop of at least 20 mm Hg systolic or 10 mm Hg diastolic within three minutes. This guides medication adjustment.

Question 19Geriatric Medicine

A 74-year-old with osteoarthritis and normal renal function needs analgesia. Which regimen best balances efficacy and safety?

  1. Meperidine for chronic pain
  2. Combination propoxyphene and acetaminophen
  3. Long-term oral indomethacin at maximal dose
  4. Scheduled acetaminophen with topical NSAID for localized knee pain Correct answer.

Explanation

Scheduled acetaminophen plus a topical NSAID offers effective localized relief with limited systemic exposure. Oral indomethacin, meperidine, and propoxyphene carry substantial risk in older adults.

Question 20Geriatric Medicine

Which statement about advance care planning documentation is most accurate?

  1. Verbal wishes are legally binding in all states without documentation
  2. A health care proxy should be chosen and preferences discussed before incapacity Correct answer.
  3. Advance directives remove the need for shared decision-making
  4. A living will is identical to a durable power of attorney for health care

Explanation

Advance care planning involves appointing a surrogate decision-maker and discussing values and preferences while the patient retains capacity. A living will states treatment preferences, whereas a durable power of attorney for health care designates a decision-maker.

Question 21Geriatric Medicine

An 81-year-old with mild Alzheimer disease still drives. Which recommendation best reflects current guidance?

  1. Revoke driving privileges immediately at diagnosis
  2. Rely solely on the Mini-Mental State Examination score to decide fitness
  3. Permit unrestricted driving without reassessment
  4. Assess driving safety periodically with input from family and consider formal evaluation Correct answer.

Explanation

Driving fitness should be reassessed periodically because impairment progresses variably, and caregiver observation plus formal driving evaluation improves safety decisions. Diagnosis alone does not mandate immediate cessation, and no single cognitive score determines fitness.

Question 22Geriatric Medicine

An 88-year-old with advanced heart failure and a life expectancy under six months asks about hospice eligibility. Which statement is most accurate?

  1. Hospice eligibility generally requires a prognosis of six months or less if the disease runs its usual course Correct answer.
  2. Hospice cannot be provided in the home setting
  3. Hospice requires forgoing all treatments including comfort medications
  4. Hospice enrollment is limited to patients with cancer

Explanation

Hospice eligibility in the United States generally requires a prognosis of six months or less, with recertification possible if the disease continues its expected course. Comfort-focused medications remain central, and hospice serves many diagnoses and settings.

Question 23Geriatric Medicine

An older adult with recurrent urinary tract infections has been on repeated antibiotic courses. Which strategy best addresses antimicrobial stewardship?

  1. Use broad-spectrum antibiotics empirically for any positive culture
  2. Differentiate asymptomatic bacteriuria from true infection and treat only symptomatic episodes Correct answer.
  3. Order urine cultures monthly regardless of symptoms
  4. Prescribe continuous prophylactic antibiotics indefinitely

Explanation

Asymptomatic bacteriuria should not be treated because it drives resistance and adverse effects without benefit. Stewardship focuses on treating only symptomatic infection with the narrowest effective agent.

Question 24Geriatric Medicine

Which pattern of medication use in an older adult most strongly suggests the prescribing cascade?

  1. Splitting a tablet to reduce cost
  2. Taking two drugs for the same indication intentionally
  3. Using generic instead of brand-name drug
  4. Adding a drug to treat a side effect of another medication Correct answer.

Explanation

A prescribing cascade occurs when an adverse drug effect is misattributed to a new condition and treated with another medication. Recognizing the sequence allows deprescribing and avoids accumulating risk.

Question 25Geriatric Medicine

An 82-year-old with depression and mild cognitive impairment has a PHQ-9 score of 16. Which treatment approach is best supported?

  1. Start an antidepressant such as sertraline with monitoring for response and hyponatremia Correct answer.
  2. Rely on benzodiazepines for mood and sleep
  3. Use a tricyclic antidepressant as first-line therapy
  4. Defer treatment because cognitive impairment precludes therapy

Explanation

Depression in older adults responds to SSRIs such as sertraline combined with psychotherapy, with monitoring for hyponatremia and drug interactions. Tricyclics and benzodiazepines carry high anticholinergic, sedative, and fall risks.

Question 26Geriatric Medicine

An 82-year-old woman is brought in by her daughter, who reports progressive memory loss over two years and now needs help managing finances. Which screening instrument is most appropriate for objectively assessing her cognition during this visit?

  1. Katz Index of Independence in Activities of Daily Living
  2. Geriatric Depression Scale
  3. Braden Scale
  4. Mini-Cog with clock drawing Correct answer.

Explanation

The Mini-Cog combines a three-item recall with a clock-drawing task and is a brief, validated cognitive screen that is relatively insensitive to education and language. It is well suited to a busy primary care visit when dementia is suspected. Mood and function scales do not establish the presence of cognitive impairment.

Question 27Geriatric Medicine

A 78-year-old man with moderate Alzheimer disease becomes agitated every afternoon and insists on leaving the house to go to a job he retired from years ago. Which initial management approach is most appropriate?

  1. Obtain an order for physical restraints during agitated periods
  2. Identify and modify triggers and redirect with structured activity Correct answer.
  3. Discontinue all cholinesterase inhibitor therapy immediately
  4. Add a scheduled antipsychotic to prevent escalation

Explanation

Behavioral and environmental strategies are first-line for behavioral and psychological symptoms of dementia, since antipsychotics carry increased mortality and cerebrovascular risk in this population. Looking for triggers such as hunger, fatigue, overstimulation, or unmet routine needs and offering redirection with meaningful activity addresses the behavior at its source.

Question 28Geriatric Medicine

An 85-year-old woman living alone reports two falls in the past year but no syncope or injury. Which element is most essential to include in her falls evaluation?

  1. Bone density testing alone
  2. A medication review targeting sedatives and antihypertensives Correct answer.
  3. Routine brain MRI with contrast
  4. Routine electroencephalography

Explanation

Medications, particularly sedative-hypnotics, anticholinergics, and antihypertensives causing orthostasis, are among the most modifiable fall risk factors. A structured medication review is a core component of multifactorial fall assessment. Imaging and EEG are not routine first-line studies absent focal findings or suspected seizure.

Question 29Geriatric Medicine

A 90-year-old man with end-stage renal disease and a life expectancy of weeks develops severe pain from a sacral pressure injury. Which analgesic approach is most appropriate?

  1. As-needed intramuscular meperidine every six hours
  2. Scheduled acetaminophen with opioid reserved for breakthrough pain
  3. Scheduled oral morphine with careful titration Correct answer.
  4. Topical lidocaine as the sole analgesic

Explanation

Severe chronic pain in serious illness warrants scheduled around-the-clock analgesia with a long-acting or regularly dosed opioid, plus as-needed doses for breakthrough pain. In end-stage renal disease, morphine metabolites accumulate and are avoided; the safest choice among these options is careful titration of an appropriate opioid, though fentanyl or hydromorphone are generally preferred over morphine in renal failure.

Question 30Geriatric Medicine

A 74-year-old woman with hypertension and osteoarthritis has a blood pressure of 148/82 mm Hg on three visits. She walks daily and has no diabetes or kidney disease. Which target best reflects current guidance for her systolic blood pressure?

  1. Less than 150 mm Hg
  2. Less than 130 mm Hg Correct answer.
  3. Less than 120 mm Hg
  4. Less than 160 mm Hg

Explanation

Current hypertension guidance for community-dwelling older adults who tolerate treatment supports a systolic target below 130 mm Hg, consistent with intensive-control trial evidence. Targets should be individualized for frailty, orthostasis, and limited life expectancy, but this independent ambulatory patient fits the standard target.

Question 31Geriatric Medicine

An 80-year-old man hospitalized with pneumonia has been bedbound for five days and now has new confusion. Which factor is the most likely precipitant to address first?

  1. Undiagnosed dementia as the primary cause
  2. Delirium triggered by immobility, infection, and disrupted sleep Correct answer.
  3. Normal age-related slowing of processing speed
  4. A new major depressive episode

Explanation

Acute confusion in a hospitalized older adult with infection and immobility is delirium until proven otherwise. Management centers on treating the underlying cause and addressing modifiable contributors such as immobility, sleep disruption, sensory deprivation, and pain. Delirium is a medical emergency with high mortality and functional decline.

Question 32Geriatric Medicine

A 79-year-old woman with osteoporosis and a prior vertebral fracture has a T-score of -2.8 at the femoral neck. Which treatment is most appropriate?

  1. Calcium and vitamin D alone
  2. Raloxifene as first-line therapy
  3. Annual vitamin D injection monotherapy
  4. A bisphosphonate with calcium and vitamin D Correct answer.

Explanation

A fragility fracture plus a T-score in the osteoporotic range establishes high fracture risk warranting pharmacologic therapy. Bisphosphonates are first-line antiresorptives with strong evidence for reducing vertebral and hip fractures, and they are given together with adequate calcium and vitamin D.

Question 33Geriatric Medicine

An 83-year-old man with chronic kidney disease stage 4 has a hemoglobin of 9.2 g/dL and ferritin of 40 ng/mL. Which step is most appropriate before considering an erythropoiesis-stimulating agent?

  1. Transfuse to a hemoglobin above 10 g/dL
  2. Start oral iron only if hemoglobin falls below 8 g/dL
  3. Evaluate and treat iron deficiency Correct answer.
  4. Begin an erythropoiesis-stimulating agent immediately

Explanation

Anemia of chronic kidney disease requires assessment of iron stores first, since functional or absolute iron deficiency blunts response to erythropoiesis-stimulating agents and increases their risk. A ferritin of 40 ng/mL suggests iron deficiency, which should be corrected before escalating therapy.

Question 34Geriatric Medicine

An 88-year-old woman with advanced Parkinson disease has dysphagia and a 6-kg weight loss over three months. Which approach best addresses her nutritional needs?

  1. Immediate percutaneous endoscopic gastrostomy placement
  2. Encourage a clear liquid diet to ease swallowing
  3. Restrict oral intake and provide intravenous fluids only
  4. Speech-language evaluation with texture-modified diet and swallowing therapy Correct answer.

Explanation

Dysphagia in Parkinson disease is best managed initially with a speech-language pathology evaluation to determine safe textures and teach compensatory strategies. Texture modification and swallowing therapy can improve safety and intake before considering enteral feeding. Gastrostomy is reserved for selected cases after careful discussion of goals and risks.

Question 35Geriatric Medicine

A 77-year-old man with heart failure and a history of falls takes a diuretic, an ACE inhibitor, and a beta-blocker. He feels lightheaded when rising. Which finding on examination most directly explains his symptom?

  1. A drop in systolic pressure of 20 mm Hg on standing Correct answer.
  2. Trace pedal edema
  3. A resting heart rate of 72 beats per minute
  4. Bilateral basilar crackles

Explanation

Orthostatic hypotension is defined as a fall in systolic pressure of at least 20 mm Hg or diastolic of at least 10 mm Hg within three minutes of standing. This finding directly links his medication regimen and volume status to his lightheadedness and fall risk.

Question 36Geriatric Medicine

A 72-year-old woman with type 2 diabetes, hypertension, and mild cognitive impairment takes nine medications. Which intervention is most likely to reduce her risk of adverse drug events?

  1. Comprehensive medication review with deprescribing of unnecessary agents Correct answer.
  2. Switching all medications to long-acting formulations
  3. Adding a daily aspirin for primary prevention
  4. Increasing all doses to maximize disease control

Explanation

Polypharmacy with cognitive impairment raises the risk of adverse drug events, falls, and hospitalization. A structured medication review using tools such as the Beers criteria or STOPP/START identifies agents to stop, simplify, or replace, reducing burden and harm.

Question 37Geriatric Medicine

An 84-year-old man with mild dementia and no other comorbidities is found to have a blood pressure of 150/78 mm Hg. His daughter asks about treatment. Which statement best reflects appropriate care?

  1. Use only diuretics in patients over 80 years
  2. Target a systolic pressure below 110 mm Hg to protect cognition
  3. Treat to a systolic goal below 130 mm Hg if tolerated, with monitoring for orthostasis Correct answer.
  4. Avoid all antihypertensive therapy because of his age

Explanation

Older adults with preserved function benefit from treating systolic hypertension to a target below 130 mm Hg when tolerated, with attention to orthostatic symptoms and falls. Age alone is not a reason to withhold therapy. Overly aggressive targets and rigid drug-class rules are not supported.

Question 38Geriatric Medicine

A 91-year-old woman with advanced dementia, dysphagia, and recurrent aspiration pneumonia is admitted with sepsis. Her documented goals emphasize comfort. Which approach is most consistent with her stated goals?

  1. Intensive care unit admission with mechanical ventilation
  2. Mandatory nasogastric feeding to prevent aspiration
  3. Cardiopulmonary resuscitation if she arrests
  4. Comfort-focused care with symptom management and treatment of reversible distress Correct answer.

Explanation

When documented goals prioritize comfort, care should focus on relieving pain, dyspnea, and other symptoms while treating reversible sources of distress, often in a palliative or comfort-focused setting. Invasive interventions such as mechanical ventilation and tube feeding are generally not aligned with comfort goals in advanced dementia.

Question 39Geriatric Medicine

A 76-year-old woman with urge incontinence has tried bladder training without improvement. Which medication is most appropriate to add while minimizing anticholinergic risk?

  1. Diphenhydramine nightly
  2. Amitriptyline at bedtime
  3. A beta-3 adrenergic agonist such as mirabegron Correct answer.
  4. Oxybutynin immediate release

Explanation

Beta-3 adrenergic agonists treat urge incontinence without anticholinergic burden, making them attractive in older adults at risk of cognitive and urinary retention effects. Anticholinergic agents can worsen cognition and cause dry mouth, constipation, and retention.

Question 40Geriatric Medicine

An 80-year-old man with chronic obstructive pulmonary disease and a body mass index of 19 kg/m² has lost 8% of his weight in six months. Which factor most strongly suggests a poor prognosis in this presentation?

  1. Occasional dry cough
  2. Unintentional weight loss with low muscle mass Correct answer.
  3. A history of seasonal allergies
  4. His current body mass index

Explanation

Unintentional weight loss and low muscle mass, often termed cachexia, predict mortality and functional decline in chronic obstructive pulmonary disease and other chronic illnesses. Nutritional status is a key prognostic marker in geriatric assessment.

Question 41Geriatric Medicine

A 78-year-old woman recovering from a hip fracture is being discharged home. Which intervention most effectively reduces her risk of functional decline?

  1. Prolonged bed rest for six weeks
  2. A structured multidisciplinary rehabilitation program with early mobilization Correct answer.
  3. Discontinuation of all weight-bearing activity
  4. Isolation at home to reduce fall risk

Explanation

Early mobilization and multidisciplinary rehabilitation after hip fracture improve function, reduce complications, and lower mortality. Prolonged immobilization increases deconditioning, delirium, and thromboembolic risk.

Question 42Geriatric Medicine

An 86-year-old man with advanced heart failure, chronic kidney disease, and a life expectancy of months reports persistent dyspnea despite optimized diuretics. Which medication is most appropriate for symptom relief?

  1. High-dose furosemide added to his current regimen
  2. A scheduled benzodiazepine for breathlessness
  3. An inhaled short-acting beta agonist
  4. Low-dose oral morphine titrated to symptoms Correct answer.

Explanation

Low-dose opioids are the mainstay for refractory dyspnea in advanced heart failure and other serious illnesses, titrated carefully to relieve breathlessness without causing respiratory depression. Nonpharmacologic measures and oxygen when hypoxemic are adjuncts.

Question 43Geriatric Medicine

A 75-year-old woman with a recent hip fracture has a serum 25-hydroxyvitamin D level of 12 ng/mL. Which regimen is most appropriate?

  1. No supplementation because she lives in a sunny climate
  2. Calcium alone without vitamin D
  3. Vitamin D3 at a replacement dose with calcium intake assessment Correct answer.
  4. High-dose vitamin D injection once yearly

Explanation

A level of 12 ng/mL indicates deficiency requiring replacement with vitamin D3, along with assessment of calcium intake and fracture prevention. Vitamin D improves calcium absorption and is essential for bone health after fragility fracture.

Question 44Geriatric Medicine

An 82-year-old man with moderate dementia and his daughter ask about advance care planning. Which statement best reflects appropriate practice?

  1. A living will is legally binding in all circumstances and cannot be revised
  2. Discussion should occur early, document his values and preferences, and be revisited over time Correct answer.
  3. Advance care planning should be deferred until he loses decision-making capacity
  4. Decisions should be made solely by the physician without family input

Explanation

Advance care planning is most effective when initiated early, while the patient can participate, and should document values, goals, and preferences. These discussions are iterative and should be revisited as health changes.

Question 45Geriatric Medicine

A 79-year-old woman has a hemoglobin A1c of 7.2% on metformin and glipizide but has had two episodes of symptomatic hypoglycemia in the past month. Which change is most appropriate?

  1. Increase the metformin dose
  2. Target an A1c below 6.5%
  3. Add a basal insulin to improve control
  4. Reduce or discontinue the sulfonylurea Correct answer.

Explanation

Symptomatic hypoglycemia in an older adult is a serious adverse event that warrants relaxing glycemic targets and eliminating agents with high hypoglycemia risk. Sulfonylureas are a common culprit and should be reduced or stopped.

Question 46Geriatric Medicine

A 73-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4 and no prior bleeding. He asks about stroke prevention. Which statement is most accurate?

  1. Aspirin alone provides equivalent stroke prevention
  2. Anticoagulation is recommended, and a direct oral anticoagulant is generally preferred over warfarin Correct answer.
  3. Anticoagulation should be avoided in all patients over 70
  4. Warfarin is preferred because it requires no monitoring

Explanation

A CHA2DS2-VASc score of 4 confers high stroke risk, and anticoagulation is recommended. Direct oral anticoagulants are generally preferred in older adults because of fewer drug and food interactions and lower intracranial hemorrhage risk compared with warfarin.

Question 47Geriatric Medicine

An 85-year-old woman with advanced chronic obstructive pulmonary disease has a life expectancy of months and recurrent hospitalizations. She asks about hospice. Which statement best reflects hospice eligibility?

  1. Hospice requires discontinuation of all comfort medications
  2. Hospice is available only to patients with cancer
  3. Hospice cannot be provided in the home
  4. Hospice requires a prognosis of six months or less if the disease runs its usual course Correct answer.

Explanation

Hospice eligibility generally requires a prognosis of six months or less if the disease follows its usual course, with documentation of decline. It is available for any terminal illness and can be provided in the home, assisted living, or facility.

Question 48Geriatric Medicine

A 77-year-old woman with depression and mild cognitive impairment has a PHQ-9 score of 16 and no suicidal ideation. Which treatment approach is most appropriate?

  1. Recommend no treatment because depression is expected with cognitive impairment
  2. Start an antidepressant with a favorable interaction profile and reassess in several weeks Correct answer.
  3. Start a tricyclic antidepressant as first-line therapy
  4. Use a benzodiazepine as monotherapy

Explanation

Moderate to severe depression warrants pharmacotherapy, and in older adults a selective serotonin reuptake inhibitor or other agent with a favorable side-effect and interaction profile is preferred. Treatment should be monitored and adjusted, with attention to cognition and falls.

Question 49Geriatric Medicine

An 80-year-old man with prostate cancer and bone metastases reports severe pain that is currently managed with as-needed oxycodone. Which change is most appropriate?

  1. Add a benzodiazepine for pain control
  2. Increase the as-needed dose frequency only
  3. Switch to a scheduled long-acting opioid with as-needed breakthrough dosing Correct answer.
  4. Discontinue opioids and use acetaminophen alone

Explanation

Severe chronic cancer pain requires around-the-clock analgesia with a long-acting opioid plus short-acting rescue doses for breakthrough pain. This approach provides steady relief and reduces the cycle of escalating pain.

Question 50Geriatric Medicine

A 90-year-old woman with advanced frailty and a life expectancy of weeks is admitted with aspiration pneumonia. Her family asks about artificial nutrition. Which statement best reflects appropriate guidance?

  1. Tube feeding should be started only if the patient is over 85
  2. Artificial nutrition is required by law in all terminal illnesses
  3. Tube feeding reliably prevents aspiration and should be started
  4. Tube feeding does not prevent aspiration and may not improve comfort or survival in advanced dementia Correct answer.

Explanation

In advanced dementia and frailty, tube feeding has not been shown to prevent aspiration pneumonia, improve survival, or improve comfort, and it may increase restraint use and complications. Decisions should be guided by the patient's goals and comfort.