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Week 1:

1. Which one of the following is most true about the rule of fourths?
2. Which one of the following is most true about aging changes?
3. An old woman who is cared for by attentive, cautious, concerned family is particularly likely to suffer from which one of the following complications after an episode of gastroenteritis?
4. Which one of the following is most true about psychological aging?
5. Of the following conditions, which one is most common and most often preventable?

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1. The US Advisory Committee on Immunization Practices and the Centers for Disease Control currently recommend which one of the following?
2. Healthcare providers should recommend that older adults engage in which one of the following?
3. Guidelines for the primary prevention of stroke recommend that aspirin be used in which one of the following?
4. Even though older adults are less likely to get counseled for smoking cessation, they have which one of the following?

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1. Which of the following is true about cultural humility?
2. Racial disparities have been a part of US healthcare for many How might this impact the expectations of older Black Americans?
3. Dementia is a relatively common condition in the geriatric population. It becomes more common as people Which is the most appropriate description of “personhood” as it relates to people with dementia?
4. Immigrant families bring cultural traditions into healthcare With regard to older adults, which of the following is true?

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1. Patient GG is an 82-year-old woman with complaints of dysuria and A urinalysis is positive for a urinary tract infection. She is 55 kg, her serum creatinine is 1.5 mg/dL, and she has no known drug allergies. Which of the following is the most appropriate antibiotic regimen?
2. An older woman with a history of mild Alzheimer disease was recently started on oxybutynin 10 mg orally twice daily for urinary incontinence. Her family reports that she has been increasingly disoriented over the past month and she notes some constipation on the review of systems during her office What management is best regarding her urinary incontinence?
3. Patient SL is a 68-year-old man you are seeing for follow-up of uncontrolled hypertension. He is currently prescribed amlodipine 10 mg daily, azilsartan 40 mg daily, metoprolol tartrate 50 mg BID (twice daily), and hydrochlorothiazide (HCTZ) 25 mg daily, and his blood pressure is consistently above Secondary causes of hypertension have been ruled out. You ask him about missing doses and he tells you that it is difficult to take so many tablets and the brand-name medication is very expensive. Select the best way to improve this patient’s adherence. You decide to discontinue brand name azilsartan and:

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Week 2:

1. An 80-year-old Black woman has a blood pressure (BP) of 168/102 mmHg and is started on amlodipine 5 mg The JNC 8 panel recommends treating this patient to a goal blood pressure of less than
2. A 54-year-old Hispanic woman has home BP of 155/95 mmHg, confirmed by multiple similar readings and office BP of 154/94 mmHg. She exercises, follows a low-salt diet, and rarely drinks alcohol. Which one of the following medications would be most appropriate for this patient?
3. A 72-year-old man with a history of hypertension recently had acute coronary syndrome for which he was hospitalized and treated with a stent to one of his coronary arteries. In addition to antiplatelet therapy, what antihypertensives are recommended to treat his BP and improve outcomes regarding his ischemic heart disease?

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1. The pathophysiology that underlies the formation of atherosclerotic plaque in coronary arteries is primarily associated with which of the following mechanisms?
2. An 80-year-old woman is evaluated in your clinic for muscle aches. Her daughter, who is a nurse, states that her symptoms worsened after recently starting atorvastatin 80 mg This medication and dose was selected based on the patient wanting to reduce her chance of a heart attack or stroke. She has a known history of stable coronary artery disease (CAD), without prior coronary revascularization. She takes low dose aspirin and her blood pressure is well controlled on lisinopril 20 mg once daily. You recognize that myalgias and myopathic symptoms are dose related and more common in older adults prescribed statins. Which of the following recommendations would be appropriate at this time?
3. A 75-year-old man with stable ischemic heart disease (SIHD) and moderate angina returns for follow-up. Prior stress testing has documented myocardial ischemia. A coronary angiogram performed 6 months ago showed that he has few options for revascularization and should be managed medically, although high-risk percutaneous coronary intervention (PCI) can be performed for lifestyle limiting symptoms. Reviewing his medications, it appears that he has been taking amlodipine 10 mg daily, in addition to statin, aspirin, and as needed sublingual What would be the most appropriate next step in his management?
4. An 88-year-old female patient with Parkinson disease presents to clinic for hospital follow-up for atrial fibrillation (AF) with rapid ventricular response (RVR). Home heart rate monitoring shows good rate control of her AF ventricular She has a history of falls and labile international normalized ratio (INR) with irregular adherence with blood draws. Her current medications include carbidopa-levodopa, metoprolol, and warfarin and she has a robust drug plan that allows for a variety of medication choices. What changes would you recommend to her medication regimen?

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1. In patients with heart failure, the most useful initial imaging modality is:
2. Compared with angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blocker are less likely to be associated with:
3. Which class of drug has not been shown to provide a mortality benefit in heart failure patients with reduced ejection fraction?
4. Which of the following would be consistent with the new onset of heart failure in an older patient?

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1. A 65-year-old male is evaluated in a follow-up examination for worsening dyspnea and chronic cough productive of mucoid sputum for the past 6 He is otherwise healthy but was diagnosed with chronic obstructive pulmonary disease (COPD) 3 years ago, and uses inhaled albuterol as needed. The patient has a 40 pack-year history of cigarette smoking but quit smoking 8 months ago. On physical examination, vital signs are normal and the patient is not in any respiratory distress. Breath sounds are decreased, but there is no edema or jugular venous distention. Spirometry shows a forced expiratory volume in the first second (FEV1) of 58% of predicted with no reversibility and an FEV1/forced vital capacity (FVC) ratio of 65%. His COPD symptoms seem poorly controlled and he has had one exacerbation in the past year. A chest radiograph is obtained and shows mild hyperinflation. Which of the following is the most appropriate therapy for this patient?
2. A 65-year-old female is evaluated for dyspnea, chronic cough, and mucoid sputum for the past 4 She has noticed that she has to walk slower than she used to and has to stop to catch her breath after walking 5 to 6 city blocks. The patient has a 40 pack-year history of cigarette smoking but quit smoking 1 year ago. She is otherwise healthy. On physical examination, vital signs are normal. Breath sounds are decreased, but there is no edema or jugular venous distention. What is the next best test you would order to make a diagnosis?
3. A 77-year-old female with asthma is evaluated for a very slow increase in the frequency of episodes of wheezing and dyspnea not relieved by short-acting beta-agonist She states that she uses her controller medications regularly with good inhaler technique, which include an inhaled long-acting beta-agonist and an inhaled low-dose corticosteroid. Despite this, she has daily daytime and frequent nocturnal symptoms of chest tightness and wheezing. She does not feel acutely ill. On physical examination, the patient is not in any respiratory distress. Her temperature is 37.0° C (98.6° F), blood pressure is 140/85 mmHg, pulse rate is 90 per minute, and respiration rate is 18/min. She has bilateral wheezing. In-office spirometry shows an FEV1 of 65% of predicted. After the supervised use of a bronchodilator in the office, there was some relief of her symptoms, and repeat spirometry 15 minutes later showed that the FEV1 increased to 85% of predicted. Which of the following is the appropriate next step in this patient’s management?

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1. Constipation in older adults may result from many Which of the following is not considered a common contributing factor to constipation in older adults?
2. Risk factors associated with constipation in older women are:
3. The first step in developing a treatment strategy for a physically active patient with constipation symptoms that are not caused by other potential causes is to:
4. Over-the-counter Milk of Magnesia and polyethylene glycol improve constipation by:
5. True or False Supplemental fiber treatment can improve symptoms related to constipation and FI.

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1. Lee is an 80-year-old man who lives alone who comes to the office for a routine visit. He lost 10 lb in the last 3 months and complains of fatigue, poor appetite, and trouble sleeping. Which of the following is least useful during his initial assessment?
2. During the physical assessment, you notice Lee has temporal wasting, loss of subcutaneous fat, and decreased handgrip strength. He also complains of dry mouth. His C-reactive protein is within normal limits. What additional lab test(s) are most useful for evaluating his nutritional status?
3. While discussing Mr. Lee’s diet, he states that his wife did all the cooking and since she passed away 5 months ago, he eats mostly soups and He does not drive, and he does not like to ask his son to take him to the store because he does not want to be a burden. What nutrition intervention would you recommend?
4. Miller is a 78-year-old female admitted to the hospital with pneumonia. She is on oxygen and is fatigued. The nurses notice her coughing when she drinks regular liquids. She states this happens at home as well. Her appetite has been poor in the hospital and she is only eating 50% of her meals. What is your first nutrition intervention?
5. Green is an 88-year-old female discharging home from the hospital after sustaining a right hip fracture from a fall. She required surgery to fix the fracture and is now ambulating using a walker. Her Mini-Nutritional Assessment in the hospital was positive for malnutrition risk. She lives alone and only has one family member who lives nearby. What nutrition interventions is least helpful once she discharges home?

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1. You are seeing an 85-year-old gentleman with a 15-year history of diabetes mellitus, coronary artery disease and coronary artery bypass grafting 7 years ago, and mild chronic obstructive pulmonary He lives in a senior living community in an independent apartment and gets help from family with shopping and medication management. He feels generally well, but complains of occasional episodes of weakness and nausea in the morning and before lunch. What is the most appropriate advice for this gentleman with respect to treatment goals for his diabetes?
2. Which of the following management strategies would have the lowest risk of hypoglycemia in an older adult with type 2 diabetes mellitus?
3. You are seeing an 80-year-old woman who recently moved to the area to live closer to her daughter. She reports a 10-year history of diabetes mellitus, which she has managed with metformin and She feels well but admits to having been very busy in the recent past. In fact, she has not seen a doctor in nearly a year. Which of the following health assessment measures would be appropriate in this patient?

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1. The most common presenting feature of hyperthyroidism in older adults is:
2. Hyperthyroidism is diagnosed with which of the following:
3. Which one of the following is correct about subclinical hypothyroidism?
4. Which of the following is correct about thyroid disease in older adults?
5. Which of the following statements about thyroid cancer are true?
6. If untreated, subclinical hyperthyroidism:

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1. A 79-year-old woman with a 1.5-cm breast cancer underwent Pathology revealed ductal carcinoma that is hormone receptor negative (estrogen receptor 0%, progesterone receptor 1%) and HER2/neu negative. Surgical margins were adequate and uninvolved with cancer. Sentinel lymph node sampling was negative for lymph node involvement. She has good performance status and no activities of daily living (ADL) or instrumental (IADL) dependencies. What treatment would you recommend?
2. An 86-year-old man with no ADL deficits who has stopped driving because of macular degeneration is evaluated for a urinary tract infection associated with urinary The consulting urologist places a Foley catheter and sends a prostate-specific antigen (PSA) level that comes back 12 ng/mL. Three months later after the Foley has been removed and he has had a good response to tamsulosin, his PSA is still 10 ng/mL. What is the appropriate next step in managing this man’s prostate problem?
3. In which of the following patients is chemical or surgical castration likely to prolong survival?
4. On admission to the hospital, an 85-year-old woman was found to have a fungating mass on her right The mass is 9 cm in diameter, partially ulcerated, and associated with edema of the arm and obvious pain. The patient has no children and had lived alone until recently, when a neighbor became concerned for what appeared to be a progressive loss of memory and neglect of the house. A nephew living in another city eventually came to take care of the situation and arranged for the admission. The patient appears confused and withdrawn; her appearance is disheveled, but she seems to be independent in her ADLs. The medical history is negative for any serious illnesses. She was able to drive her own car until shortly before this admission. The nephew does not wish to authorize hospice “right now.” A positron-emission tomography scan was negative for metastatic disease. In addition to determining the cause of her delirium, which of the following is the best way to address the breast mass?
5. A 78-year-old man has an emergency partial colectomy for lower gastrointestinal A localized colonic adenocarcinoma is completely resected. The surgeon did not dissect lymph nodes for metastatic sampling. The patient wants to know if he should have chemotherapy. Should he?
6. An 80-year-old woman has no weight loss, no pain, and no distention but over 2 years increasingly complains of constipation despite adequate medical treatment. A colonoscopy is negative. An abdominal CT is It reveals well-circumscribed pelvic masses, the largest adherent to the ovarian ligament. The best first step is:

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1. Your patient, a 68-year-old male, presented to the hospital with gastrointestinal bleeding from a duodenal ulcer that was treated His hemoglobin at discharge was stable at 10 g/dL, and he has had no recurrent signs of bleeding. He is now in your office 1 week after hospital discharge for a follow-up visit, being treated for iron deficiency anemia with iron sulfate 325 mg three times daily and is complaining of dyspepsia with iron supplementation. Your next step in management should be:
2. A 72-year-old female with progressive fatigue is found to have a hemoglobin of 1 g/dL, mean corpuscular volume of 108 fL, and a platelet count of 67×109/L on a routine laboratory evaluation. She has a normal B12 and folate level. She has never had a history of anemia and does not have signs or symptoms of bleeding or hemolysis. She does not use alcohol, and she has no liver disease. Your next step in management should be:
3. An 83-year-old female presents to your clinic for a routine physical On basic laboratory tests you note a hemoglobin level of 11.2 g/dL (1 year ago was 11.8 g/dL), a hematocrit of 33.6%, a white blood count of 8.1×103 µL (normal differential), a mean corpuscular volume 96.2 fL, a mean corpuscular hemoglobin concentration of 37 g/dL, and a platelet count 287,000×103 µL. Her creatinine clearance is 66 mL/min/1.73m2. On subsequent laboratory testing, she is found to have a ferritin level of 72 ng/mL, a normal transferrin saturation, B12, C-reactive protein, and thyrotropin levels. The most likely diagnosis at this time is:

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1. A 65-year-old otherwise healthy woman presents to the office with dysphagia that has been ongoing for nearly a She states that sticky foods, such as rice and tougher foods, such as beef or chicken, can transiently get stuck in her esophagus. On one occasion, she has had to vomit food out because it would not pass with time or by drinking water. She has had no weight loss and her symptoms have not been particularly progressive in nature. She has never had an endoscopy, but is up-to-date with her health care maintenance, including colon cancer screening. She reports no significant family history of gastrointestinal (GI) diseases or malignancies. Her examination is notable only for conjunctival pallor. Laboratories are significant for a microcytic anemia. A barium esophagram is performed, which reveals a thin, smooth, transverse filling defect in the midesophagus. Which of the following complications is this patient most at risk for?

2. A 70-year-old man undergoes an upper endoscopy for the evaluation of He has a large nonbleeding ulcer and biopsies reveal the present of Helicobacter pylori infection. He is given a 10-day course of clarithromycin, tetracycline, and omeprazole twice daily. His symptoms resolve. A urea breath test performed 2 weeks later is positive for H. pylori. Which of the following is the best next step in management of this patient?
3. A 72-year-old woman with a history of chronic heartburn comes in to discuss gastroesophageal reflux disease She asks whether she should remain on her proton-pump inhibitor (PPI); she has been on lansoprazole 15 mg daily for the past 12 years. With the medication, diet, and lifestyle changes, she has been asymptomatic for almost all of that time. An upper endoscopy performed 4 years ago revealed a small hiatal hernia and mild erosive esophagitis. She is concerned about long-term risks of PPIs. Which of the following is the most appropriate recommendation at this time?

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