BCPS - Geri Practice Questions and answers 2023

BCPS - Geri Practice Questions and answers 2023Geri 1 + 2 An 85-year-old woman (weight 65 kg) who resides at home with her daughter has a medical history significant for type 2 diabetes and hypertension, and 1 year ago, she had a right hip fracture after a fall. Her regularly scheduled medications include glyburide 10 mg daily, lisinopril 10 mg daily, metformin 500 mg twice daily, aspirin 81 mg daily, and a multivitamin daily. Her as-needed medications include melatonin 6 mg at bedtime as needed for sleep, meclizine 25 mg ½ tablet three times daily as needed for dizziness, and docusate 100 mg twice daily. Her laboratory results show fasting plasma glucose 90 mg/dL, sodium (Na) 138 mEq/L, potassium (K) 4.5 mEq/L, chloride (Cl) 102 mEq/L, carbon dioxide (CO2) 25 mEq/L, blood urea nitrogen (BUN) 30 mg/dL, SCr 1.8 mg/dL, and TSH 4.0 mU/L. 1. Considering the potential for altered pharmacokinetics, which set of medications is most likely to cause problems for the patient? A. Aspirin and melatonin. B. Lisinopril and meclizine. C. Lisinopril and metformin. D. Glyburide and metformin. 2. Considering the potential for increased pharmacodynamic sensitivity, which set of medications is most likely to cause problems for the patient? A. Aspirin and melatonin. B. Lisinopril and meclizine. C. Lisinopril and metformin. D. Glyburide and metformin. Answer D: Renal elimination is usually the most significantly changed pharmacokinetic value in older adults. This patient's advanced age and diseases will add to her loss of renal function. Using the Cockcroft-Gault equation, this patient's estimated CrCl is 24 mL/minute/1.73 m2. Creatinine clearance = [(140 − 85) × 65]/[(72 × 1.8)] × 0.85. At this level of function, glyburide elimination would be prolonged, and metformin use is contraindicated (Answer D is correct). Answer B: Common pharmacodynamic changes associated with aging include impaired homeostasis for electrolytes with angiotensin-converting enzyme inhibitors such as lisinopril and increased sensitivity to anticholinergic adverse effects from drugs such as meclizine (Answer B is correct). Geri 3, 4, 5 Questions 3-5 pertain to the following case. A 70-year-old woman (height 66 inches, weight 71.7 kg [158 lb]) is in the clinic for an evaluation by the clinical pharmacist for polypharmacy. She has complaints of fatigue, light-headedness, constipation, and "too many medicines." Her medical history is significant for hypertension, coronary artery disease (drug-eluting stent 8 years ago), chronic obstructive pulmonary disease, diabetes mellitus, incontinence, frequent urinary tract infections, depression, and moderate dementia. Vital signs include blood pressure 160/82 mm Hg, heart rate 51 beats/minute, respiratory rate 16 breaths/minute, and oxygen saturation 99% on room air. Her current medications are as follows: fluticasone/salmeterol 250/50 1 puff twice daily, aspirin 81 mg daily, acetaminophen 650 mg three times daily, clopidogrel 75 mg daily, donepezil 10 mg daily, glipizide 5 mg twice daily, lisinopril 10 mg daily, loratadine 10 mg daily, metoprolol 50 mg twice daily, paroxetine 50 mg daily, ranitidine 150 mg twice daily, simvastatin 40 mg at bedtime, and tolterodine 2 mg at bedtime. Nitrofurantoin 50 mg twice daily for 10 days was initiated 3 days ago. Laboratory values from her physician visit 3 days before are as follows: Na 130 mg/dL, K 4.2 mEq/dL, Cl 99 mg/dL, CO2 24 mEq/dL, BUN 24 mg/dL, SCr 1.6 mg/dL, fasting glucose 67 mg/dL, A1C 6.3%, urinalysis negative except for blood- small, pH 7.5, RBC 11-25/high-power field (HPF), white blood cells 0-2/HPF, and bacteria 168/HPF. 3. Which medication list best depicts the medications with the greatest potential to harm this patient, according to the AGS 2015 Beers Criteria? A. Paroxetine, ranitidine, donepezil, tolterodine. B. Donepezil, metoprolol, glipizide, simvastatin. C. Glipizide, donepezil, nitrofurantoin. D. Metoprolol, clopidogrel, ranitidine. 4. Given the available patient information, which set of medications is least appropriate for this patient, according to the Medication Appropriateness Index? A. Fluticasone/salmeterol, ranitidine, donepezil, tolterodine. B. Metoprolol, clopidogrel, ranitidine. C. Aspirin, glipizide, donepezil, nitrofurantoin. D. Paroxetine, nitrofurantoin, simvastatin. 5. Which medications would best be discontinued, according to the Choosing Wisely criteria? A. Paroxetine, ranitidine, donepezil, tolterodine. B. Metoprolol, clopidogrel, ranitidine. C. Glipizide, donepezil, nitrofurantoin. D. Ranitidine, nitrofurantoin, glipizide, tolterodine. Answer A: However, paroxetine should be used with caution in patients with hyponatremia; ranitidine is a histamine-2 receptor antagonist, which should be avoided in patients with dementia, and this patient's CrCl is less than 50 mL/minute/1.73 m2, requiring a dose reduction; donepezil as a CI should be avoided in patients with syncope because it can cause bradycardia; and tolterodine has strong anticholinergic properties and should be avoided in patients with dementia (Answer A is correct). Answer B: Ranitidine has no listed indication in this patient, clopidogrel has exceeded the recommended therapy duration for her stent, and metoprolol has a significant drug-drug interaction with donepezil, given her bradycardia (Answer B is correct). Answer C: Because the patient's A1C is less than 7.5%, glipizide should be reevaluated; donepezil use in dementia requires periodic reassessment of risk-benefit; and asymptomatic bacteriuria should not be treated with antimicrobials; these medications should be evaluated for continued need and possible discontinuation, according to the Choosing Wisely criteria (Answer C is correct). 00:09 01:13 Geri 6 + 7 A 70-year-old woman is admitted to the hospital with a broken arm after a fall. While in the hospital, she is on bedrest most of the time, loses 2 kg (current weight 63 kg), and has trouble sleeping. She is to be discharged to a rehabilitation facility for 2-3 weeks of theapy. Her medications at discharge are glipizide 5 mg daily, lisinopril 10 mg daily, aspirin 81 mg daily, a multivitamin daily, mirtazapine 15 mg at bedtime, calcium 500 mg twice daily, and tramadol 25 mg every 8 hours as needed for pain. 6. When recommending medication changes for this patient, which functional assessment is most important to evaluate? A. IADLs. B. Depression. C. Pressure sores. D. Gait and balance. 7. To maintain and improve function in this patient, which intervention is best to implement? A. Add simvastatin 10 mg daily. B. Increase lisinopril to 20 mg daily. C. Add vitamin D 1000 units twice daily. D. Change tramadol to naproxen 500 mg twice daily as needed for pain. Answer D: This patient had a geriatric syndrome (a fall) and hazards of hospitalization (decline in organ systems and function) that occur with many older adult patients. At this time, she has several risk factors for another fall, including a history of falls, diseases such as diabetes and hypertension, dizziness, and use of several drugs. An assessment of gait and balance would help determine the severity of her risk (Answer D is correct). Answer C: Efforts to maintain bone and muscle strength are more important for this patient than is primary prevention of cardiovascular disease with simvastatin or lisinopril. Most older adults do not consume a diet rich in vitamin D; moreover, most older adults have less sun exposure and are more likely to be deficient in vitamin D, which is a risk factor for falls and reduced muscle strength. Furthermore, naproxen is not a good alternative for the patient because of increased risk of GI bleeding and worsening renal function (Answer C is correct). Geri 8 An 84-year-old widow lives at home alone. She can perform ADLs and most IADLs with her daughter's assistance. Her current medications are hydrochlorothiazide 12.5 mg daily for hypertension, tolterodine long citalopram 20 mg daily for depression, acetaminophen 650 mg as needed for arthritis, and calcium/vitamin D for prevention of osteoporosis. The patient's physician administers the MMSE, and her score is 23/30. On physical examination, no cogwheel rigidity or tremor is noted. Which recommendation would be best at this time? A. Add donepezil 5 mg daily. B. Discontinue tolterodine and reassess the patient. C. Add vitamin B12 1000-mg injection monthly. D. Change hydrochlorothiazide to lisinopril 5 mg daily. Answer B: Anticholinergics such as tolterodine can cause confusion, so it would be best to discontinue this agent and reassess cognition before treating for AD (Answer B is correct). Geri 9 An 87-year-old man with AD receives rivastigmine 6 mg twice daily. His family notes improved functional ability but reports that he has nausea and vomiting that appear to be related to rivastigmine. Which recommendation is best for the patient at this time? A. Advise the patient to take rivastigmine with an antacid. B. Change rivastigmine to the patch that delivers 9.5 mg daily. C. Discontinue rivastigmine and initiate memantine 5 mg twice daily. D. Add prochlorperazine 25 mg by rectal suppository with each rivastigmine dose. Answer B: Rivastigmine is a potent inhibitor of acetyl and butyryl cholinesterase, leading to significant cholinergic adverse effects such as nausea, vomiting, and diarrhea. However, use of the transdermal delivery system generates even plasma concentrations and lessens the incidence of cholinergic adverse effects. Because the maintenance dose has been achieved with rivastigmine 12 mg, this patient can change to the patch that delivers 9.5 mg/day (Answer B is correct). Geri 10 A 75-year-old woman with AD who lives at home with her husband has been treated with donepezil 10 mg daily for about 3 years. When she began therapy, her MMSE score was 21/30; her present MMSE score is 17/30. The patient cannot perform most IADLs but can perform most ADLs with cueing. About 2 months ago, her donepezil dose was increased to 23 mg, but she could not tolerate it, and it was reduced back to 10 mg daily. Her husband asks about changing her drug treatment to help maintain her function. Which is the next best course of action? A. Retry donepezil 23 mg daily. B. Initiate memantine 5 mg daily. C. Add vitamin E 400 units twice daily. D. Change donepezil to rivastigmine 9.5-mg patch daily. Answer B: Because she has benefited from donepezil use, she should not abruptly discontinue it. Some clinical trials with memantine show an additional treatment response when memantine is added to donepezil therapy. When the benefits, risks, and costs have been openly discussed and the family prefers to consent to therapy, a time-based trial is reasonable. Memantine should be initiated at 5 mg daily (Answer B is correct). Geri 11 + 12 You are evaluating the medication profile of an 87-year-old woman who resides in a secure advanced dementia unit. Her medical history includes dementia (likely AD), Parkinson disease, and OA. She needs assistance with all ADLs, including total assistance with bathing and dressing, as well as help with feeding. She transfers with minimal help to a wheelchair. Her medication regimen includes donepezil 10 mg daily, memantine 10 mg twice daily, carbidopa/levodopa 25/100 mg four times daily, and a multivitamin supplement daily. The patient's most recent MMSE score is 5/30. When reviewing the nursing notes, you see several references to the patient's continuously crying out, "Help me, help me," beginning around 5 p.m. On medical evaluation, reversible causes of her hypervocalization are ruled out. Which initial approach is most appropriate for this patient? A. Initiate ibuprofen 400 mg every 8 hours. B. Order haloperidol 1 mg every 6 hours as needed for agitation. C. Begin music therapy with songs the patient enjoyed when younger. D. Move the patient to a private room to minimize social contacts after 3 p.m. 12. After 2 months, the patient's agitation increases such that the nursing staff cannot bathe or feed her. Assuming nonpharmacologic approaches are ineffective, which is the best pharmacologic approach to treat her behavioral symptoms? A. Increase donepezil to 23 mg daily. B. Begin melatonin 6 mg at bedtime. C. Add quetiapine 25 mg at 4 p.m. daily. D. Add citalopram 10 mg daily. Answer C: Patients in the late stages of dementia (as evidenced by an MMSE score of 5/30) with behavior issues would benefit most from nonpharmacologic treatment such as music therapy (Answer C is correct). Answer C: The patient has become a harm to self (because of refusing care), so a course of quetiapine is appropriate, assuming other nonpharmacologic treatments have been tried unsuccessfully (Answer C is correct). Geri 13 A 75-year-old woman reports urinary urgency, frequency, and loss of urine when she cannot get to the bathroom in time. She also wears a pad at night that she changes two or three times because of incontinence. Her medical history is significant for MCI (MMSE score 25/30), OA, and hypothyroidism. A urinalysis is negative. Physical examination is normal, and her PVR is normal (less than 100 mL). Which therapy would be best to initiate for this patient at this time? A. Mirabegron. B. Darifenacin. C. Pelvic floor exercises and solifenacin. D. Pelvic floor exercises and tolterodine immediate release. Answer C: This patient has symptoms of urge incontinence. Pelvic floor exercises in conjunction with drug therapy should be offered for initial therapy (Answer C is correct). Geri 14 An 85-year-old man with LUTS visits his physician, who determines his AUASI score is 15. His blood pressure is 118/70 mm Hg sitting. A digital rectal examination confirms the diagnosis of BPH, and the physician schedules a further workup including a prostate ultrasound, which shows a prostate volume of 31 g. Which therapy is best at this time? A. Terazosin. B. Finasteride plus saw palmetto. C. Tamsulosin. D. Finasteride plus tamsulosin. Answer C: Pharmacologic therapy targeted at reducing urethral sphincter pressure has proved effective in reducing BPH symptoms. Tamsulosin is an α-adrenergic blocker with more specific activity for the genitourinary system. Given that the patient already has low normal blood pressure, tamsulosin would be preferred to terazosin (Answer C is correct) Geri 15 An 85-year-old man presents with pain from hip OA. He has hypertension, coronary artery disease, and BPH. For his OA, he has been taking acetaminophen 650 mg three times daily. He reports that acetaminophen helps but that the pain persists and limits his ability to walk. Which is the best next step for this patient? A. Change acetaminophen to celecoxib. B. Add hydrocodone. C. Change acetaminophen to ibuprofen. D. Add glucosamine. Answer: B The AGS recommends opioids for OA when older patients do not respond to initial therapy with acetaminophen (Answer B is correct). Geri 16 A 65-year-old woman received a diagnosis of RA 1 year ago. At that time, her RF titer was 1:64; she presented with joint inflammation in both hands and about 45 minutes of morning stiffness. She began therapy with oral methotrexate and currently receives methotrexate 15 mg weekly, folic acid 2 mg daily, ibuprofen 800 mg three times daily, and omeprazole 20 mg daily. At today's clinic visit, the patient reports the recurrence of her symptoms. Radiographic evaluation of her hand joints reveals progression of joint space narrowing and bone erosion. Which is the next best step for treating this patient's RA? A. Administer etanercept. B. Change to leflunomide. C. Add prednisone bridge therapy. D. Change to hydroxychloroquine. Answer A: Etanercept has a response in 60%- 75% of patients whose therapy with methotrexate has failed (Answer A is correct). Geri SA 1 +2 An 85-year-old man presents to the primary care clinic after the death of his spouse 1 month earlier. His medical history is significant for hypertension, hyperlipidemia, benign prostatic hypertrophy (BPH), and major depressive disorder. His current medications include lisinopril 10 mg daily, atorvastatin 20 mg daily, tamsulosin 0.4 mg daily, diazepam 5 mg at bedtime as needed for sleep, and escitalopram 10 mg daily. His daughter reports that he has been more lethargic and unsteady walking during the past 3 days. The patient reports trouble sleeping and taking diazepam every night this past week. His blood pressure is 135/72 mm Hg and heart rate is 76 beats/ minute. Urinalysis is negative, thyroid-stimulating hormone (TSH) is within the reference range, and Geriatric Depression Scale score is 6/15. 1. Which medication is most contributing to this patient's lethargy and confusion? A. Diazepam. B. Lisinopril. C. Atorvastatin. D. Escitalopram. 2. Which age-related change in pharmacokinetics most likely underlies this patient's medication-related problem? A. Delayed oral absorption. B. Decreased renal excretion. C. Slowed metabolism in the liver. D. Decreased volume of distribution. Answer: A Diazepam is a long-acting benzodiazepine that can accumulate in older patients, resulting in excessive lethargy, sedation, and unsteady gait, and the patient admits taking it every night during the past week (Answer A is correct) Answer C: In addition, changes in metabolism through phase I (oxidation) are diminished (Answer C is correct). Diazepam tends to accumulate with reduced capacity 00:02 01:13 Geri SA 3, 4 , 5 A 76-year-old woman was recently admitted to a longterm care facility for rehabilitation after several falls at home. Her medical history is significant for hypertension, hypothyroidism, Alzheimer disease (AD), hyperlipidemia, and osteoarthritis (OA). She takes metoprolol succinate 50 mg daily, levothyroxine 75 mcg daily, atorvastatin 10 mg daily, and donepezil 10 mg daily. Her blood pressure is 126/80 mm Hg and heart rate is 66 beats/minute. Basic metabolic panel results are all within reference ranges; 25-hydroxyvitamin D concentration is 20 ng/mL, TSH is 1.89 mU/L, total cholesterol is 180 mg/dL, low-density lipoprotein cholesterol is 140 mg/dL, high-density lipoprotein cholesterol is 35 mg/dL, and triglycerides is 176 mg/dL. Her Mini-Mental State Examination (MMSE) score is 16/30, and her Geriatric Depression Scale score is 2/15. 3. Which recommendation would be most appropriate to reduce this patient's risk of falls? A. Begin memantine titration. B. Initiate vitamin D 1000 units daily. C. Decrease metoprolol succinate to 25 mg daily. D. Initiate calcium carbonate 500 mg twice daily. 4. Which intervention is best to reduce this patient's risk of ischemic stroke? A. Initiate aspirin 81 mg daily. B. Increase atorvastatin to 20 mg daily. C. Initiate hydrochlorothiazide 25 mg daily. D. Increase metoprolol succinate to 100 mg daily. 5. Which would be most appropriate for the patient's osteoarthritic knee pain? A. Ibuprofen 200 mg four times daily. B. Acetaminophen 650 mg three times daily. C. Tramadol 50 mg three times daily as needed for pain. D. Hydrocodone/acetaminophen 5/325 mg every 4 hours as needed for pain. Answer B: Adding vitamin D to this resident's regimen, given her deficient serum concentrations, may help reduce falls (Answer B is correct). Answer A: The U.S. Preventive Services Task Force recommends aspirin use in women 55-79 years of age to prevent ischemic strokes in women with a low risk of GI bleeding. This patient, who has no history of GI bleeding, would probably benefit from low-dose aspirin (Answer A is correct). Answer B: An initial trial of acetaminophen at doses less than 3 g/day is reasonable for frail patients with OA pain (Answer B is correct). Geri SA 6, 7, 8 An 80-year-old woman presents to your clinic accompanied by her daughter, who no longer feels comfortable leaving her mother alone because of her mother's "increasing forgetfulness." The patient's medical historyis significant for type 2 diabetes, hypertension, coronary artery disease, congestive heart failure, and OA. She takes the following medications: acetaminophen 650 mg every 6 hours as needed for pain, lisinopril 20 mg daily, furosemide 20 mg daily, potassium chloride 20 mEq daily, carvedilol 12.5 mg twice daily, and glipizide 5 mg daily. Her MMSE score is 18/30. Blood tests obtained last week showed a normal basic metabolic panel, except for a fasting plasma glucose reading of 65 mg/dL. Her hemoglobin A1C (A1C) is 5.6%. A urinalysis is negative. No nutritional deficiencies are noted. The patient's blood pressure is 130/80 mm Hg and heart rate is 60 beats/minute. She receives a diagnosis of AD. 6. Which initial intervention would be most appropriate to help with this patient's cognitive function? A. Donepezil 10 mg daily. B. Galantamine extended release (ER) 24 mg daily. C. Memantine 10 mg twice daily. D. Rivastigmine patch 4.6 mg daily. 7. Which intervention would be most appropriate to prevent an adverse drug reaction? A. Discontinue glipizide. B. Discontinue lisinopril. C. Reduce carvedilol to 6.25 mg twice daily. D. Reduce potassium chloride to 10 mEq daily. 8. One year later, the patient returns to the clinic. She has moved in with her daughter. Lately, she wanders around the house continuously. She often changes clothes, cries out, and asks repetitive questions. Her current medication regimen includes donepezil 10 mg daily, which she has been taking for the past 6 months. Which would be most appropriate for this patient's new behavioral symptoms? A. Initiate olanzapine 5 mg daily. B. Initiate risperidone 0.5 mg twice daily. C. Change the donepezil dosage to 23 mg daily. D. Change acetaminophen to 650 mg every 6 hours around-the-clock. Answer D: The rivastigmine patch 4.6 mg is the appropriate initial starting dose (Answer D is correct). Answer A: This patient's current fasting blood glucose of 65 mg/ dL and A1C of 5.6% should prompt the pharmacist to request glipizide discontinuation (Answer A is correct). Answer D: Adding acetaminophen to treat possible pain that could be causing the patient's behavior should be tried before more aggressive strategies (Answer D is correct).