Question 1

Which of the following accompanies decreased ovarian function?

Accepted Answer

Menopause, or the cessation of menses for 1 year, commonly occurs in the late 40s to early 50s. Many experience hot flashes, sweating, chills, anxiety, decreased sleep, and urge incontinence. Dyspareunia is common secondary to decreased vaginal secretions. Sexual interest does not normally decrease. The clitoris and length of the vaginal vault decrease in response to decreased estrogen.

Question 2

You are examining an elderly man and notice the following: decreased vibration sense in the feet and ankles, diminished gag reflex, right patellar reflex less than the left, and diminished abdominal reflexes. Which of these is abnormal?

Accepted Answer

Asymmetry on any examination is usually reason for concern. The other changes are commonly associated with aging. You may consider looking for other neurologic signs on the right, although occasionally you may mistake an abnormally brisk reflex to be normal when compared to the other side. It is usually a good idea to question whether the opposite side is actually the abnormal one when you find asymmetry on examination.

Question 3

Mrs. Glynn is 90 years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living?

Accepted Answer

Instrumental activities of daily living involve higher thought processes such as preparing food, whereas bathing, dressing, and transferring are considered physical activities of daily living.

Question 4

Mr. Kelly comes to you today for a burning pain in his lower abdomen. This has gone on for 2 months. He has received radiation for prostatic cancer for the past quarter. What assumptions could you draw from this?

Accepted Answer

This scenario is consistent with acute pain, although this may become persistent if it lasts beyond 3 months. The burning quality to the pain should be a red flag, along with descriptions of pain as "discomfort" or "soreness." Depressed affect or changes in posture or gait are also red flags. Studies have found that pain reporting in the elderly is accurate. Although depression may be present, we have no indications of it in this scenario.

Question 5

Mr. White's son brings him in today because he notes that Mr. White has not been himself lately. He seems forgetful and has not taken care of himself as he normally does. He has reported falling twice at home to his son and has telephoned late at night because of insomnia. His blood pressure and diabetes have been difficult to control and his warfarin dosing has become more difficult. Which of the following should you suspect?

Accepted Answer

All of these answers are common diseases of the elderly and many have atypical presentations in this age group. The fact that his hypertension has become more difficult to control and his warfarin dosing is challenging to manage should lead you to consider that there is alcohol use. Further questioning, quantifying his use of alcohol, and application of the CAGE questionnaire may be useful.

Question 6

Claire's daughter brings her in today after Claire fell at her home. Which assessments are indicated at this time?

Accepted Answer

Falls are common in the elderly and can often result in serious injuries. When assessing the cause of falls, gait and balance should be checked first. Medication, particularly use of more than three, is associated with falls. Vision problems, lower-limb joint problems, and cardiovascular problems such as arrhythmias may be reasonable to search for. Orthostatic vital sign changes should be sought.

Question 7

Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar aspects of her forearms and on her abdomen. She otherwise has no complaints and her diabetes and hypertension are well managed. Her son from out of state accompanies her today and has recently moved in to help her. What should you suspect?

Accepted Answer

The different colors of the bruising indicate that they have occurred at different times and are unlikely to have resulted from a single fall. The location of the bruising on the ulnar aspects of the forearms potentially indicates that she was trying to defend herself and are not typical areas to be bruised by a fall. Depression may be evident, but this is more likely to be a result rather than a cause of her situation today. While nothing is proven, it would be wise to interview her without her son in the room. If in doubt, a social worker consult may be helpful to determine if elder abuse is occurring.

Question 8

A patient comes to you for the appearance of red patches on his forearms that have been present for several months. They remain for several weeks. He denies a history of trauma. Which of the following is likely?

Accepted Answer

Actinic purpura is a common benign skin condition of the elderly, frequently involving the forearms. Pseudoscars are white patches and cherry angiomas are bright-red raised lesions usually found on the torso. Actinic keratoses are lesions resembling nevi, often with features which would be concerning if considering melanoma (review the ABCDEs of melanoma), but they produce a slightly greasy scale when scratched with a nail.

Question 9

On routine screening you notice that the cup-to-disc ratio of the patient's right eye is 1:2. What ocular condition should you suspect?

Accepted Answer

This cup-to-disc ratio means that the cup takes up 50% of the disc, which is abnormally large. This is usually an indication of glaucoma, which is a common cause of visual loss in the elderly. The cup-to-disc changes are not seen in diabetes, hypertension, or macular degeneration. Many elderly do not have regular eye examinations and are not screened for glaucoma.

Question 10

Which of the following is true of assessment of the vascular system in the elderly?

Accepted Answer

It is the minority of patients with peripheral vascular disease who experience claudication; therefore, ankle-brachial ratios should be performed more frequently. The aorta should be 3 cm or less. Bruits usually indicate pathology, and even when there is not a significant blockage, the risk of vascular disease throughout the body is increased. Orthostatic vital signs are very useful in this population. Remember to observe the pulse as well, as failure of the heart to increase its rate is a common cause of orthostatic hypotension. This can occur as a result of autonomic neuropathy or medications such as beta-blockers, among other causes.

Quiz 20: The Older Adult