1. N.H. is an 85-year-old woman who resides in a nursing home.

She weighs 65
kg. Her medical history is significant for type 2 diabetes mellitus, hypertension,
and moderate dementia, likely attributable to vascular changes. Two years ago,
she had a cerebrovascular accident, and 1 year ago, she sustained a right hip
fracture after a fall. Her regularly scheduled medications include glyburide 10
mg/day, lisinopril 10 mg/day, metformin 500 mg two times/day, donepezil 10
mg/day, aspirin 81 mg/day, and a multivitamin daily. Her as-needed medications
include zolpidem 5 mg/day as needed for sleep, meclizine 25 mg ½ tablet three
times/day as needed for dizziness, and the house bowel regimen. When
recommending medication changes for this patient, which functional assessment
is most important to evaluate?
A. IADLs.
B. Depression.
C. Gait and balance.
D. Pressure sores.

1. Answer: C
This patient is similar to many other nursing home residents, with many chronic
diseases requiring drug management. At this time, she has several risk factors
for falls, including a history of fall with hip fracture; diseases such as diabetes,
dementia, and hypertension; dizziness; and use of several drugs. An assessment
for gait and balance would help determine the severity of her risk.
2. Your evaluation of N.H. reveals that she has not used any of her as-needed
medications in 2 months. In addition, her laboratory results reveal the following:
fasting plasma glucose 90 mg/dL, sodium 138 mEq/L, potassium 4.5 mEq/L,
chloride 102 mEq/L, CO2 25 mEq/L, blood urea nitrogen 30 mg/dL, SCr 1.8
mg/dL, and TSH 4.0 mU/L. Which pharmacokinetic parameter is most likely
altered in N.H.?
A. Oral absorption.
B. Distribution.
C. Metabolism.
D. Renal excretion.

2. Answer: D
Renal elimination is usually the most significantly changed pharmacokinetic
parameter in older people. In this patient, her advanced age and diseases will
add to her loss of renal function. Using the Cockcroft-Gault equation, this
patient’s estimated creatinine clearance is 24 mL/minute. Creatinine clearance =
[(140 − 85)65/(72 × 1.8)] × 0.85

3. On the basis of your assessment of age- and disease-related changes in N.H.,

which is best to address first?
A. Diabetes treatment.
B. Alzheimer disease treatment.
C. Hypertension treatment.
D. Stroke prevention.

3. Answer: A
The diabetes treatment should be addressed promptly. Because the patient has
considerable renal insufficiency, she does not meet the prescribing guidelines for
metformin. Use of metformin in individuals with impaired renal function increases
the likelihood of lactic acidosis. In addition, glyburide is partly eliminated in the
kidney, with a duration of effect of about 24 hours, and is not recommended for
elderly patients with poor renal elimination. This patient could be experiencing
periods of hypoglycemia that contribute to her dizziness.

4. To maintain and improve function in N.H., which intervention is best to

implement?
A. Add a calcium and vitamin D supplement.
B. Add simvastatin 10 mg/day.
C. Add warfarin.
D. Assess for incontinence and treat with anticholinergic agents.

4. Answer: A
Efforts to maintain bone and muscle strength are important for this patient. Most
older people do not consume a diet rich in calcium or vitamin D. In addition,
because the patient resides in a nursing home, she will have less sun exposure
and is more likely to be deficient in vitamin D, which is a risk factor for falls and
reduced muscle strength.

5. An 85-year-old woman is assessed at a memory loss clinic to determine the

cause of her cognitive impairment. Her most recent score on the MMSE is 24/30.
Present diagnoses include Parkinson disease, hypothyroidism, and OA of both
knees. She has had these conditions for more than 10 years, is stable, and is
independent in her ADLs. Her present medications include carbidopa/levodopa
continuous release, trihexyphenidyl, celecoxib, levothyroxine, docusate, and
bisacodyl. Which medication change is best to consider at this time?

A. Add donepezil 5 mg/day.

B. Slow dosage reduction of carbidopa/levodopa.

C. Slow dosage reduction and discontinue trihexyphenidyl.

D. Replace celecoxib with acetaminophen.

5. Answer: C
This patient has mild-moderate dementia in addition to Parkinson disease.
Although some patients with Parkinson disease develop dementia, many do not.
This patient has been stable for some years. When evaluating her cognitive loss,
it is important to limit the use of any drug that could contribute to confusion.
Anticholinergics such as trihexyphenidyl can cause confusion. Because this drug
is likely part of the patient’s Parkinson disease treatment, the dose should be
slowly reduced, and the patient should be monitored for exacerbations of her
Parkinson disease.

6. An 87-year-old man with Alzheimer disease is on therapy with rivastigmine. He

has been titrated up to rivastigmine 6 mg two times/day. His family notes
improvement in his functional ability but reports that he is experiencing nausea
and vomiting that appear to be related to rivastigmine. Which is the best
recommendation at this time?

A. Advise the patient to take his rivastigmine with an antacid.

B. Add prochlorperazine 25 mg by rectal suppository with each rivastigmine

dose.

C. Discontinue rivastigmine and initiate memantine 5 mg twice daily.

D. Change rivastigmine to the daily patch that delivers 9.5 mg/day.

6. Answer: D
Rivastigmine is a potent inhibitor of acetyl and butyl cholinesterase, leading to
significant cholinergic adverse effects such as nausea, vomiting, and diarrhea.
These adverse effects can be diminished by a slow-dosage titration of the drug.
In addition, when a patient is at his or her full therapeutic dose, use of the
transdermal delivery system will generate even plasma concentrations and
lessen the incidence of cholinergic adverse effects. On the basis of the
maintenance dose achieved of 12 mg of rivastigmine, this man can be changed
to the 18-mg patch that delivers 9.5 mg/day.

7. R.A. is a 75-year-old woman with Alzheimer disease who has been treated
with donepezil 10 mg/day for about 3 years. When she began therapy, her
MMSE was 21/30; her present MMSE is 17/30. R.A. is living at home with her
husband. She cannot perform most IADLs but can perform most ADLs with
cueing. R.A.’s husband asks about changing her drug treatment to help maintain
her function. Which is the next best course of action?

A. Change her treatment from donepezil to rivastigmine.

B. Discontinue donepezil.

C. Add memantine 5 mg/day.

D. Add vitamin E 400 units two times/day.

7. Answer: C
Over 3 years, R.A. has declined 4 points on her MMSE, which suggests a
treatment response to donepezil. Furthermore, R.A. is still able to live at home
with her husband, and she has maintained some function in her basic ADLs.
Because she has benefited from acetylcholinesterase inhibitor use, she should
not abruptly discontinue it. Clinical trials with memantine show that an additional
treatment response can be observed when memantine is added to donepezil
therapy. Memantine should be initiated at 5 mg/day and increased every 2 weeks
until the full therapeutic dose is achieved (10 mg two times/day).

8. You are evaluating the medication profile of an 87-year-old female nursing

home resident. She resides in a secure advanced dementia unit. Her medical
history includes dementia probably caused by Alzheimer disease, Parkinson
disease, and OA. She requires assistance with all ADLs including total
assistance with bathing and dressing and help with feeding. She ambulates with
the assistance of a four-wheeled walker. Her medication regimen includes
donepezil 10 mg/day, memantine 10 mg two times/day,carbidopa/levodo-pa
25/100 mg four times/day, oxybutynin extended release 5 mg/day, and a
multivitamin supplement daily. The patient’s MMSE score is 5/30, and her GDS is
4/15. When reviewing the nursing notes, there are several references to the
patient’s continuously crying out, “Help me, help me.” Which additional
assessment tool is most necessary in assessing this patient?
A. The Brief Psychiatric Rating Scale.
B. Functional Assessment Staging.
C. An evaluation of incontinence.
D. Framingham Risk Assessment.

8. Answer: C
This patient has several issues related to her medication regimen. Patients in late
stages of dementia (as evidenced by an MMSE of 5/30) will develop a functional
incontinence caused by their loss of cognition and inability to recognize toileting
needs. Oxybutynin is an anticholinergic agent useful in treating overactive
bladder rather than functional incontinence, and it has pharmacologic properties
that oppose the action of donepezil. A review of the patient’s incontinence history
will help determine whether this drug is efficacious in the treatment of her UI.
9. Which change would be best to reduce inappropriate medications?
A. Change carbidopa/levodopa to a continuous-release formulation.
B. Discontinue oxybutynin.
C. Discontinue memantine.
D. Reduce dose of donepezil.

9. Answer: B
Discontinue oxybutynin. This drug is classified as an inappropriate drug
according to Beers consensus criteria. In addition, oxybutynin is highly
anticholinergic and may lead to confusion in older patients. If the patient does
have overactive bladder (rather than functional incontinence), alternative
medications can be used that more specifically target the bladder muscle with
less potential for central nervous system effects.
10. This patient is medically assessed, and reversible causes of her hyper-
vocalization are ruled out. Which represent the best approach to treating her
behavioral symptoms?
A. Implement a behavioral approach.
B. Add valproic acid.
C. Add quetiapine.
D. Add citalopram.
10. Answer: A
Hyper-vocalization is a difficult behavior to address. In general, medications are
not very efficacious in this instance. Adding quetiapine would likely result in seda-
tion in the patient as well as add the increased risk of mortality seen with APs.
Although the behavior might decrease during periods of sedation, the behavior
often returns when the patient adjusts to or develops a tolerance of the sedative
properties. The other drug choices, valproic acid and citalopram, do not have
much evidence of effectiveness in the literature. A behavioral approach is the
best method to try in this patient. Types of interventions that could be effective
include those that create a soothing, serene environment for the patient, such as
soft music. Activities appropriate to the patient’s level of cognition might also be
helpful as a distracting mechanism as well as a way to improve interactions.
Reassurance by staff is also particularly helpful so that the patient feels more
comforted often, moving a patient from his or her room and closer to the nurses’
station will help a patient feel less alone and less afraid.

11. A 75-year-old woman reports urinary urgency, frequency, and loss of urine
when she cannot make it 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 Alzheimer disease (MMSE 23), OA, and hypothyroidism.
A urinalysis is negative, her examination is normal, and her post void residual
(PVR) is normal (less than 100 mL). Which intervention would be best at this
time?

A. Bethanechol.

B. Pelvic floor exercises plus estrogen vaginal cream.

C. Darifenacin.

D. Oxybutynin.

11. Answer: C
This patient is showing symptoms of urge incontinence. Estrogen vaginal cream
is a treatment for stress incontinence, but it would unlikely affect her UI.
Bethanechol is potentially an option for overflow incontinence, but it could worsen
her urge symptoms. Oxybutynin is an antimuscarinic agent that might help
relieve her symptoms of UI, but it would also be the most likely option to cause
adverse events and worsen her Alzheimer disease because it is able to cross the
blood-brain barrier so easily. There is some evidence that darifenacin does not
worsen cognition, and it would be preferred over oxybutynin in this patient.

12. A.W. is an 85-year-old man who presents to his physician with LUTS. A
digital rectal examination confirms the diagnosis of BPH, and the physician
schedules a further workup including a prostate ultrasound, which indicates his
prostate volume is 31 g. A.W.’s score on the AUASI is 15. His BP is 118/70
sitting, 102/62 stand-ing. Which therapy is best at this time?

A. Terazosin.

B. Finasteride plus saw palmetto.

C. Tamsulosin.

D. Finasteride plus tamsulosin.

12. Answer: C
Pharmacologic therapy targeted at reducing urethral sphincter pressure has
proven 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 orthostasis, tamsulosin would be preferred over terazosin.
Orthostatic hypotension can still occur with all α-adrenergic blockers, so patients
should be monitored when therapy is initiated. Finasteride, an α-reductase
inhibitor, and combination therapy with these agents are recommended when
there is evidence of large prostate size. Saw palmetto is not recommended in
combination with 5-α-reductase inhibitors because saw palmetto may reduce the
efficacy of the reductase inhibitors.

13. W.F. is an 85-year-old man who presents to his physician with pain from hip
OA. He also has hypertension, coronary artery disease, and BPH. For his OA,
W.F. has been taking acetaminophen 650 mg three times/ day. W.F. reports that
acetaminophen helps but that he still experiences pain that limits his ability to
walk. Which is the best next step for W.F.?

A. Change the analgesic to celecoxib.

B. Add hydrocodone.
C. Change the analgesic to ibuprofen.

D. Add glucosamine.

13. Answer: B

The American Geriatrics Society recommends treatment with opioids for OA

when older patients do not respond to initial therapy with acetaminophen. The
NSAIDs and COX-2 inhibitors are seldom considered when a thorough
assessment of the patient shows that the risk of treatment (GI bleeding and renal
disease) does not outweigh the potential benefit. Glucosamine can be added to
this patient’s medication regimen; however, even if effective, it will not provide
immediate relief of pain.

14. F.A. is a 55-year-old woman with rheumatoid arthritis. On diagnosis 1 year

ago, F.A. had an RF titer of 1:64, signs and symptoms of inflammation in the
joints of both hands, and about 45 minutes of morning stiffness. She began
therapy with methotrexate, and she presently receives 15 mg/week, folic acid 2
mg/day, ibuprofen 800 mg three times/day, and omeprazole 20 mg/day. At
today’s clinic visit, F.A. reports a recurrence of her symptoms. Radio-graphic
evaluation of her hand joints shows progression of joint space narrowing and
bone erosion. Which is the next best step for F.A.?

A. Administer etanercept.

B. Switch to hydroxychloroquine.

C. Add prednisone bridge therapy.

D. Change to leflunomide.

14. Answer: A
This is an example of a young woman with indicators of poor prognosis with
rheumatoid arthritis (positive RF, young age, many symptoms) who has not
responded to therapy with methotrexate. Although the next treatment step is not
entirely clear, her best choices are between combination DMARD therapy and a
biologic agent. Leflunomide would not be preferred because its efficacy is similar
to that of methotrexate. Hydroxychloroquine would not be recommended as sole
therapy for someone who has not responded to methotrexate. Etanercept has a
response in 60%–75% of patients whose therapy with methotrexate has failed.
Glucocorticosteroids are used as adjunctive therapy for the first several months
of treatment with a disease-modifying agent.

15. R.J. is a 79-year-old woman with a history of mild dementia (Mini-Mental

State Examination [MMSE] 23/30), hypertension, hypothyroidism, depression,
and neuropathic pain. She presents to your clinic and reports taking atenolol 25
mg twice daily, levothyroxine 125 mcg/day, amitriptyline 25 mg at bedtime, and
citalopram 20 mg/day. Her husband states that she has become increasingly
confused in the past 2 weeks. R.J.’s laboratory values are within normal limits,
including a normal thyroid-stimulating hormone (TSH) and negative urinalysis.
Her Geriatric Depression Scale (GDS) is 3/15. Her blood pressure (BP) is 145/85
mm Hg, and heart rate (HR) is 65 beats/minute. Which is the most likely
contributor to her confusion?
A. Dementia is worsening.
B. Amitriptyline is causing anticholinergic effects.
C. Depression is not adequately treated.
D. Urinalysis is falsely negative and should be repeated.

15. Answer: B
Amitriptyline is highly anticholinergic and can cause sudden confusion in the
elderly. A worsening of this patient’s dementia could lead to confusion, but it
would not likely occur in such a short time. Although confusion could be a
symptom of depression, the GDS is not positive. There is no reason to repeat a
urinalysis.
Questions 16 and 17 pertain to the following case.
J.T. is an 82-year-old community-dwelling woman with a history of stage III
Parkinson disease, hypertension, and urinary incontinence (UI). She is receiving
carbidopa/levodopa, pramipexole, selegiline, tolterodine, diazepam, metoprolol,
and hydrochlorothiazide. When she comes to your pharmacy to pick up her
medications, she walks slowly with a cane, stooped over.
16. Which is the most important intervention you can make to reduce her risk of
falls?
A. Refer J.T. to her neurologist for reassessment of her Parkinson disease
medications.
B. Advise J.T. to speak to her internist about discontinuing diazepam.
C. Suggest to J.T. that she see a physical therapist to institute a therapeutic
exercise program.
D. Measure J.T.’s BP to rule out postural effects from treatment of her disease
conditions.
16. Answer: B
All the choices presented for this question might reduce the risk of falls in this
patient. However, Answer: B is best because a great deal of literature documents
the association between the use of benzodiazepines with long elimination half-
lives and hip fracture. Furthermore, no diagnosis exists that warrants a
benzodiazepine for this patient. If a diagnosis were added that required a benzo-
diazepine, a better choice would be lorazepam. Parkinson disease is a risk factor
for falls. Exercise can reduce the likelihood of falls. Avoiding postural
hypotension from antihypertensive medications will also help reduce falls.
However, of all four choices, use of diazepam is inappropriate because of its
pharmacokinetic profile and lack of indication.
17. While picking up her medications at your pharmacy, J.T. buys incontinence
supplies. She confides in you that her incontinence is more severe because she
cannot get to the bathroom in time. On further questioning, you learn that J.T.
believes her slowed movement is a worsening problem. Which is the best
description of J.T.’s symptoms?
A. Stress incontinence.
B. Urge incontinence.
C. Functional incontinence.
D. Overactive bladder.

17. Answer: C
This patient’s symptoms suggest that she cannot ambulate well enough to get to
the bathroom. Her ambulation problems could be attributed to worsening Parkin-
son disease. This type of incontinence is referred to as “functional incontinence.”
One intervention that could help the patient with functional incontinence is the
adoption of a scheduled toileting program.
18. An 85-year-old woman is taking ferrous sulfate to treat an iron deficiency
anemia. Changes in which age-associated pharmacokinetic property can most
affect this agent?
A. Absorption.
B. Distribution.
C. Metabolism.
D. Renal elimination.

18. Answer: A
Older patients have several age-related physiologic changes in the GI tract that
can alter the absorption of medications. A decrease in stomach acidity occurs,
and drugs that require an acidic environment to dissolve and/or be absorbed will
be affected. Iron absorption is reduced with reduced acidity. Fortunately, most
drugs are absorbed through passive diffusion, which does not change
appreciably in the older patient.

19. Questions 19–22 pertain to the following case.

W.G. is a 75-year-old African American man with coronary artery disease,
hypertension, type 2 diabetes mellitus, chronic low back pain caused by
osteoarthritis (OA) of the spine, peripheral neuropathy, and benign prostatic
hypertrophy (BPH). W.G. weighs 72 kg and is 71″ tall, and his serum creatinine
(SCr) is 1.4 mg/dL. W.G.’s medications include metoprolol extended release 50
mg/day, lisinopril 20 mg/day, metformin 1000 mg two times/day, gabapentin 900
mg three times/day, glipizide extended release 10 mg/day, citalopram 20 mg/day,
acetaminophen 1000 mg three times/day, Tylenol PM as needed at night, and
hydrocodone-acetaminophen 5 mg/500 mg 1 tablet as needed for pain every 4–6
hours.
19. Considering age-associated pharmacokinetic changes, a dose reduction in
which medication may be most indicated for W.G.?
A. Metoprolol.
B. Metformin.
C. Glipizide.
D. Gabapentin.

19. Answer: D
Appropriateness of the dose of metoprolol can be ensured by evaluating patient
parameters such as BP and HR; metoprolol, which undergoes about a 50% first-
pass effect, is metabolized by the CYP2D6 isoenzyme system. Given this
patient’s estimated creatinine clearance of 46 mL/minute, the risks and benefits
of continuing metformin would need to be weighed; however, if action were
taken, a discontinuation of the drug would be recommended rather than a
dosage reduction. Glipizide, which is also eliminated by metabolism, does not
generally require renal adjustment. Gabapentin, Answer: D, is correct because
the dose is too high for the patient’s renal function. The gabapentin dosage
should not exceed 1400 mg/day.
20. Which is most strongly linked to W.G.’s likelihood of experiencing a
medication adverse event?
A. Advanced age.
B. Use of many medications.
C. Lower back pain.
D. Renal insufficiency.
20. Answer: B
The use of several medications has the strongest association with adverse drug
reactions (ADRs). Although older patients might seem more sensitive to drugs
because of the pharmacokinetic and pharmacodynamic changes that occur with
aging, age is not as important as polypharmacy when the data showing a
correlation between age and ADRs are controlled for in the number of drugs
taken. Diagnoses such as renal impairment of lower back pain alone do not
increase the risk of ADRs more than polypharmacy.
21. Which intervention is most important to avoid liver toxicity in W.G.?
A. Discontinue gabapentin.
B. Decrease total dose of glipizide.
C. Decrease total dose of acetaminophen.
D. Discontinue metformin.

21. Answer: C
The FDA has reduced the amount of acetaminophen in combination products
and in the over-the-counter available doses of acetaminophen. About 400 deaths
occur annually because of unintentional overdose with acetaminophen because
many consumers do not know the ingredients of combination drug products. This
patient could easily be consuming more than the current recommended maximal
dose of 3000 mg of acetaminophen daily. Gabapentin, glipizide, and metformin
are unlikely to cause liver toxicity.
22. Which intervention would be most appropriate to avoid aggravation of urinary
symptoms associated with BPH?
A. Discontinue Tylenol PM.
B. Discontinue glipizide.
C. Discontinue citalopram.
D. Discontinue hydrocodone with acetaminophen.

22. Answer: A
Tylenol PM contains diphenhydramine, a strong anticholinergic antihistamine.
Anticholinergic medications can block bladder contractions, which can lead to
both an inability to void and increased PVR. This potential adverse effect is of
particular concern in a man with BPH who may have some baseline amount of
outlet obstruction because of an enlarged prostate gland.
23. A patient with a recent diagnosis of Alzheimer disease is considering
treatment with a cholinesterase inhibitor. Which best justifies therapy initiation?
A. MMSE score of 20/30.
B. Neuropsychiatric inventory (NPI) score of 75/120.
C. MMSE score of 10/30.
D. NPI score of 20/120.

23. Answer: A
The best evidence for using the cholinesterase inhibitors is in patients with mild-
moderate Alzheimer disease. A patient scoring a 10/30 on the MMSE would be
classified as having severe dementia, where benefit would not be as
pronounced. The NPI helps assess psychiatric symptoms in a patient. The data
are conflicting about whether cholinesterase inhibitors benefit a patient with
neuropsychiatric symptoms.
24. After initiating a cholinesterase inhibitor, which would be most appropriate to
monitor?
A. New or worsening hypertension.
B. New or worsening depression.
C. New or worsening hallucinations.
D. New or worsening urge incontinence.

24. Answer: D
Cholinesterase inhibitors prevent the breakdown of acetylcholine, resulting in
increased cholinergic activity. Initiating cholinesterase inhibitors in older people
with dementia can worsen incontinence through the increase in acetylcholine
stimulation of the bladder. This type of incontinence would be classified as urge
incontinence.
Questions 25–28 pertain to the following case.
L.M. is a 92-year-old woman who is admitted to a nursing facility after treatment
of urosepsis at the local hospital. Her diagnoses include hypertension,
generalized anxiety disorder, dementia, transient ischemic attacks, frequent
urinary tract infections, OA, and incontinence. L.M.’s medications include aspirin
81 mg/day, a multivitamin daily, amlodipine 5 mg/day, omeprazole 20 mg at
night, sertraline 100 mg/day, cranberry capsules four times/day, donepezil 10 mg
at night, lorazepam 0.5 mg every 8 hours as needed for anxiety, quetiapine 25
mg three times/day, and the house bowel regimen. L.M. weighs 62 kg; her
laboratory parameters are within normal limits except for anSCr of 1.5 mg/dL and
blood urea nitrogen of 22 mg/ dL. Her Tinetti fall risk assessment is 9/28 (high
risk), MMSE is 21/30, and GDS is 1/15 (low risk).
25. Given this patient’s medication regimen, which is L.M. at the highest risk of
developing?
A. Agitation.
B. Weight loss.
C. Death.
D. Pain.

25. Answer: C
There is a small, but consistently increased, risk of death in older patients when
APs are initiated. Analysis of the literature that documents this risk shows that
death usually occurs within the first 6 months of prescribing an AP and is
attributable to many causes. The increased risk has been observed with all the
APs. This has led to black box labeling requirements by the FDA.
26. L.M. is somnolent for most of the day and unable to participate in activities.
Which intervention is most appropriate?
A. Taper off quetiapine over 1 month.
B. Discontinue donepezil.
C. Add a 7-day course of levofloxacin.
D. Discontinue the cranberry supplement.

26. Answer: A
Several medications can often increase sedation and somnolence in older
people. In this patient, lorazepam and quetiapine have the greatest likelihood of
causing sedation. There is no indication for quetiapine, and an attempt at down-
titration of this drug and discontinuation should be made. In the future, the same
attempt should be made with lorazepam because the goal should be to treat this
patient’s generalized anxiety disorder with sertraline alone.
27. L.M. is becoming combative during her personal hygiene care in the morning,
which is a change in behavior for this patient. Which is the best approach to
address this behavioral problem?
A. Treat L.M. with acetaminophen 500 mg three times/day for pain.
B. Avoid confrontation with L.M. and discontinue her personal care.
C. Allow L.M. to sleep longer in the morning to avoid fatigue.
D. Evaluate L.M. for reversible causes of combative behavior.

27. Answer: D
Patients should be assessed for reversible causes of behavior issues when a
change in their status occurs. This evaluation should include assessing the
patient for signs and symptoms of hunger, dehydration, depression, pain,
delirium, sleep deprivation, infection, and drug adverse effects. Any reversible
causes for the combative behavior should be corrected and a behavioral
approach implemented to achieve proper hygiene and personal care.
28. The nursing staff recommends initiating analgesic treatment for L.M.’s OA.
Which is the best treatment regimen to recommend?
A. Ibuprofen 200 mg four times/day.
B. Acetaminophen 650 mg three times/day.
C. Tramadol 25 mg three times/day.
D. Oxycodone 5 mg four times/day.

28. Answer: B
The patient is 92 years old, so extra caution must be taken in prescribing
analgesics when the risk of treatment could exceed the benefit. Acetaminophen
is recommended as first-line therapy for the treatment of OA, and a lower dose
should be used in this patient. Nonsteroidal anti-inflammatory drugs are not
recommended because of the increased risk of GI bleeding and renal toxicity.
This patient is receiving aspirin 81 mg/day, which is another precaution to the
use of NSAIDs in older patients. Tramadol and oxycodone could be considered
later if benefits outweigh risks, but they are generally not first line.
29. S.C. is a 69-year-old woman with a history of rheumatoid arthritis who is
admitted to a nursing facility (after a 2-week hospitalization for sepsis). She
reports pain in her hands and requests treatment. Her physical examination and
laboratory tests are within normal limits, except for weight 47 kg, SCr 1.2, and
glucose 160. Which medication would be most appropriate to initiate at this time?
A. Etanercept.
B. Naproxen.
C. Prednisone.
D. Golimumab.

29. Answer: C
Although prednisone is not a long-term solution to treat this patient’s rheumatoid
arthritis, it would be appropriate to treat her pain for the short term. She would
not likely be a candidate for etanercept so close to her hospitalization for sepsis.
Nonsteroidal anti-inflammatory drugs should be avoided given her renal function.
Patients receiving golimumab have not responded to other therapies, and the
drug is to be used in combination with methotrexate.

30.Which one of the following opioids can increase the risk of seizures in an
elderly patient with decreased renal function?
(A) hydrocodone
(B) meperidine
(C) morphine
(D) oxycodone

Answer: B.
Meperidine and its metabolite, nor-meperidine are renally eliminated. In addition,
nor-meperidine can increase the risk for seizures.
31.A 65-year-old white man reports difficulty getting urination started, feeling like
his bladder is not emptied, and getting up several times at night to urinate. His
vitals are: sitting blood pressure 134/70 mm Hg, heart rate 66 beats per minute,
standing blood pressure 132/62 mm Hg, heart rate 68 beats per minute. Labs:
BUN/SCr 18/0.9, K 3.9, CBC, U/A within normal limits. Post-void residual (PVR)
80 ml, PSA is 5, and prostate is enlarged. Which one of the following is the best
choice for pharmacologic management?
(A) initiate finasteride 5 mg PO QD
(B) initiate doxazosin 1 mg PO QHS
(C) initiate tamsulosin 0.4 mg PO QD
(D) initiate finasteride 5 mg PO QD and doxazosin 1 mg PO QHS

31.Answer: D.
Symptoms consistent with moderate BPH are trouble initiating urination,
incomplete emptying of the bladder, and nocturia [AUA score 15]. Pharmacologic
management is recommended since BPH is symptomatic. Finasteride is
recommended for patients with an enlarged prostate. However, for patients at a
high risk of disease progression (elevated PSA, enlarged prostate, high PVR),
literature now supports the use of combination 5 alpha-reductase inhibitor
therapy and a alpha1-blocker. Tamsulosin is an alternative for patients who can
not tolerate alpha1-blockers due to allergy or orthostatic hypotension. All alpha1-
blockers should be initiated at the lowest possible dose and titrated every 2–7
days as tolerated.
32.A 92-year-old white man with Alzheimer’s disease has been taking donepezil
10 mg PO QD for 3 years. His mental status remained stable for 2 years, but
over the last year has had continued cognitive decline. He is still able to feed
himself, but requires increasing assistance with toileting and dressing. What do
you recommend?
(A) discontinue donepezil
(B) add vitamin E 400 IU PO BID
(C) add memantine 5 mg PO QD
(D) add galantamine 4 mg PO BID
32.Answer: C.
Discontinuation of cholinesterase inhibitor therapy has resulted in continued
progressive decline of dementia, if another cholinesterase inhibitor is not
initiated. The recommended dose of vitamin E for dementia is 1000 IU BID. The
addition of memantine would be reasonable since the patient has continued to
decline despite at least 6 months of therapy on a therapeutic dose of donepezil.
At this time, there is no data to support combination cholinesterase inhibitor
therapy.
33.Age-related decreases in liver function include all of the following EXCEPT:
A. liver blood flow
B. liver volume
C. phase I metabolism
D. phase II metabolism

33.Answer D.
Phase II metabolism is relatively unaffected by age.
34.RJ is a 79 yo woman hospitalized with a right hip fracture after experienced
another one of her "dizzy spells" and fell while working in the garden. PMH is
also significant for osteoporosis, HTN, DM type 2. Current meds: alendronate, 70
mg PO q Sunday, HCTZ 25 mg po daily, lisinopril 10 mg po daily, glipizide 2.5
mg. daily. During her physical exam she admits that she has felt very anxious
and has had trouble sleeping ever since her husband passed away 3 weeks ago.
She is looking forward to having her daughter come to stay with her next week
for an extended visit since she lives alone. The physician would like to prescribe
a low dose of Valium for the next few weeks upon discharge, "just to get her over
the hump" but is worried about her fall risk and wants to know if another benzo is
more appropriate. What is the most correct response?
A. All benzodiazepines increase fall risk in elderly patients, regardless of half-life,
dose, or duration.
B. Long-acting benzos like diazepam should be avoided due to increased fall
risk; choose a short-acting benzo like oxazepam or alprazolam instead.
C. Diazepam will not increase the patient's fall risk appreciably, provided it is
used only in low doses.
D. Diazepam will not increase the patient's fall risk appreciably, provided it is
used only for a short period of time (< 30 days)

34.Answer A.
Though the risk is also dose-related, several studies have shown that both short-
and long-acting benzodiazepines approximately double the risk of falls/hip
fractures in elderly patients. Risk seems highest in the first couple of weeks of
use. In a recently published meta-analysis of 22 studies assessing the
association between medication use and falls in patients 60 years and older,
benzodiazepines were associated with an adjusted OR of 1.41 (95% CI 1.20-
1.71) for falls.
35.DS is a 72 yo male who was diagnosed with Alzheimer's disease 6 months
ago. At the time his MMSE was 22 and he was started on rivastigmine 1.5 mg bid
which has been gradually tapered upwards. Today at his visit his MMSE is
unchanged and his wife, who is his primary caregiver reports that his cognitive
abilities have stabilized for now. However, she is concerned that he is no longer
showing interest in reading or watching movies, which he used to enjoy very
much. His physician believes that DS is suffering from mild depression and would
like to add an antidepressant. What is the best option for DS at this time?
A. Paroxetine, 10 mg poqday
B. Citalopram, 10 mg poqday
C. Amitriptyline, 25 mg poqhs
D. Sertraline, 100 mg po daily

35. Answer B.
Paroxetine and amitriptyline both have anticholinergic effects which can
decrease the efficacy of cholinesterase inhibitors like donepezil. Sertraline is an
acceptable first choice but the recommended starting dose is lower (25 mg/day)
36.All of the following side effects should be anticipated when titrating
rivastigmine EXCEPT:
A. nausea
B. urinary retention
C. bradycardia
D.diaphoresis

36. Answer B.
Rivastigmine is a cholinesterase inhibitor. Cholinergic side effects, including
nausea, bradycardia, and diaphoresis can occur, and can sometimes be dose-
limiting. Urinary incontinence may also occur. In contrast, urinary retention is a
common side effect with anti-cholinergic medications (such as diphenhydramine
or tricyclic antidepressants).
37.Which of the following age-related changes can affect a elderly patient's
sensitivity to warfarin?
A. Decreased CYP2C9 activity
B. Decreased liver blood flow
C. Decreased liver volume
D. Decreased bioavailability
37 AnswerC.
While age-related changes in phase I metabolism occur, evidence suggests that
it is due mostly to a decrease in liver volume rather than impaired enzymatic
activity. Decreased liver blood flow also occurs in elderly patients leading to
clinically significant changes in metabolism of drugs with a high extraction ratio,
such as lidocaine and morphine; warfarin is a low ER drug. Finally, changes in
oral absorption that occur in elderly patients (including increased gastrointestinal
pH, delayed GI motility, and decreased salivary flow) may alter the rate of
absorption but do not significantly alter overall oral bioavailability.
38.Match the following drugs used to treat rheumatoid arthritis with their unique
side effects:
1. Methotrexate a. macular damage
2. Sulfasalazine b. alopecia
3.Prednisone c. pulmonary fibrosis
4.Leflunomide d. urine & skin discoloration
5.Hydroxychloroquine e. hypertension

38.
1-c
2-d
3-e
4-b
5-a
39.Match the following biological agents used to treat rheumatoid arthritis with
their correct biological target/mechanism of action (a listed mechanism of action
may be used more than once):
1. Abatacept (Orencia)
2. Adalimumab (Humira)
3. Anakinra (Kineret)
4. Etanercept (Enbrel)
5. Infliximab (Remicade)
6. Rituxumab (Rituxan)

a. binds to TNF; prevents it from interacting with receptors on the surface of

inflammatory cells.
b. binds to IL-1 receptors on target cells; prevents interactions between IL-1 and
those cells that promote migration of inflammatory leukocytes to tissue
c. binds to CD80/CD86 receptors on antigen-presenting cells; prevents their
ability to activate T cells
d. depletes B cells
39.
1-C
2-A
3-B
4-A
5-A
6-D
40.Which of the following biological agents used in the treatment of rheumatoid
arthritis should not be given without oral methotrexate?
A. anakinra
B. infliximab
C. etanercept
D. rituxumab

40.ANSWER B.
Infliximab is a foreign protein that can stimulate the production of antibodies.
MTX is given to prevent this from happening.
41.Anakinra (Kineret) is an IL-1 receptor antagonist used to treat rheumatoid
arthritis. It can be given as monotherapy or in combination with any of the
following DMARDs except:
A. Etanercept
B. Methotrexate
C. Sulfasalazine

41. ANSWER A
Anti-TNF agents such as etanercept (as well as infliximab and adalimumab) are
contraindicated with anakinra due to increased risk of serious infection.
Sources: Lexi-Comp; Prescribing information, Kineret.
42.A 75-year-old man with a history of orthostatic hypotension, urinary retention,
and progressing dementia is brought to the emergency department by his son,
who reports that his father has become increasingly aggressive and agitated
during the past few weeks. This behavior has led to the patient’s threatening
several home health aids, who now refuse to continue caring for him. As they
await a physician, the patient pushes a nurse and begins shouting obscenities.
Which would be the best pharmacologic intervention to manage the patient’s
current symptoms?
A. Clonazepam 0.5 mg orally once
B. Haloperidol 0.5 mg orally once.
C. Quetiapine 50 mg orally once.
D. Trazodone 50 mg orally once

42. Answer B. Haloperidol 0.5 mg orally once.

Answer B is correct. Because of the patient’s medical history and current
behavioral disturbances (which are posing harm to others), an antipsychotic is
warranted at this time. Haloperidol is preferred to quetiapine because of its onset
of action and lack of orthostatic hypotension and sedation, which quetiapine may
exhibit to a greater extent
43.