A 70-year-old man comes to the office because he has progressive difficulty speaking. The patient's family states that over the past 2 years he has gradually been speaking less. Another physician prescribed propranolol for anxiety related to his work as a museum docent, discussing art with tour groups. His difficulty continued, and in the last year, his responsibilities at work have been shifted. His family thinks he understands most of what is said to him, but he answers questions in 1- or 2-word phrases, typically just nouns and verbs. His memory seems to be relatively spared, and he performs many chores around the house, including cleaning and helping with cooking. The patient is partially independent in ADLs. However, because of his language difficulties, he cannot safely leave the house alone. More recently, he has acted inappropriately toward family members, and they are concerned about what he might do in public if he is alone. History includes hypertension, anxiety, and anemia. There is no history of drug or alcohol abuse. Show
Physical examination is consistent with the history provided by the family. Laboratory findings include macrocytic anemia with a low level of vitamin B12. Levels of homocysteine, methylmalonic acid, and thyrotropin are normal. Renal function and hepatic synthetic function are intact. There is no evidence of prior stroke on MRI of the brain. Which one of the following is the most
likely cause of the patient's cognitive impairment? A 73-year-old man comes to the office because he has memory problems, which have become most evident to his wife this year. In addition, he has had repeated unexplained falls. History includes hypertension, hyperlipidemia, diabetes, urinary incontinence, and constipation. Seven years ago he began to have impaired smelling, altered taste, and fitful sleep with recurrent dream enactment; the dream enactments wake his wife at night. Symptoms progressed, and fluctuating cognitive dysfunction and bilateral arm tremors developed. For several years, he has had hallucinations of children in the room. The hallucinations do not frighten him, but they worsened during hospitalization for urinary tract infection last year. Neuroleptic agents were administered, but his condition deteriorated and he required restraints for several hours. Behavioral interventions for the patient's neuropsychiatric symptoms have been unsuccessful. MRI of the brain shows mild white matter changes. Which one of the following medications should NOT be considered for this patient? (A) Clonazepam A 71-year-old man is referred to the office for follow-up after a thyrotropin level of 0.5 mIU/L is found during evaluation for a concern for memory loss. He feels well and has no tremor, palpitations, or heat intolerance. On further questioning, his wife, who has accompanied him, states that she is worried about his memory and his ability to drive. She reports that he has had trouble remembering plans they make with friends and, most recently, he got lost driving to a local restaurant that they have been going to for years. On examination, blood pressure is 125/80 mmHg, heart rate is 72 beats per minute, and BMI is 23 kg/m2. Thyroid gland is of normal size, with no palpable nodules. Electrocardiography is normal. Laboratory findings: A 71-year-old woman comes to the office for a 1-year follow-up appointment. During review of systems, she describes noticing problems with memory for the past 8 months. She forgets where she places objects and has trouble remembering the names of people right away. She has never gotten lost. She lives alone at home and performs all ADLs. She has fallen twice in the past year and is developing a fear of falling. She drives without incident, mostly to local, familiar places. Recently, she has asked her daughter to join her in grocery shopping because she forgets items. She cleans and cooks simple meals, but her daughter goes to her house weekly to help. She still enjoys gardening and going to the senior center most days of the week. She reports no symptoms of depression or hallucinations and has had no recent illness. History includes hypertension and osteopenia. Current medications are lisinopril 10 mg/d and calcium with vitamin D. There is no history of smoking. Her mother had Alzheimer disease in her 80s, and she is concerned that she will, too. On examination, blood pressure is 156/92 mmHg, heart rate is 68 beats per minute, and O2 saturation is 100%. Her score on the Mini-Mental State Examination (MMSE) is 24 of 30. She rises from the chair on the second try and displays path deviation when she walks down the hall. In addition to repeating the MMSE in 6 months, which one of the following is the most appropriate intervention? (A) Increase lisinopril dosage to achieve target blood pressure <140/90 mmHg. The husband of an 82-year-old woman calls the clinic to report changes in her behavior over the last few days. She is confused, becomes agitated when he assists with ADLs, and will not eat because she thinks she is being poisoned. History includes hypertension, depression, osteoarthritis, probable Alzheimer disease (diagnosed 2 years ago), and urinary incontinence. Her score on the Mini-Mental State Examination was 22 of 30 at her last visit 2 months ago. Medications include acetaminophen 325 mg four times daily, donepezil 5 mg/d, extended-release memantine 14 mg/d, hydrochlorothiazide 25 mg/d, lisinopril 10 mg/d, tolterodine 2 mg twice daily, and citalopram 20 mg/d. The donepezil and memantine were begun 2 years ago, tolterodine was increased 1 week ago, and citalopram was increased (from 10 mg) 2 months ago. A visiting nurse obtains laboratory samples later that day. Laboratory findings: Which one of the following is most appropriate at this time? (A) Discontinue tolterodine. An 85-year-old man is brought to the office by his son because his symptoms of Alzheimer disease have significantly worsened over the last 6 months. Probable late-onset Alzheimer disease was diagnosed 5 years ago, and until recently the disease had progressed slowly. History also includes hypertension and diabetes. Medication includes maximum dosages of donepezil and memantine. The son is the primary caregiver and health care proxy. The patient frequently wanders outside the house at night. He is convinced that people are breaking into his home at night, and his son recently found him in the kitchen holding a knife, yelling "intruder" at the window curtains. Reorientation tactics to address this behavior have not been successful. A thorough evaluation for reversible causes of acute psychosis is negative. The patient's son requests pharmacologic management of the psychosis, understanding the risks it entails in patients with dementia. Which one of the following regimens should be prescribed to help manage the patient's symptoms? (A) Begin haloperidol at a low dosage, increase the dosage until symptoms are controlled, then taper as soon as possible. An 86-year-old woman is admitted to the hospital from a nursing home because over the past 2 days she has become increasingly lethargic, sleeping on and off throughout the day, and is slow to respond to questions. The staff accompanying her reports that she is normally alert and oriented, pleasant, and actively involved in her care. History includes hypertension, type 2 diabetes mellitus, paraplegia from a car accident 30 years ago, and recurrent pressure ulcers. On arrival in the emergency department, temperature is 39.3° C (102.8° F), blood pressure is 88/40 mmHg, and heart rate is 100 beats per minute. Behavior fluctuates between lethargy and mild agitation. She provides no useful history. Which one of the following is the most appropriate next step in her care? (A) Obtain CT of the head with contrast. A 73-year-old woman comes to the office a few days after the death of her husband from endstage renal disease and metastatic cancer. She was his sole caregiver for the last 3 years and took care of all medical and practical decisions in his last days. She now is distressed and barely able to speak. She is sleeping poorly, has lost weight, and feels isolated and unable to function. She has no children or other family, and she neglected friendships because of the demands of caregiving. She declines medication to help her sleep and agrees to return in a few days for follow-up. One week later, she is calmer, but she still cries easily, cannot sleep, and is unable to concentrate. She realizes that she neglected her health during her husband's illness and wants to start taking care of herself, but she has a feeling of futility at the idea of engaging in any activity. She states that she has no active or passive suicidal ideation. History includes hypertension, osteoarthritis, and hypercholesterolemia. Which one of the following is the most appropriate course of action? (A) No treatment is necessary for normal grief
reaction. An 82-year-old woman comes to the office for follow-up related to treatment of depressive disorder. At an appointment 4 months ago, she was tearful and sad and described loss of appetite, poor sleep, and loss of interest in usual activities. She had no psychotic symptoms or suicidal ideation. She attributed her symptoms to a change in her living situation: her son had recently moved in with her after he lost his job and got divorced. In addition to depression, history includes diabetes mellitus, hypertension, coronary artery disease, and osteoarthritis. There is no history of suicide attempt or psychiatric hospitalization. Current medications are metformin, levothyroxine, hydrochlorothiazide, metoprolol, and docusate, as well as ibuprofen as needed. Trials of sertraline and venlafaxine were attempted beginning 4 months ago, but she did not tolerate either drug. Mirtazapine was started, with the dosage titrated up to 45 mg nightly. She has now taken mirtazapine for 3 months. She reports better mood and improved sleep and appetite, and she cries less. However, she spends most of her time in bed and remains uninterested in usual activities, and she is troubled by adverse effects of constipation and weight gain. Laboratory findings include hemoglobin A1c of 8% and glomerular filtration rate of 35 mL/min. Thyrotropin level is normal. Which one of the following treatment options should be considered next? (A) Discontinue mirtazapine and initiate tricyclic antidepressant. An 82-year-old man comes to the office because he wakes up to urinate up to 4 times each night. His wife states that he snores loudly, and she frequently nudges him during sleep so that he will turn over on his side. He reports daytime napping because he does not feel rested. History includes heart failure secondary to diastolic dysfunction, type 2 diabetes, chronic kidney disease (baseline creatinine of 1.3 mg/dL), hypertension, and hyperlipidemia. He had transurethral resection of the prostate 5 years ago for benign prostatic hypertrophy. Current medications are carvedilol, lisinopril, furosemide, atorvastatin, aspirin, glargine insulin at bedtime, and tamsulosin. The furosemide dosage is 40 mg/d, which he takes at 9 AM. On examination, BMI is 32 kg/m2 and blood pressure is 145/80 mmHg. Heart sounds are regular in rate and rhythm, with a loud P2 heard best during inspiration over the left parasternal region, intercostal space 2. There is bilateral 2+ pitting edema at the calves. Rectal examination reveals a nontender prostate estimated to weigh 30 g (minimally enlarged). Ultrasonography of the bladder shows 50 mL of residual urine after normal voiding. Urinalysis reveals 0-5 WBCs/high-power field and is otherwise unremarkable. Which one of the following is the most appropriate next step in evaluation of the nocturia? (A) Overnight sleep study or polysomnography You are asked to evaluate Mrs. P who is a 65-year-old female who has been exhibiting increased confusion over the past 3 days, accompanied by disorganized thinking, visual hallucinations of little children playing in her room, physical aggression during ADLs, and an inability to focus her attention on exercise instructions when working with the physical therapist. The morning shift nurses state she "seems just fine", however night shift
staff report she is more confused, restless and agitated at night. Which of the following accurately describes the CAM criteria she meets for a diagnosis of delirium? Mr. G is an 86-year-old male with a PMH for Lewy Body Dementia, HTN, diabetes, and CAD s/p CABG 10 years ago. He recently suffered an AMI and is in the ICU. The nursing staff report he has been very confused, paranoid and hallucinating for the past few nights; gets physically aggressive during care; and frequently pulls at his tubes/IVs. The hospitalist ordered Haldol 5mg IV q4 hrs and Ativan 1mg q4hrs prn IV for agitation. He has also
recently been placed in bilateral wrist restraints. The family is concerned that he is now drooling, somnolent and rigid. The nursing staff note the Ativan doesn't seem to help at all and possibly makes him more agitated. Which is the most appropriate initial plan for Mr. G? What easily enacted strategy can middle aged people use to improve their memory quizlet?What easily enacted strategy can middle-aged people use to improve their memory functioning? Pay greater attention to material when it is first encountered.
What technique can be used to lengthen the time that information stays in short(one technique for extending the amount of information we can hold in short-term memory is called chunking. Involves grouping information together into meaningful units, or hunks.
Which memory capacity tends increase with age?A type of memory called semantic memory continues to improve for many older adults. Semantic memory is the ability to recall concepts and general facts that are not related to specific experiences.
Which of the following memory deficits would be least likely in older adulthood quizlet?Older adults are less likely to exhibit memory binding to a context.
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What easily enacted strategy can middle aged people use to improve their memory functioning quizlet?
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