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423 Cards in this Set

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According to the updated Beer’s list (2012 update), what is the maximum duration of use of non-benzodiazepine hypnotics in elderly?
a.30 days
b.90 days
c.6 months
d.Should not be used
b.90 days
non-benzodiazepines such as Eszopiclone, Zolpidem, Zaleplon should not be used chronically (>90 days).
Benzodiazepines in elderly are not indicated for ________________
a. Generalized anxiety disorder
b. Agitation
c. Ethanol withdrawal
d. Periprocedural anesthesia
Answer B: Older adults have increased sensitivity to benzodiazepines and slower metabolism of long acting agents. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents in older adults. May be appropriate for seizure disorders, rapid eye movement sleep disorders, benzodiazepine withdrawal, ethanol withdrawal, severe generalized anxiety disorder, periproceduralanesthesia, end-of-life care. Avoid benzodiazepines (any type) for treatment of insomnia, agitation, or delirium.
In a patient with end stage renal disease with a CrCl of 6ml/min diagnosed with alzheimer’s disease, what is NOT the best option?
a. Donepezil
b. Rivastigmine
c. Galantamine
d. Memantine
C: galantamine is not recommended in CrCl<9ml/min. No renal adjustment is necessary for donepezil and rivastigmine. A reduction in maintenance dose is recommended for memantine with a CrCl of 5-29ml/min.
Which of the following agents has an FDA approved indication for severe alzheimer’s disease?
a. Donepezil
b. Rivastigmine
c. Galantamine
d. None of the above
A: donepezil is approved for mild, moderate, and severe disease. Rivastigmine, and galantamine are
approved for mild to moderate disease.
1.According to American geriatric society, what is the recommended HbA1c goal in a geriatric patient with a life expectancy of <5 years?
a.<8%
b.<7%
c.<6.5%
d.<10%
a.<8%
***
Metformin use should be avoided in patient with a serum creatinine of ___________
a.>1.4 (males), >1.5 (females)
b.>1.5 (males), >1.4 (females)
c.>1.4 (males),>1.3 (females)
d.>1.3 (males), >1.4 (females)
b.>1.5 (males), >1.4 (females)
1.Which of the following iron salts contains the highest percentage of elemental iron?
a.Ferrous sulfate
b.Ferrous gluconate
c.Ferrous fumarate
d.Ferrous bisglycinate
[C] Ferrous fumarate contains 33% followed by ferrous sulfate, ferrous bisglycinate each contains 20%, ferrous gluconate 12%
****
2.At what Hgb are erythropoiesis stimulating agents indicated?
a.Hgb<10g/dL
b.Hgb<11g/dL
c.Hgb<13g/dL
d.Hgb<9g/dL
a.Hgb<10g/dL
1.How often should a beta-blocker be titrated in a heart failure patient?
a.3 days
b.1 week
c.2 week
d.6 week
c.2 week
It is recommended to titrate BB no more often than every 2 weeks, as tolerated
2.The onset of diuresis following furosemide administration is within _______ ?
a.1 hour
b.2 hour
c.3 hour
d.4 hour
Answer: A. Onset of diuresis following furosemide administration is within 1 hour.
1.Which loop diuretic has the most erratic oral absorption leading to the least bioavailability?
a.furosemide
b.torsemide
c.bumetanide
d.ethacrynic acid
ANSWER: A – Furosemide is absorbed erratically following an oral dose, and food will delay this absorption but will not alter the diuretic response. Diuresis generally begins 30 to 60 minutes after oral administration. Following oral administration torsemide is rapidly absorbed with about 80% bioavailability. First-pass metabolism is insignificant. Following oral administration, bumetanide is 85—95% absorbed. Ethacrynic acid is absorbed rapidly following an oral dose. Bioavailability is approximately 100%, with onset of diuresis occurring within 30 minutes after oral administration.
2.Which of the following is incorrect?
a.ACC/AHA Stage A heart failure – patients at high risk for heart failure but without structural damage or symptoms
b.ACC/AHA Stage C heart failure – refractory heart failure; marked symptoms at rest despite maximal medical therapy
c.ACC/AHA Stage C heart failure corresponds to NYHA Functional Class II & III
d.Both B & C are incorrect
ANSWER: B – It should be stage D.
1.In general, which of the following choices is the best option when initiating an anxiolytic in an elderly patient?
a.Diazepam
b.Clonazepam
c.Alprazolam
d.Chlordiazepoxide
Rationale: All options except C are long-acting benzodiazepines. Elderly patients experience increased sensitivity to benzodiazepines in general and metabolize these agents at a slower rate. The decreased metabolism rate can lead to accumulation which is particularly problematic as these patients may have increased cognitive impairment, falls, sedation, and delirium.
2.Which of the following statements is false?
a.The goal of the Beers criteria is to improve the care of older adults by reducing their exposure to potentially inappropriate medications.
b.Antispasmotics should be avoided in elderly patients except in short-term palliative care to reduce oral secretions.
c.The START and STOPP lists do not replace the Beers criteria, but should be used in conjunction with the Beers criteria.
d.The 2012 Beers criteria includes information that comprehensively addresses the needs of palliative and hospice care elderly patients.
d.The 2012 Beers criteria includes information that comprehensively addresses the needs of palliative and hospice care elderly patients.

Rationale: AGS 2012 Updated Beers Criteria – states in the discussion section that one of the limitations of the criteria is that it does not comprehensively address how hospice or palliative care patients should be addressed.

Option A –directly states goal of the criteria in the introduction section of Beers criteria

Option B – states this under antispasmotic section of Beers criteria

Option C – The START/STOPP lists some information not found on the Beers criteria (such as information on which drugs should be initiated by clinicians in elderly patients). Likewise, the Beers criteria has some information not found on the START/STOPP lists.
1.Which of the following is not a contraindication to the use of metformin?
a.Patient above the age of 70 years old
b.Man with a SCr of 1.5 mg/dL or greater
c.Woman with a SCr of 1.4 mg/dL or greater
d.Patient with metabolic acidosis
Answer A. Metformin is contraindicated in patients above the age of 80 years old due to reduced renal function and risk of accumulation leading to possible lactic acidosis
2.Which of the following diabetic medications carry the greatest risk of hypoglycemia?
a.exenatide
b.pioglitazone
c.glyburide
d.glipizide
Answer C. Sulfonylureas can potentially cause hypoglycemia with first-generation agents and glyburide carrying the greatest risk of all the agents within the class.
3.Which of the following statements is false?
a.Darbepoetin alfa has a longer half-life than epoetin alfa.
b.Omontys (peginesatide) is a new FDA approved medication for the treatment of anemia in CKD patients with or without dialysis.
c.Using ESAs to target a hemoglobin level of greater than 11 g/dL increases the risk of serious adverse cardiovascular events and has not been shown to provide additional patient benefit.
d.Darbepoetin alfa is derived from Chinese hamster ovarian cells and is contraindicated in patients with known hamster protein hypersensitivity.
ANSWER: B – Omontys is only approved for treatment of CKD anemia in patients on dialysis.
4.Which of the following is not a target of iron therapy in CKD in non-dialysis patients?
a.Serum ferritin >100 ng/mL
b.TSAT > 20%
c.Serum ferritin >90 ng/mL
d.Both B and C
ANSWER: C – the goal for serum ferritin in >100 ng/mL in non-dialysis patients.
5.Which of the following is considered a pseudo-irreversible cholinesterase inhibitor?
a.donepezil
b.rivastigmine
c.tacrine
d.galantamine
ANSWER: B – Rivastigmine is considered a pseudo-irreversible inhibitor of AChE. Rivastigmine binds to the esteratic site of the acetylcholinesterase enzyme but dissociates much more slowly than acetylcholine. This 'pseudo-irreversible' action explains why the cholinesterase inhibition of rivastigmine in the brain lasts much longer (average 10 hours) than the short plasma half-life of the drug (~1.5 hrs) would predict.
6.Which of the following is false regarding rivastigmine?
a.It has an extremely long half-life of about 70 hours.
b.Severe nausea and vomiting can occur with the transdermal formulation.
c.The drug has similar affinity for acetylcholinesterase and butylcholinesterase.
d.The maximum oral dose is 12 mg/day.
ANSWER: A – the half-life of rivastigmine is about 1.5 hours.
1.Which of these statements is false regarding the DOSE trial?
a.High dose diuretics provide no benefit over low conventional doses of diuretics in patients with heart failure
b.Continuous vs intermittent dosing was used in the trial
c.Patients in the high dose diuretic group had an improvement in renal function
d.None of the above, they all are correct
Answer: c (there actually was a decline in renal function that was reversible a week after the high dose therapy was stopped)
2.What is the target dose of carvedilol for a 5’8” male patient with heart failure that weighs 195lbs?
a.12.5 mg BID
b.25mg BID
c.50mg BID
d.50mg Q daily
c.50mg BID
***
1.Which drug contributed to the most hospitalizations for adverse drug events in the elderly?
a.Digoxin
b.Warfarin
c.Oral anti-platelet
d.Oral hypoglycemic
b.Warfarin
2.According to the START/STOPP criteria, an elderly patient on chronic systemic glucocorticoids should be started on (assuming no contraindications)
a.Metformin
b.SSRI
c.Calcium plus Vitamin D
d.Alendronate
Answer: d. alendronate (bisphosphonate)
1.According to the NKF-K/DOQI, at what stage of CKD should a provider assess the hemoglobin levels to check for anemia?
a.Stage 1
b.Stage 2
c.Stage 3
d.Stage 4
c.Stage 3
****
2.When making dose adjustments to patients’ medications which is the most reasonable formula to use to calculate the renal clearance?
a.MDRD
b.Cockcroft-Gault
c.CKD-EPI
d.Mayo Quadratic GFR Estimation
b.Cockcroft-Gault
1.What does agnosia mean?
a.Poor coordination and unsteadiness
b.A person is unable to perform tasks or movements when asked
c.an impairment of language ability
d.a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective
d.a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective
1.Concerns with the use of polypharmacy in elderly patients include:

A. Increased risk of adverse drug reactions
B. Increased non-adherence to medications
C. Increased healthcare costs
D. All of the above
D. All of the above
1.All of the following are age-related changes which may effect drug metabolism and response in the elderly EXCEPT for:

A. Decreased lean body mass
B. Increased hepatic blood flow
C. Decreased renal function
D, Increased gastric pH
B. Increased hepatic blood flow
Which of the following factors limits the use of tacrine for the management of Alzheimer’s disease?

A. Potential risk for hepatotoxicity
B. Four times daily dosing schedule
C. Intolerable GI side effects
D. Answers A and B
D. Answers A and B
All of the following are potential side effects associated with the use of antipsychotics in AD patients EXCEPT:

A. Extrapyramidal symptoms
B. Somnolence
C. Dystonia
D. All of the above are potential side effects
D. All of the above are potential side effects
1.All of the following are phosphorous dietary restrictions EXCEPT:
a.Dark-colored soda
b.Cheese
c.Dried beans
d.Salmon
d.Salmon
All of the following factors contribute to the development of diabetes in an elderly patient EXCEPT

A. Decreased beta cell function
B. Increased fasting glucose production
C. Impairment in insulin mediated glucose disposal
D. All of the above contribute to the development of diabetes
D. All of the above contribute to the development of diabetes
Which of the following is a concern when using a sulfonylurea in an elderly diabetic patient?

A. Hyperglycemia
B. Need for higher doses to achieve appropriate glycemic response
C. Black box warning for increased cardiovascular risk
D. All of the above are concerns
C. Black box warning for increased cardiovascular risk
1.All of the following medication classes have been shown to improve mortality in patients with congestive heart failure EXCEPT:
A.Beta-blockers
B.Loop diuretics
C.ACE-inhibitors
D.Aldosterone antagonists
B.Loop diuretics
1.Which of the following is the most appropriate target dose for a patient with congestive heart failure receiving carvedilol?
A.3.125 mg twice daily
B.12.5 mg twice daily
C.25 mg twice daily
D.50 mg twice daily
C.25 mg twice daily
1.
Tradjenta (linagliptan):

a. is a glucagon-like peptide-1 (GLP-1) receptor agonist.
b. is a dipeptidyl peptidase-4 (DPP-4) inhibitor.
c. requires renal dosing, therefore is of concern in the elderly population with renal impairment.
d. is available as a twice daily injectable for use before morning and evening meals.
b. is a dipeptidyl peptidase-4 (DPP-4) inhibitor.
You notice a diabetic, elderly patient of yours has recently been prescribed a new prescription from a different physician for a medication, which may alter his blood sugar. You advise the patient:

a. “Your new prescription for your short course of prednisone may lower your blood sugar levels.”
b. “Your new prescription for hydrochlorothiazide may raise your blood sugar levels.”
c. “Your new prescription for metoprolol may cause an increase in noticeable symptoms of low blood sugar levels.”
d. “Your new prescription for Seroquel (quetiapine) will cause a drop in your blood sugar levels, but overall is a great medication for a man of your age.”
The correct answer is B. Hydrochlorothiazide can increase blood sugar levels, as well as prednisone and steroids, and Seroquel. Metoprolol and beta blockers can cause the signs of hypoglycemia to be reduced or absent. Seroquel has a black box warning since it can raise the risk of death in elderly people due to confusion and memory loss (dementia).
1.A patient with Alzheimer’s disease with dementia presents to the pharmacy with a prescription for Cogentin (benzatropine) for tremors. You would like to check the potential anticholinergic activity, evidence by receptor binding activity or adverse events. Which source of information would you consult?
a.MMSE (Folstein Test)
b.ADAS-cog
c.The Anticholinergic Risk Scale for Commonly Prescribed Medications
d.Abnormal Involuntary Movement Scale (AIMS)
The correct answer is C. Adverse effects of anticholinergic medications may contribute to events such as falls, delirium, and cognitive impairment in older patients. To further assess the risk, the Anticholinergic Risk Scale (ARS) was developed which is a ranked categorical list of commonly prescribed medications with anticholinergic potential.
1.Which statement regarding depression in the elderly is true?
a.Depression is a normal part of aging.
b.Elderly are often over treated for depression as a result of coexisting problems, such as chronic pain, cognitive impairment, or substance misuse.
c.Treatment of depression in the elderly has been associated with worsened emotional, social, and physical functioning.
d.The choice of antidepressant in the elderly should be guided by the patient’s preferences, treatment history, costs, availability, drug interactions, and cost.
The correct answer is D. The first statement in A is false since depression is not a part of the normal aging process. Answer choice B is incorrect since the elderly are often undertreated as a result of these coexisting problems. With choice C, the treatment of depression will improve the quality of life, not worsen it.
2.According to the 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, which medications may be used with caution due a potential cause of hyponatremia?
a.Serotonin-norepinephrine reuptake inhibitors (SNRI) and Selective serotonin reuptake inhibitors (SSRI)
b.Benzodiazepines and sedative hypnotics
c.Anticholinergics and H2 receptor antagonists
d.Prasugrel and Dabigatran
The correct answer is A. Choice B and C are incorrect since these medications are to be avoided because of high risk of worsening delirium and adverse CNS effects. Choice D may be used in caution due to a potential increased risk of bleeding in older adults.
1.A patient, 68-year-old WM, arrives to the hospital with a chief complaint of chest pain during activities like walking to the restroom, fatigue after brushing his teeth, and walking out to his car. He feels fine when he is resting. Which class of the NYHA Heart Failure Classification does this patient fit?
a.NYHA Heart Failure Class I
b.NYHA Heart Failure Class II
c.NYHA Heart Failure Class III
d.NYHA Heart Failure Class IV
The correct answer is C, NYHA Heart Failure Class III. This patient is experiencing marked limitations on physical activity, symptomatic at less than ordinary levels of activity, and is comfortable at rest.
(KNOW DIFFERENCE BETWEEN CLASS I AND IV)
2.Which medications would NOT be the best choice of therapy for a 68 year old African American man with heart failure (LVEF of 30%), hypertension, PAD, CAD, and osteoarthritis?
a.Optimize patient’s current dose of ACE inhibitor and provide Ultram (tramadol) for arthritis pain
b.Supplement patient’s standard heart failure regimen with an aldosterone antagonist, spironolactone.
c.Change patient’s metoprolol tartrate to Toprol XL
d.Add Cardizem (diltiazem) for its negative inotropic effect and instruct him to use ibuprofen for his arthritis pain.
The correct answer is D. Adding Add Cardizem (diltiazem) for its negative inotropic effect and instructing him to use ibuprofen for his arthritis pain. Cardizem can precipitate or exacerbate heart failure due to its inotropic effects. Ibuprofen can also exacerbate heart failure. It is for these reasons, choice D is not the best choice of therapy for this patient.
1.How long patient would a patient need to get warfarin, prior and after cardioversion in a patient without permanent A-Fib or recurrent Paroxysms?
a. 4 weeks prior and after
b.3 weeks prior and one month after
c.1 weeks prior and 2 weeks after
d.3 days prior and one week after
b.3 weeks prior and one month after
2.Which condition could cause auto-anticoagulation?
a.CHF
b.Liver impairment
c.Kidney impairment
d.HIV
b.Liver impairment
1.Which criteria would confirm epoetin resistance?
a.Na retention
b.Combination of volume overload and uremic toxin
c.Accumulation of the Atrial Natriuretic peptid (ANP)
d.HCT rises less than four points after one month therapy
d.HCT rises less than four points after one month therapy
2.At which level of ferritin should parenteral Iron therapy be held?
a) 100-300 ng/ml
b) 300-500 ng/ml
c) Over 800 ng/ml
d) We have to continue therapy regardless the amount of ferritin
c) Over 800 ng/ml
1.How long does it take antidiabetic agent(s) to decrease HbA1C in elderly patients with renal insufficiency?
a.There is no change in A1C for this kind of patient.
b.Less than 120 days
c.120 days
d.More than 120 days
d.More than 120 days
1.Which drug has potential anti- cholinergic adverse effects such as urinary retention, confusion, and sedation on elderly people?
a. Diphenhydramine
b. Acetaminophen
c.Donepezil
d.Gabapentin
a. Diphenhydramine
2.What are the signs and symptoms of early confusion in Alzheimer’s disease?
a.Loss ability to speak, to walk, to feed himself, and incontinent of urine & feces
b.Patient needs assistance with daily activities; forget details related to past life, and family members.
c.Difficulty remembering right words in conversation, declined cognitive causing interference with work and social functions, and memory loss could cause anxiety.
d.No subjective or objective change in intellectual functioning
c.Difficulty remembering right words in conversation, declined cognitive causing interference with work and social functions, and memory loss could cause anxiety.
1.What are the criteria to initiate ACEI/ARB therapy for a patient who has acute decompensated heart failure?
a.SBP>90 mmHg, MAP> 50
b.SBP>90 mmHg, MAP <50
c.SBP<90 mmHg, MAP <50
d.We could initiate ACEI/ARB at any time of therapy
a.SBP>90 mmHg, MAP> 50
1.Which agent is less prescribed due to its liver toxicity effect and frequent daily doses?
a.Tacrine
b.Memantine
c.Rivastigmine
d.Donepezil
a.Tacrine
Which of the following medication classes has not been shown to slow the progression of cardiac dysfunction and improve mortality?

A. ACE inhibitors
B. Loop diuretics
C. Beta blockers
D. Aldosterone antagonists
B. Loop diuretics
Systolic heart failure is associated with all of the following except

A. LVEF < 40%
B. Impaired heart contractility
C. Enlarged flabby heart
D. Impaired heart relaxation
D. Impaired heart relaxation
****
Which of the following would NOT be a concern in an elderly patient?

A. A woman taking Metformin with a SCr of 1.52
B. A patient with impaired renal function taking pioglitazone for many years
C. A patient taking Acarbose without regards to meals
D. The use of a DPP-IV inhibitor in a patient with a past medical history of pancreatitis
B. A patient with impaired renal function taking pioglitazone for many years
Which of the following is true with regards to the use of statin therapy in diabetic patients?

A. Statin therapy should be initiated in diabetic patients without CVD who are over the age of 40 and have 2 or more other CVD risk factors.
B. Statin therapy should be initiated in diabetic patients with overt CVD as long as they are over the age of 50.
C. Statin therapy should be initiated in diabetic patients without CVD who are over the age of 40 and have 1 or more other CVD risk factors.
D. Statin therapy should be initiated in diabetic patients without CVD who are over the age of 50 and have one or more other CVD risk factors.
C. Statin therapy should be initiated in diabetic patients without CVD who are over the age of 40 and have 1 or more other CVD risk factors.
Which of the following medications and appropriately matched medication class can contribute to the anticholinergic burden in the elderly?

A. Temazepam- Long acting benzodiazepine
B. Olanzapine- First generation antipsychotic
C. Amitriptyline- Tertiary TCA
D. Solifenacin- Non-selective antimuscarinic
C. Amitriptyline- Tertiary TCA
****
2. Which of the following is an example of a new side effect versus new disease?

A. Prescribing cascade involving antihistamines and benzodiazepines used for sleep maintenance.
B. Prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs used to manage urinary incontinence.
C. Prescribing cascade involving the switch from a nonselective antimuscarinic to a more selective antimuscarinic used to manage urinary incontinence.
D. Prescribing cascade involving the use of SNRI’s and benzodiazepines used to manage anxiety.
B. Prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs used to manage urinary incontinence.
All of the following are correct regarding erythropoiesis-stimulating agents (ESAs) except

A. There is a black box warning for increased risk of serious CV events when target Hgb >11g/dL
B. There is a black box warning for increased risk of thromboembolism, stroke and mortality when Hgb>10g/dL
C. There is a black box warning for an increased risk of thromboembolism, stroke and mortality when target Hgb>11g/dL
D. The use of ESAs is contraindicated in uncontrolled HTN
B. There is a black box warning for increased risk of thromboembolism, stroke and mortality when Hgb>10g/dL
All of the following are true in regards to anemia in CKD except

A. Hgb testing should be carried out in all patients with CKD regardless of stage or cause
B. Hgb levels should be measured at least annually
C. Anemia in CKD is due to reduced renal erythropoietin production
D. Further evaluation to diagnose anemia should be undertaken in adult females when Hgb concentrations are <10 g/dL
D. Further evaluation to diagnose anemia should be undertaken in adult females when Hgb concentrations are <10 g/dL
All of the following medications can cause cognitive dysfunction and should be ruled out prior to the diagnosis of Alzheimer’s dementia except

A. Risperidone
B. Diazepam
C. Diphenhydramine
D. Acetaminophen
D. Acetaminophen
****
Which of the following are geriatric syndromes associated with diabetes?

a. polypharmacy
b. mania
c. depression
d. cognitive impairment
b. mania
Mania is associated with metabolic syndrome and diabetes.
*****
Which NYHA class of heart failure presents with symptoms at rest?
A) class I
B) class II
C) class III
D) class IV
D) class IV
(ON FINAL EXAM)
Which ACC/AHA stage of heart failure presents with heart failure but no symptoms?
A) stage A
B) stage B
C) stage C
D) stage D
B) stage B
What is an example of a non-pharmacological bladder re-training method to control over-active bladder?
A) Scheduled voiding regimen with gradually progressive voiding intervals
B) Use of a bladder diary
C) Urgency control strategies
D) All of the above
D) All of the above
Which benzodiazepine would be more appropriate to use in a 75 year old patient with anxiety if necessary?
A) chlordiazepoxide
B) diazepam
C) lorazepam
D)quazepam
C) lorazepam
Which DPP-4 inhibitor does NOT have to be renally adjusted?
A) sitagliptin
B) saxagliptin
C) linagliptin
D) All of the above
C) linagliptin
Which sulfonylurea appears most likely to cause hypoglycemia?
A) glipizide
B) glyburide
C) glimepiride
D) All of the above
B) glyburide
When analyzing anemia in a CKD patient, benefits of MCHC over MHC are:
A) MCHC will only be low in hypochromic anemia
B) MCHC will only be low in microcytic anemia
C) MCHC indicates folic acid deficiency
D) MCHC indicates B12 deficiency
A) MCHC will only be low in hypochromic anemia
****
SAs are contraindicated in which of the following conditions:
A) ESRD
B) uncontrolled hypertension
C) serum ferritin >100 mcg/dL
D) TSAT >20%
B) uncontrolled hypertension
A patient who presents with Heart Failure symptoms with a minimal amount of activity, which Functional Class would they fall into according to the NYHA classification

A. Class I
B. Class II
C. Class III
D. Class IV
C. Class III
Which of the following drugs will NOT precipitate heart failure?

A. Negative inotropic drugs
B. Beta Blockers
C. NSAIDS
D. ACE Inhibitors
D. ACE Inhibitors
All the following are true about the Anticholinergic Cognitive Burden (ACB) List except?

A. Each definite anticholinergic may increase the risk of cognitive impairment by 46% over 6 years.
B. Each 1 pt increase in ACB total score correlates with a 50% increase in the risk of death.
C. Each 1 pt increase in ACB total score a decline in MMSE of .5 over 2 years has been seen.
D. The scoring of the ACB is in increments of 0,5,10 and 15 points
A. Each definite anticholinergic may increase the risk of cognitive impairment by 46% over 6 years.
Which of the following are required to make a diagnoses of diabetes?

A. HbA1C =/> 6.5%
B. FPG =/> 126 mg/dL
C. Random Glucose =/> 200 mg/dL with symptoms
D. All of the above
D. All of the above
What type of cancer is associated with pioglitazone?

A. Colon Cancer
B. Kidney Cancer
C. Bladder Cancer
D. Breast Cancer
C. Bladder Cancer
Supplemental iron should be administered to prevent iron deficiency in CKD patients and to maintain what Hgb level?

A. >8
B. 9-10
C. 11-12
D. 12-13
C. 11-12
In CKD patients stages 3,4 and 5, the serum level of total CO2 should maintained at what level to avoid metabolic acidosis?

A. >19 mEq/L
B. >20 mEq/L
C. > 21 mEq/L
D. >22 mEq/L
D. >22 mEq/L
Which of the following is matched incorrectly?

A. Expressive aphasia: Having trouble recognizing people’s facial expressions
B. Expressive aphasia: Using the wrong word “word salad” when speaking to others
C. Receptive aphasia: Having trouble understanding other people when they talk
D. Receptive aphasia: Having trouble understanding a written instruction
A. Expressive aphasia: Having trouble recognizing people’s facial expressions
Which of the following cholinesterase inhibitors is approved for management of severe Alzheimer’s symptoms?

A. Aricept (donepezil)
B. Cognex (tacrine)
C. Razadyne (galantamine)
D. Exelon (rivastigmine)
A. Aricept (donepezil)
1.Which of the following angiotension receptor blockers (ARBs) does NOT have an FDA indication for heart failure?
a.Candesartan (Atacand)
b.Valsartan (Diovan)
c.Losartan (Cozaar)
d.All of the above ARBs are indicated for heart failure
c – losartan (Cozaar). Candesartan and Valsartan have FDA labeled indications for the treatment of heart failure (supported by data from the CHARM trial and Val-HeFT trial, respectively). Losartan (Cozaar) can be used off label for heart failure because it is better tolerated than the others, but it is not FDA approved for this use. Conflicting results have been reported from large outcome trials comparing losartan to captopril for the treatment of heart failure. In a comparison with captopril (ELITE I study), the losartan group had a lower all-cause mortality and hospitalization than the captopril group.
2.Which of the following drugs does NOT exacerbate heart failure according to the ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults?
a.NSAIDS
b.Calcium channel blockers
c.Antiarrhythmics
d.SSRIs
d.SSRIs. The ACCF/AHA 2009 Focused Update specifically mention NSAIDs, calcium channel blockers and antiarrhythmics as agents that could potentially exacerbate the syndrome of heart failure. NSAIDs cause sodium retention and peripheral vasoconstriction, calcium channel blockers lead to worsening HF and can increase the risk of cardiovascular events and antiarrhythmics exert cardiodepressant and proarrhythmic effects.
1.Which of the following medications does NOT have anticholinergic properties according to the Beers Criteria?
a.oxybutynin
b.clozapine
c.metoprolol
d.scopolamine
c – metoprolol. All of the other medications are listed as being strongly anticholinergic.
2.Instrumental activities of daily living (IADL) are considered to be more complex than the basic activities of daily living (ADLs). Which activity listed below would be considered to be an IADL?
a.Grooming
b.Cleaning
c.Bathing
d.Dressing
b.Cleaning
1.Which dipeptidyl peptidase-4 (DPP4) inhibitor does NOT need to be adjusted for renal dysfunction?
a.sitagliptin
b.liraglutide
c.linagliptin
d.saxagliptin
c – linagliptin. Linagliptin (Tradjenta) does not need to be renally adjusted. Sitagliptin and saxagliptin must be adjusted when CrCl <50 mL/min. Liraglutide (Victoza) is a GLP-1 receptor agonist, not a DPP4 inhibitor.
2.Which of the following medication classes is an appropriate second line choice for a diabetic geriatric patient who is already taking metformin?
a.Insulin
b.Alpha-glucosidase inhibitors
c.Thiazolidinediones
d.Dipeptidyl peptidase 4 (DPP4) inhibitors
d – dipeptidyl peptidase 4 (DPP4) inhibitors. These agents are recommended due to their once daily dosing and their low risk of causing hypoglycemia. Alpha-glucosidase inhibitors may be used but are generally avoided due to GI adverse effects. Thiazolidinediones are not recommended due to their cardiovascular risk profile. Insulin is on the Beers List, has a high risk of causing hypoglycemia and also requires more education on injecting and self-monitoring blood glucose.
1.Red blood cells in anemia due to chronic kidney disease presents as which of the following types?
a.Hypochromic, microcytic
b.Normochromic, normocytic
c.Normochromic, macrocytic
d.Hyperchromic, normocytic
b – normochromic, normocytic. In general, the anemia of CKD is normochromic and normocytic; that is, morphologically indistinguishable from the anemia of chronic disease. Macrocytosis indicates folate or B12 deficiency, microcytosis indicates iron deficiency and hypochromia likely reflects iron-deficiency erythropoiesis.
****
2.Which of the following is FALSE regarding therapy with epoetin alfa (Epogen, Procrit)?
a.It can be used in patients on dialysis and non-dialysis patients
b.It is contraindicated in patients with uncontrolled hypertension
c.It is dosed three times a week
d.It has a longer half life than darbepoetin alfa
d – it has a longer half life than darbepoetin alfa. Epoetin alfa has a shorter half life compared to darbepoetin alfa. Darbepoetin has an additional 2 N-linked carbohydrate chains that results in about a 3 fold longer half life. The half life of IV epoetin alfa in CKD is 4 – 13 hours. The half life of IV darbepoetin alfa in CKD is 21 hours.
1.Which cholinesterase inhibitor also works on the butylcholinesterase enzyme in addition to its activity on acetylcholinesterase?
a.Donepezil (Aricept)
b.Rivastigmine (Exelon)
c.Galantamine (Razadyne)
d.Mementine (Namenda)
b – rivastigmine (Exelon).Rivastigmine is a potent, selective inhibitor of brain acetylcholinesterase (AChE) and butylcholinesterase (BChE) .
2.Which assessment tool is used in clinical trials to measure efficacy of Alzheimer’s disease medications?
a.MMSE (Folstein Test)
b.Clock Drawing Test
c.ADAS-cog
d.AIMS test
c – ADAS cog.The Alzheimer's Disease Assessment Scale Cognitive Behavior Section (ADAS-cog)is a validated measure of cognitive performance and has been used widely in Alzheimer's disease trials.
Which of the following medications does NOT adversely affect heart failure?
A. Felodipine
B. Rosiglitazone
C. Cilostazol
D. NSAIDS
A. Felodipine
Systolic heart failure can be attributed to which disease state?
A. Coronary artery disease
B. Thyroid disease
C. Hypertension
D. All of the above
D. All of the above
Which of the following medications is NOT on the Beer's list?

A. alprazolam
B. fluoxetine
C. clonidine
D. nortriptyline
B. fluoxetine
Which of the following statements is FALSE?

A. Citalopram at doses greater than 40mg increases the risk of QT prolongation in the elderly.
B. Duloxetine is labeled for use in depression, as well as DPN and generalized anxiety disorder.
C. Anticholinergics can increase the risk of falls in the elderly.
D. Tricyclic antidepressants are preferred over SSRI's due to decreased anticholinergic activity.
D. Tricyclic antidepressants are preferred over SSRI's due to decreased anticholinergic activity.
Older adults with diabetes are at increased risk of which of the following geriatric syndromes?

A. Urinary incontinence
B. Injurious falls
C. Depression
D. All of the above
D. All of the above
Which of the following does NOT cause insulin resistance with aging?

A. Weight loss
B. Decreased beta cell function
C. Impaired insulin-mediated glucose disposal
D. Sedentary lifestyle
A. Weight loss
List in order of highest percentage of elemental iron to lowest.

A. Ferrous sulfate > ferrous gluconate > ferrous fumarate
B. Ferrous gluconate > ferrous fumarate > ferrous sulfate
C. Ferrous fumarate > ferrous sulfate > ferrous gluconate
D. All three contain equal amounts of elemental iron.
C. Ferrous fumarate > ferrous sulfate > ferrous gluconate
Ferrous fumarate contains about 33% elemental iron, while ferrous sulfate contains 20% and ferrous gluconate contains 12%.
(ON FINAL EXAM)
The following labs are seen in CKD associated renal osteodystrophy EXCEPT:

A. hyperphosphatemia
B. hypercalcemia
C. increased parathyroid hormone (PTH)
D. All of the labs above are seen in renal osteodystrophy
Answer: B

The correct answer should be HYPOcalcemia.
Which of the following medications for Alzheimer’s disease is available as a patch?
A. Donepezil (Aricept)
B. Rivastigmine (Exelon)
C. Galantamine (Razadyne)
D. Memantine (Namenda)
B. Rivastigmine (Exelon)
Define apraxia:
A. loss of coordination or unsteadiness

B. inability to recognize objects, persons, sounds, shapes or smells while there is no significant memory loss
C. impaired language ability

D. inability to perform tasks or movements when requested, even though the request is understood
D. inability to perform tasks or movements when requested, even though the request is understood

Answer: D (A is the definition of ataxia. B is the definition of agnosia. C is the definition of aphasia.)
(ON FINAL EXAM)
1.When would you counsel the patient to monitor for angioedema while taking an ACE inhibitor?
a.Within 2-3 hours of taking the first dose
b.Within 1 week of taking the first dose
c.Within 4 weeks of taking the first dose
d.At all times while on therapy
d.At all times while on therapy
2.Which of the following is the most appropriate therapy for a patient with heart failure?
a.Propranolol titrated to 80 mg twice daily as tolerated
b.Metoprolol tartrate titrated to 50 mg twice daily as tolerated
c.Carvedilol titrated to 200 mg twice daily as tolerated
d.Metoprolol succinate titrated to 200 mg once daily as tolerated
d.Metoprolol succinate titrated to 200 mg once daily as tolerated
1.Which of the following are physiological changes seen in the elderly?
a.Increase in creatinine clearance.
b.Decrease in lean body mass.
c.Increase in intestinal motility.
d.Increase in cardiac output.
b.Decrease in lean body mass.
2.An elderly patient presents with dry mouth, dilated pupils, decreased bowel sounds, dry skin, urinary retention, and delirium. Which of the following toxidromes is the patient most likely suffering from?
a.Anticholinergic.
b.Opioid.
c.Cholinergic.
d.Sympathomimetic.
a.Anticholinergic.
3.Which sulfonylurea is the worst choice for elderly diabetics due to its high risk of hypoglycemia?
a.Glyburide
b.Glipizide
c.Glimepiride
d.Glyclopyramide
a.Glyburide
4.A patient has Type 2 Diabetes and hypertension. Which of the following would be the best choice to treat the patient’s blood pressure?
a.Metoprolol and BP goal <130/80 mmHg
b.Digoxin and BP goal <140/90 mmHg
c.Lisinopril and BP goal <130/80 mmHg
d.Amlodipine and BP goal <120/80 mmHg
c.Lisinopril and BP goal <130/80 mmHg
(ON FINAL EXAM)
5.Which of the following are potential barriers to the efficacy of oral iron supplementation in elderly patients?
a.Side effects
b.Compliance
c.Decreased absorption
d.All of the above
d.All of the above
6.Which of the following is a complication of untreated anemia in the geriatric population?
a.Increased cognitive function
b.Decreased physical function
c.Decreased risk of cardiovascular disease
d.Decreased mortality
b.Decreased physical function
7.Which of the following worsen cognitive function in elderly patients with dementia?
a.Diphenhydramine
b.Diltiazem
c.Dabigatran
d.Doxazosin
a.Diphenhydramine
8.All of the following are goals of therapy for Alzheimer ’s Disease except:
a.Cure Alzheimer’s Disease
b.Slow decline in cognitive function
c.Manage behavioral symptoms
d.Support caregivers
a.Cure Alzheimer’s Disease
Cilostazol

a. is contraindicated in patients with heart failure of any NYHA class.
b. is contraindicated in patients with heart failure of NYHA classes III or IV.
c. can be used with caution in patients with heart failure.
d. can be used safely in patients with heart failure.
a. is contraindicated in patients with heart failure of any NYHA class.
Diastolic heart failure is characterized by

a. the inability of the heart to relax
b. LVEF >40%
c. abnormal left ventricular filling& elevated filling pressures
d. all of the above
d. all of the above
Which of the following statements about The Beers Criteria is/are TRUE?

a. The Beers Criteria lists medications that should never be used in geriatric populations.
b. The Beers Criteria is intended for use in all ambulatory and institutional settings of care for populations aged 55 and older in the United States.
c. 2012 changes to the Beers Criteria include the addition of a third category, medications to be used with caution in older adults.
d. There is no evidence of poor outcomes from the use of potentially inappropriate medications in older adults.
c. 2012 changes to the Beers Criteria include the addition of a third category, medications to be used with caution in older adults.
Which of the following statements regarding depression is/are TRUE?

a. Depression is a normal part of aging.
b. There is no risk of untreated depression.
c. Antidepressants can never be used in geriatric populations.
d. Elderly Americans are disproportionately likely to die by suicide.
d. Elderly Americans are disproportionately likely to die by suicide.
Elderly patients with diabetes mellitus have higher rates of the following when compared to elderly patients without diabetes mellitus:a.Cognitive impairment
b.Urinary incontinence
c.Falls
d.All of the above
d.All of the above
Which of the following is false in regards to the increased risk of hypoglycemia in elderly patients with diabetes mellitus?a.Decreased renal or hepatic clearance of antidiabetic agents
b.Drug-drug interactions

c.Impaired counter-regulatory hormone responses
d.There is not an increased risk of hypoglycemia in these patients.
d.There is not an increased risk of hypoglycemia in these patients.
Primary risk factors for CKD include all of the following EXCEPT:

a. Diabetes
b. Obesity
c. CV disease
d. Age >60
b. Obesity
(ON FINAL EXAM)
The blood pressure goal in CKD is
a. 130/80
b. 120/80
c. 140/90
d. 140/80
a. 130/80
Which of the following statements are true?

a. The AIMS test is the used to detect & track executive function.
b. The Clock Drawing test is used to detect tardive dyskinesia.
c. The MMSE is used to assess cognitive function.
d. The AIMS test is used to detect & track cognitive function.
c. The MMSE is used to assess cognitive function
Drugs that may cause cognitive dysfunction include

a. anticholinergics
b. anticonvulsants
c. corticosteroids
d. all of the above
d. all of the above
1.In addition to heart failure, BNP values may be elevated in which other disease state?
a.Type 1 Diabetes
b.Rheumatoid Arthritis
c.End Stage Renal Disease
d.None of the above, BNP is only elevated in HF
c.End Stage Renal Disease
2.What mechanism of action of Bystolic (nebivolol) may lead to an increase in exercise tolerance in cardiac patients?
a.Selective Beta1 blockade
b.Increased nitric oxide formation/decreased NO degradation
c.Intrinsic sympathomimetic activity
d.None of the above, Bystolic does not increase exercise tolerance
b.Increased nitric oxide formation/decreased NO degradation
3.How soon after initiation of therapy should donepezil be titrated up from the starting dose of 5mg QD to 10mg QD?
a.7-10 days
b.2-4 weeks
c.4-6 weeks
d.Whenever the patient shows signs of declining mental function
c.4-6 weeks
4.Late life depression affects a significant number of elderly patients, and can negatively impact all other disease states. All of the following at risk factors for late life depression EXCEPT:
a.Medical illness or disability
b.Decreased social contact
c.Death of a loved one
d.None of the above
d.None of the above
5.Diabetic patients who smoke are at an increased risk for which of the following types of diabetic related complications?
a.Microvascular
b.Macrovascular
c.Both Microvascular and Macrovascular
d.None of the above
c.Both Microvascular and Macrovascular
6.According to the 2012 Beer’s List, which of the following medications should be avoided in geriatric patients with chronic constipation?
a.Lorazepam
b.Hydroxyzine
c.Omeprazole
d.Citalopram
b.Hydroxyzine
7.Risk factors that increase susceptibility to CKD include all of the following except:
a.Advanced age
b.Family history
c.Increased birth weight
d.Low income
c.Increased birth weight
8.Which of the following is the correct dose of sodium bicarbonate as prophylaxis for metabolic acidosis?
a.10-20mEq QDay
b.10-20mEq BID
c.20-30mEq QDay
d.20-30mEq BID
c.20-30mEq QDay
9.Which type of dementia is not associated with cholinergic dysfunction, and is therefore not treated with cholinesterase inhibitors?
a.Lewy Body Dementia
b.Alzheimer’s Disease
c.Frontotemporal Dementia
d.Both A & B
c.Frontotemporal Dementia
10.Agnosia is the loss of the ability to:
a.Eat
b.Perform purposeful movements
c.Recognize, or comprehend the meaning of, various stimuli
d.Control involuntary movements
c.Recognize, or comprehend the meaning of, various stimuli
(ON FINAL EXAM)
1.Which of the following types of dementia are matched with their correct characteristics?

a. Frontotemporal dementia - B-amyloid plaques
b. Alzheimer’s dementia - Lewy bodies
c. Frontotemporal dementia - Pick bodies
d. Alzheimer’s dementia - Multiple mini-infarcts
Answer: C. Alzheimer’s disease is characterized by beta amyloid plaques, Lewy body dementia is characterized by lewy bodies and presents with Parkinsonian symptoms, vascular dementia occurs in a step-wise fashion due to multiple infacts, and frontotemporal dementia is characterized by Pick bodies.
2.Acetylcholine is thought to indirectly affect the release of all of the following neurotransmitter except:

a. Serotonin
b. Dopamine
c. Norepinephrine
d. Glutamate
b. Dopamine
1.Symptoms of cardiac insufficiency at rest classify a patient as which NYHA class?
a.I
b.II
c.III
d.IV
Answer: D. A patient with Class IV heart failure is unable to carry out any physical activity without discomfort. They have symptoms of cardiac insufficiency at rest and if any physical activity is undertaken, discomfort is increased.
2.In the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) amiodarone was compared to the use of an ICD. Results of this study were:
a.ICD was superior to amiodarone for reducing mortality
b.ICD was inferior to amiodarone for reducing mortality
c.There was no mortality difference in patients treated with ICD or with amiodarone
d.Amiodarone had a mortality benefit over placebo
Answer: A. The ICD was superior to amiodarone or placebo for reducing mortality in patients with NYHA class II or III symptoms and LVEF < 35%, regardless of the etiology of heart failure. Importantly, this study also found that amiodarone had no benefit compared with placebo; this drug, because of its multiple adverse effects, drug interactions, and lack of effect on mortality, should not be used for primary prevention of sudden death. However, because of the neutral effects of amiodarone on survival, it is often used in patients with symptomatic atrial fibrillation to maintain sinus rhythm and/or to prevent ICD discharges. The ACC/AHA guidelines recommend the ICD for both primary and secondary prevention to improve survival in patients with current or previous heart failure symptoms and reduced LVEF.
1.Which of the following is false regarding the diagnosis of Alzheimer’s Disease?
a.A definitive diagnosis is possible
b.Patients typically present with one or all of the following: apraxia, aphasia, agnosia
c.The disease has a gradual onset and continuing decline
d.Current therapies do not cure the disease
a.A definitive diagnosis is possible
2.Which of the following is not a risk factor for Alzheimer’s Disease?
a.Increasing age
b.High cholesterol
c.Family history
d.Female sex
Answer: D. A large number of women with Alzheimer’s Disease may be due to the fact that women have a longer life expectancy.
1.What is a contraindication for ESA use?
a.CrCL <30 mL/min
b.uncontrolled hypertension
c.history of falls
d.dialysis
b.uncontrolled hypertension
Blood pressure may rise during ESA use, therefore hypertension should be controlled in all patients before starting ESAs.
1.Which of the following about glucagon is FALSE
a.It is used in emergencies to lower blood glucose
b.It needs to be reconstituted before administration
c.If a patient is unresponsive after a dose you may give another dose
d.Glucagon can be given IM or SC
A is False. Glucagon is used to raise blood glucose in hypoglycemic emergencies. It is supplied in a kit that requires reconstitution prior to use and you may give another dose to an unresponsive patient after 15 minutes while waiting for emergency assistance. Glucagon can be given IM, SC or IV actually.
2.According to the American Geriatric Society, how long does it take for treatment to reduce microvascular complications in diabetics?
a.6 months
b.1 year
c.5 years
d.8 years
Answer: D 8 years. When considering treatment options and goals this is something to take into consideration in patients who may have a limited life expectancy. However, glucose control does provide enhancement of wound healing and reduction of symptoms associated with hyperglycemia.
Which of the following medications has anticholinergic activity?
a. hydrocholorothiazide
b. oxybutynin
c. fluoxetine
d. atenolol
b. oxybutynin
Which of the following antidepressants also has an indication to treat diabetic peripheral neuropathy?
a. fluoxetine
b. citalopram
c. sertraline
d. duloxetine
d. duloxetine
Which of the following antiarrhythmics has been shown to not adversely affect survival in a patient with heart failure?
A. Quinidine
B. Dronedarone
C. Dofetilide
D. Propafenone
C. Dofetilide
Which of the following is false about the use of digoxin in a patient with heart failure?

A. The use of digoxin does not improve mortality
B. Serum levels of digoxin should be targeted between 1.1-1.9 ng/mL
C. Digoxin has been shown to decrease hospitalizations
D. Digoxin can help control ventricular response in patients with concomitant arrhythmias
B. Serum levels of digoxin should be targeted between 1.1-1.9 ng/mL
Which of the following is not associated with anticholinergic activity?
A. Dizziness
B. Constipation
C. Dry mouth
D. Decreased heart rate
D. Decreased heart rate
Which of the following medications should not be initiated in a patient with NYHA Class III or IV heart failure?
A. Pioglitazone
B. Metformin
C. Glyburide
D. Sitagliptin
A. Pioglitazone
Per the ADA's Standard of Diabetes Care-2012, which of the following is not an appropriate reason for a less stringent A1C goal of <8%?
A. Patients with limited life expectancy
B. Advanced microvascular and macrovascular changes
C. Extensive comorbid conditions
D. Patients without a history of severe hypoglycemia
D. Patients without a history of severe hypoglycemia
How often should you routinely monitor the phosphorus and calcium levels in a patient with stage 3 CKD?
A. Every 12-24 months
B. Every 6-12 months
C. Every 3-6 months
D. Every 1-3 months
B. Every 6-12 months
Which of the following is not a side effect associated with use of epoetin?

A. Hypertension
B. Seizures
C. Red cell aplasia
D. Hyperkalemia
D. Hyperkalemia
Which of the following is not characteristic of Alzheimer's Disease?
A. Neuritic plaques
B. Increased acetylcholine transmission
C. Neurofibrillary tangles
D. Loss of neurons and synapses
B. Increased acetylcholine transmission
Which of the following is not evaluated by the ADAS-cog in rating cognitive function?

A. Word recall and recognition
B. Orientation
C. Ability to draw a clock
D. Naming objects
C. Ability to draw a clock
When considering concerns of anticholinergic medications in the elderly which of the following would be considered peripheral adverse effects?

a) Falls
b) Confusion
c) Constipation
d) Loss of independence
c) Constipation
Which of the following medications is the most anticholinergic?

a) Diazepam
b) Metoprolol
c) Tylenol PM
d) Donepezil
c) Tylenol PM
The A1C goal of less than 8% is set for patients who meet all of the following criteria except

a) Frail older adults
b) Life expectancy of less than 5 years
c) Those of whom risks of intensive glucose control outweighs the benefits
d) None of the above
d) None of the above
Which of the following is correct with regards to general care for older diabetics.

a) Foot care: Annually
b) High risk for retinopathy: every 2 years
c) Low risk for retinopathy: every 5 years
d) None of the above
a) Foot care: Annually
Which of the following is describes stage 4 CKD?


a) GFR of 60-89
b) GFR of <15
c) GFR of 30-59
d) None of the above
d) None of the above
Which of the following is DOES NOT increase a patients risk for an osteoporotic fracture?.

a) Age >80
b) BMI <21 kg/m2
c) Lopressor
d) Furosemide
c) Lopressor
How many mg of elemental iron is in 325mg of ferrous sulfate?
a. 65mg
b. 325mg
c. 100mg
d. 160mg
a. 65mg
Which of the following is the target hemoglobin for a patient with CKD anemia?
a. 9-10g/dL
b. 11-12g/dL
c. 12-13g/dL
d. >13g/dL
b. 11-12g/dL
1. Which of these symptoms can be attributed to a SE of an anticholinergic medication?
a. diarrhea
b. insomnia
c. dry mouth
d. urinary incontinence
c. dry mouth
Which of these benzodiazepines is the best choice in an elderly patient?
a. flurazepam
b. lorazepam
c. diazepam
d. clorazepate
b. lorazepam
This definition: “a person is unable to perform tasks or movements when asked, even though the request or command is understood, they are willing to perform the task, the muscles needed to perform the task are working and the task may have already been learned” defines which of the following words?
a. ataxia
b. apraxia
c. aphasia
d. agnosia
b. apraxia
(ON FINAL EXAM)
Which of the following medications is available in a patch formulation?
a. donepezil
b. galantamine
c. rivastigmine
d. mementine
c. rivastigmine
What is the target dose of Carvedilol for a heart failure patient weighing <85kg?
a. 6.125mg PO BID
b. 10mg PO BID
c. 25mg PO daily
d. 25mg PO BID
d. 25mg PO BID
How often should a beta blocker be dose titrated up for a heart failure patient?
a. every three days
b. every week
c. every 2 weeks
d. every month
c. every 2 weeks
Which of the following medications will not normally cause hypoglycemia when used alone?
a. insulin
b. glimepiride
c. nateglinide
d. metformin
d. metformin
Which of the following medications will probably NOT worsen glycemic control in a diabetic patient?
a. olanzapine
b. diltiazem
c. atenolol
d. HCTZ
b. diltiazem
Which condition can Metformin exacerbate due to a lowering of Vitamin B12 in a patient?
a. hypertension
b. peripheral neuropathy
c. angina
d. constipation
b. peripheral neuropathy
1.The following drug classes may cause drug-induced cognitive dysfunction that may easily be confused with dementia in elderly patients.
a.Anticholinergics
b.Opioids
c.Antihistamines
d.All of the above
d.All of the above
All of the above medication classes may cause sedation, confusion, and/or delirium in the elderly, being easily confused with declined cognitive function.
2.Which of the following cholinesterase inhibitors has fallen out of favor due to poor tolerability and hepatotoxicity?
a.Tacrine
b.Donepezil
c.Rivastigmine
d.galantamine
Answer: A, Tacrine is plagued with side effects and hepatotoxicity. Newer cholinesterase agents are preferred.
3.Which of the following agents indicated for the treatment of overactive bladder is most likely to reduce the efficacy of donepezil?
a.Trospium
b.Solifenacin
c.Oxybutynin
d.None of the above will interact with donepezil
Answer: C, oxybutynin is a nonselective muscarinic antagonist that crosses the blood brain barrier and can therefore interfere with the efficacy of cholinesterase inhibitors. Solifenacin and trospium have poor CNS penetration.
4.Which of the following would be the least appropriate option to treat an 87 year old male’s insomnia?
a.Zolpidem
b.Doxepin
c.Zaleplon
d.Melatonin
Answer: B, doxepin is a tricyclic antidepressant of used for insomnia due to its strong anticholinergic and sedative properties
5.Which of the following sulfonylureas would be the least appropriate option to control hyperglycemia in an elderly patient?
a.Glimepiride
b.Glyburide
c.Glimepiride
d.None of the above are appropriate
Answer: B, Of the 2nd generation sulfonylureas, glyburide is associated a higher likelihood of hypoglycemia.
6.Which of the following may be an indication to discontinue or hold metformin in an elderly patient?
a.Current severe illness
b.Radiographic contrast administration
c.Hepatic disease
d.All of the above
d.All of the above
7.Your patient, RL, is 75 year old female with stage 4 CKD. ESA therapy with darbepoetin alfa was initiated 2 weeks ago. Her hemoglobin at that time was 8.8 g/dL. Today, her labs come back and her hemoglobin level is now 9.9 g/dL. Which is the most appropriate action to take?
a.Increase ESA dose by 25%
b.Discontinue ESA therapy
c.Decrease ESA dose by 25%
d.Continue current therapy
c.Decrease ESA dose by 25%
Answer: C, If the hemoglobin rises > 1 g/dl in any 2-week period, reduce the dose by 25% or more as needed to reduce rapid responses
8.Which IV iron is associated with high rate of anaphylactic reactions, requiring administration of a small test dose prior to the full dose?
a.Iron sucrose
b.Iron dextrose
c.Sodium ferric gluconate
d.Ferumoxytol
Answer: B, Before administering therapeutic doses by any route, a test dose of 25 mg (0.5 ml) of iron dextran should be given by the route and method of administration for which therapeutic doses will be administered. Observe patient for at least 1 hour after test dose administration. Because anaphylactic reactions are known to occur after uneventful test doses, subsequent test doses should be considered
9.Which of the following ranges of GFR describe stage 3 chronic kidney disease?
a.30 – 59 ml/min
b.60 – 89 ml/min
c.15 – 29 ml/min
d.< 15 ml/min
a.30 – 59 ml/min
1.Which of the following statements regarding cholinesterase inhibitors is FALSE?
a.Razadyne® is formulated as both a transdermal patch and oral tablets
b.Aricept® is dosed only once daily
c.Rivastigmine affects both acetylcholinesterase and butylcholinesterase
d.Class side effects may include dizziness, GI upset, and postural hypotension
The correct answer is A. Exelon®(rivastigmine) comes as both tablets and a patch. Razadyne® (galantamine) has immediate release or extended release tablets. Answers B through D are all correct as stated.
2.Which of the following statements is true regarding pharmacological management of Alzheimer’s Disease?
a.Combining a cholinesterase inhibitor with an NMDA receptor antagonist is often considered for moderate-severe cases.
b.Using two cholinesterase inhibitors is reserved for only severe cases.
c.23mg of donepezil was shown to have improvements on both subjective and objective scoring systems compared to the 10mg dose.
d.When starting a cholinesterase inhibitor, it takes 4-6 months to evaluate their effect
The correct answer is A. Combining the two types of products is often seen in more severe cases. Answer B is wrong because combining two cholinesterase inhibitors is not done due to the risk for severe adverse effects and lack of benefit. Answer C is wrong because the 23mg donepezil dose showed statistical (but not clinical) significance on the more objective SIB test, while having no difference on the clinician’s subjective evaluation. Answer D is wrong because it is typical to evaluate the effect of a cholinesterase inhibitor 4-6 weeks after initiation, not 4-6 months.
1.Which of the following is NOT a potential contributing factor to cardiomyopathies?
a.HIV
b.Atrial fibrillation
c.Hyperthyroidism
d.Ethanol
Answer: C. Hypothyroidism, not hyperthyroidism, contributes to cardiomyopathies. Answers A, B, and D are correct.
2.What is the target dose of Coreg® for heart failure?
a.3.125mg BID
b.12.5mg QD
c.25mg BID
d.25mg QD
Answer: C. 3.125mg BID would be a starting dose and 25mg BID is a target dose. Coreg (carvediolol) is not dosed once daily.
1.Which sulfonylurea would likely be the most dangerous to use in a geriatric patient?
a.Glipizide (Glucotrol®)
b.Tolbutamide (Orinase®)
c.Chlorpropamide (Diabinese®)
d.Glimepiride (Amaryl®)
The correct answer is C, chlorpropamide, due to its long half life, which makes it dangerous to use in geriatric patients whose clearance is lower. The risk of hypoglycemia is higher with chlorpropamide over the other 3 agents listed.
1.When using Aranesp® to treat anemia associated with chronic kidney disease, which of the following is true?
a.Has a longer duration of action than Procrit®
b.Is available in a transdermal formulation
c.Has a shorter half-life than Procrit®
d.Requires that all prescribers be enrolled in the ESA APPRAISE REMS program
Correct answer: A. Aranesp (darbepoietin) has a longer duration of action than Procrit (epopoietin), is only available as an injectable product, has a 2-3 times longer half-life than epopoietin, and only prescribers using ESAs in cancer patients to treat cancer-related anemias are required to enroll in the APPRAISE program.
How long should a patient be on 5 mg/day of Aricept before you can increase the dose to 10 mg/day?

A. 1 to 2 weeks
B. 4 to 6 weeks
C. At least 3 months
D. At least 6 months
B. 4 to 6 weeks
Which of the following diabetic medications is least likely to cause hypoglycemia?

A. Sitagliptin (Januvia)
B. Miglitol (Glyset)
C. Repaglinide (Prandin)
D. Glipizide (Glucotrol)
B. Miglitol (Glyset)
ymptoms of hypoglycemia include all of the following except?

A. Frequent urination
B. Dizziness or lightheadedness
C. Shakiness
D. Nervousness or irritability
A. Frequent urination
In patients with HF with a LVEF < 40 % what would be the target daily dose of metoprolol succinate?

A. 100 mg QD
B. 100 mg BID
C. 200 mg QD
D. Metoprolol succinate in not indicated for patients with HF
C. 200 mg QD
Which lab value would give us information about the type of anemia a patient is suffering from?
A. Hemoglobin
B. Hematocrit
C. Total red blood cells
D. Mean corpuscular volume
D. Mean corpuscular volume
The ability of ARICEPT 23 mg/day to improve cognitive performance in moderate to severe Alzheimer's disease was assessed using the:

A. Mini Mental Status Exam (MMSE)
B. Alzheimer's Disease Assessment Scale- Cognitive Subscale (ADAS-cog)
C. Severe Impairment Battery (SIB)
D. Clinician's Interview-Based Impression of Change (CIBIC-plus)
C. Severe Impairment Battery (SIB)
1.Which stage of heart failure corresponds with structural heart disease with prior or current symptoms of heart failure?
a.Stage A
b.Stage B
c.Stage C
d.Stage D
c.Stage C
1.Which score on the Anticholinergic Cognitive Burden Scale corresponds to possible anticholinergic effects with no evidence of clinically relevant effects?
a.0
b.1
c.2
d.3
b.1
2.Why was megestrol added to the new 2012 Beer’s List?
a.Can cause extrapyramidal effects including tardive dyskinesia
b.Can cause CNS adverse effects, including confusion and hallucinations
c.Increased risk of thrombolic events and possibly death
d.Increased risk of cognitive impairment, delirium, and falls
c.Increased risk of thrombolic events and possibly death
1.What genetic components are associated with early onset Alzheimer’s Disease?
a.Chromosome alterations at 1, 14, or 21
b.Apolipoprotein E (APOE) genotype
c.Trisomy of chromosome 21
d.GLP deficiency
a.Chromosome alterations at 1, 14, or 21
2.Which test is NOT used for assessing cognition in Alzheimer’s Disease?
a.Mini Mental State Examination (MMSE)
b.Clock Drawing Test (CDT)
c.Abnormal Involuntary Movement Scale (AIMS)
d.Alzheimer’s Disease Assessment Scale-Cognitive Section (ADAS-Cog)
c.Abnormal Involuntary Movement Scale (AIMS)
Which of the following medications was just NEWLY ADDED to the Updated 2012 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults?

a. Baby aspirin
b. Metformin
c. Sliding-scale insulin
d. Donepezil
C. Sliding-scale insulin: Higher risk of hypoglycemia without improvement in hyperglycemia management regardless of care setting. Note: Aspirin greater than 325 mg is included on the list. Metformin and donepezil are not included on the list.
Warfarin is part of a small group of medications that recently have been associated with the most number of adverse drug events in older adults, why was it NOT included in the 2012 Updated Beers Criteria?

a. Bleeding is not associated with increased morbidity in the Geriatric population.
b. Often, there is not a safer alternative and recognizing the risk of use and close monitoring should then reduce the harm and improve medication safety.
c. Warfarin has not been associated with increased falls or decreased cognition, like other medications on the Beer’s Criteria and therefore should not be included.
d. This is a “trick” question; warfarin IS included on the 2012 Updated Beers Criteria.
Answer: B. There is often not a safer alternative to warfarin in older adults. Many of the studies for newer anticoagulants show increased bleeding/morbidity in elderly patients and warfarin “may” be the best option.
Which of the following drugs classes can precipitate heart failure?

a. Beta Blockers
b. NSAIDs
c. Antiarrhythmics
d. All of the above
Answer: D – Certain beta blockers (such as propranolol or atenolol) can decrease contractility and cause heart failure to worsen in some patients. NSAIDs can cause inhibition of prostaglandin synthesis which can adversely affect cardiovascular homeostatis. Several class I antiarrhythmic agents, such as flecainide and propafenone, have been demonstrated to increase mortality through mechanisms of depression of left ventricular function and, in some cases, exacerbation of ventricular arrhythmias.
According to the A-HeFT trial, which of the following heart failure patients is most likely to benefit from adding hydralazine & isosorbide dinitrate (BiDil™) to their existing therapy?

a. 76 year old Asian female, NYHA class II, with diabetes
b. 71 year old African American male, NYHA class IV, with depression
c. 92 year old Caucasian male, NYHA class III, with dementia
d. 80 year old Caucasian female, NYHA class I, with osteoporosis
Answer: B- The A-HeFT trial demonstrated a 43% reduction in all-cause mortality through the addition of hydralazine & isosorbide dinitrate (BiDil™) in African American patients with HF classified as NYHA III or IV and reduced LVEF.
3.
Which of the following statements is FALSE?

a. People over the age of 65 are more likely to experience insomnia.
b. Depression is part of the normal again process.
c. Alzheimer’s Disease is the most common cause of progressive dementia over age 65.
d. Each year, 1 out of 3 adults over 65 experience a fall.
b. Depression is part of the normal again process.
4.
Which of the following drugs was NOT added to the Beers Criteria in 2012?

a. Sliding Scale Insulin
b. Dabigatran
c. APAP
d. Megesterol
C- Aspirin (not APAP) was added to the Beers Criteria in 2012 to be used with caution.
5.
Which of the following statements concerning DM in geriatric patients is FALSE?

a. Hypoglycermia risk increases due to decreased renal & hepatic clearance of antidiabetic agents.
b. 2 years of treatment are needed to decrease microvascular complications.
c. Patients should receive daily aspirin therapy if no pertinent contraindications exist.
d. Glucose control tends to be focused on treating increases in postprandial glucose.
Answer: B- 8 years of treatment are needed to decrease microvascular complications in elderly DM patients. 2 years of treatment can help decrease MACROVASCULAR complications.
6.
Which class of drug therapy would be an appropriate choice for a 75 year old DM patient with a history of pancreatitis, CHF, and an allergy to sulfa drugs?

a. TZDs- such as pioglitazone
b. Sulfonylureas- such as glipizide
c. Meglitinides- such as repaglinide
d. DPP-IV inhibitors- such as sitagliptin
Answer: C- Pancreatitis, CHF, and an allergy to sulfa drugs are not CI’s for meglitinide therapy. TZDs can cause fluid retention in CHF patients, Sulfonylureas are not appropriate for a sulfa drug allergy, and DPP-IV inhibitors can cause or worsen pancreatitis.
Which of the following is NOT usually abnormal in a case of CKD-MBD?

a. Calcium
b. Vitamin K
c. Phosphorus
d. Vitamin D
B- Calcium, Phosphorus, and Vitamin D abnormalities (along with PTH abnormalities) are seen in cases of CKD-MBD. Vitamin K does not appear abnormal due to mineral bone disorders.
When considering complications arising from CKD, which of the following is FALSE?

a. Hypocalcemia can be treated with calcium supplementation plus calcitriol.
b. CKD related anemia can increase the risk of angina and worsen symptoms of CHF.
c. Hyperphosphatemia can be treated in any stage of CKD with Fosrenol, Renvela, or Zemplar.
d. CKD is considered a heart disease equivalent.
C- Fosrenol is for ESRD. Renvela is for ESRD when a patient is on hemodialysis. Zemplar is used in CKD stages 3 through 5.
Which of the following is NOT a cognitive symptom of Alzheimer’s Disease/Dementia?

a. Aphasia
b. Aggression
c. Apraxia
d. Agnosia
b. Aggression

Answer: B- Aggression is a non-cognitive symptom seen in Alzheimer’s Disease/Dementia patients. Cognitive symptoms include memory loss, aphasia, apraxia, agnosia, disorientation, and impaired executive function.
When considering cholinesterase inhibitor therapy, which of the following is FALSE?

a. Increasing acetylcholine allows for improved memory/cognition.
b. Concurrent use of anticholinergic agents (such as TCAs) should be avoided.
c. These agents decrease levels of acetylcholine in the synaptic cleft by inhibiting acetyl- and butyryl- cholinesterase.
d. Common side effects of these agents include headache, sweating, dizziness, urinary incontinence, and gastrointestinal symptoms (such as nausea, vomiting, and diarrhea).
Answer: C- Cholinesterase inhibitors work by INCREASING levels of acetylcholine in the synaptic cleft by inhibiting acetyl- and butyryl- cholinesterase. Increases in acetylcholine allows for improved memory/cognition.
Which of the following clinical trials did not show efficacy results with the use of beta blockers in heart failure patients?
a.VALIANT
b.CIBIS II
c.COPERNICUS
d.MERIT-HF
a.VALIANT
1.According to the 2012 updated Beers criteria, which of the following medications should be used with caution in an elderly patient?
a.diphenhydramine
b.fluoxetine
c.diazepam
d.gabapentin
b.fluoxetine
2.In an elderly patient with concomitant dementia and insomnia, which of the follow drug option/rationale pairs is correct?
a.The patient should start taking Elavil (amitriptyline) at bedtime to help with sleep, especially since depression can be common in the elderly.
b.The patient should not treat insomnia with any medications because they all have a high risk of side effects in the elderly.
c.The patient should start taking Ambien (zolpidem) at bedtime to help with sleep because it is a non-benzodiazepine and does not affect memory or risk of falls like benzodiazepines.
d.The patient should start taking Rozerem (ramelteon) at bedtime to help with sleep because it can be used long term and is not known to adversely affect memory.
Answer: d - The patient should start taking Rozerem (ramelteon) at bedtime to help with sleep because it can be used long term and is not known to adversely affect memory.
1.If a patient has edema and a true sulfa allergy, which diuretic should be recommended?
a.Furosemide
b.Hydrochlorothiazide
c.Ethacrynic acid
d.Bumetanide
c.Ethacrynic acid
2.Which of the following statements is true about A1c level?
a.For accurate results, patients should be fasting at least 8 hours prior to testing
b.Conditions that substantially increase or decrease the lifespan of red blood cells, such as anemia, can affect A1c measurements
c.An A1c of less than 7% may be reasonable for some patients, including elderly at risk for hypoglycemia
d.Fructosamine measurements, like A1c, correlate to glucose control over the past 3 months and can be substituted for A1c in patients with conditions altering red blood cell lifespan
Answer: b – Conditions that substantially increase or decrease the lifespan of red blood cells, such as anemia, can affect A1c measurements
1.What is not a common side effect of oral iron tablets or capsules which patients should be counseled about?
a.Dyspepsia
b.Nausea and/or vomiting
c.Tooth discoloration
d.Stool discoloration
c.Tooth discoloration
2.Which of the following is false of CKD and hypertension?
a.Patient’s with CKD are likely to have problems with fluid retention which is a major contributor to hypertension
b.Diurnal blood pressure rhythm that causes blood pressure to decrease during the nighttime hours in CKD patients is likely to lead to worsening hypertension
c.The use of erythropoiesis-stimulating agents is contraindicated in patients with uncontrolled hypertension
d.ESRD may lead to calcification of arteries and these structural changes may contribute to hypertension
Answer: b – ESRD patient display abnormal diurnal blood pressure rhythm during which blood pressure does not decrease during the nighttime hours which leads to more sustained elevations in blood pressure over a prolonged period of time
2.Which cognitive assessment is most often used in clinical trials?
a.AIMS
b.MMSE
c.ADAS-cog
d.MSTAD
c.ADAS-cog
3.What patient would benefit most from initiating Namenda?

A. A patient with a MMSE of 10

B. A patient with a MMSE of 22

C. A patient with his/her first signs of dementia contemplating drug therapy

D. A patient with normal cognition trying to prevent dementia
Answer: a – Namenda is indicated for moderate to severe Alzheimer’s
Which of the following is NOT a recommended drug category of the 2012 update of the Beers list?

a. Medications to be used with caution in older adults
b. Potentially inappropriate medications and classes to avoid in older adults
c. Potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate
d. Potentially inappropriate medications and classes to avoid in older adults with assisted daily living
d. Potentially inappropriate medications and classes to avoid in older adults with assisted daily living
What medication most likely contributed to NS’s uncontrolled diabetes in Case 2?
a.Celexa
b.Carafate
c.Spironolactone
d.Seroquel
d.Seroquel
Metformin is contraindicated with a SCr of greater than or equal to __ mg/dl?a.1.3 in women; 1.4 in men
b.1.4 in women; 1.5 in men
c.1.5 in women; 1.4 in men
d.1.6 in women; 1.5 in men
b.1.4 in women; 1.5 in men
The erythropoiesis-stimulating agents that are approved to treat dialysis-independent anemic CKD patients include?
a. Aranesp and Procrit
b. Procrit and Omontys
c. Omontys and Aranesp
d. None of the above
a. Aranesp and Procrit
Which of the following recommendations are appropriate renal dose adjustments for Zestril?

a. CrCl< 50 ml/min: Reduce recommended dose by 50% for adults (e.g., initial dosage 10 mg PO once daily). CrCl< 10 ml/min: Reduce initial dosage to 2.5 mg PO once daily.
b. CrCl< 40 ml/min: Reduce recommended dose by 50% for adults (e.g., initial dosage 10 mg PO once daily). CrCl< 10 ml/min: Reduce initial dosage to 5 mg PO once daily.
c. CrCl< 30 ml/min: Reduce recommended dose by 50% for adults (e.g., initial dosage 5 mg PO once daily). CrCl< 20 ml/min: Reduce initial dosage to 2.5 mg PO once daily.
d. CrCl< 30 ml/min: Reduce recommended dose by 50% for adults (e.g., initial dosage 5 mg PO once daily). CrCl< 10 ml/min: Reduce initial dosage to 2.5 mg PO once daily.
d. CrCl< 30 ml/min: Reduce recommended dose by 50% for adults (e.g., initial dosage 5 mg PO once daily). CrCl< 10 ml/min: Reduce initial dosage to 2.5 mg PO once daily.
Which cholinesterase inhibitor can be taken with or without food?
a. Donepezil
b. Rivastigmine
c. Galantamine
d. Tacrine
a. Donepezil
Which of the following causes are associated with increased death rates (and a black box warning) in atypical antipsychotics used for dementia-related psychosis?

a. Heart failure
b. Sudden death
c. Infections (pneumonia)
d. All of the above
d. All of the above
1.Which drug class produces the most rapid symptomatic improvement in heart failure patients?
a.Diuretics
b.Digoxin
c.ACE inhibitors / ARBs
d.Beta Blockers
a.Diuretics
The 2 most crucial monitoring parameters for aldosterone antagonists are:
a.Sodium and Potassium
b.Potassium and Creatinine
c.BUN and Chloride
d.Sodium and Creatinine
b.Potassium and Creatinine
1.Which of the following drug classes does the 2012 Beers List warn about the use in patients with a history of falls and fractures due to the risk of ataxia?
a.TCAs
b.SSRIs
c.SNRIs
d.Both a and b
d.Both a and b
2.The drug Cymbalta (duloxetine) has an FDA approved indication for:
a.Depression
b.Diabetic neuropathy
c.Generalized anxiety disorder (GAD)
d.All of the above
d.All of the above
3.What goal A1C does the American Diabetes Association (ADA) recommend for patients with a history of severe hypoglycemia, limited life expectancy, and advanced microvascular or macrovascular complications?
a.< 6.5%
b.< 7%
c.< 7.5%
d.< 8%
d.< 8%
(ON FINAL EXAM)
4.At what serum creatinine level is metformin contraindicated?
a.≥ 2.0 in males, ≥ 1.5 in females
b.≥ 1.6 in males, ≥ 1.5 in females
c.≥ 1.5 in males, ≥ 1.4 in females
d.≥ 1.4 in males, ≥ 1.3 in females
c.≥ 1.5 in males, ≥ 1.4 in females
5.According to the KDOQI guidelines, what hemoglobin levels are used to define anemia?
a.< 12 g/dL in males, < 11 g/dL in females
b.< 12.5 g/dL in males, < 11 g/dL in females
c.< 13.5 g/dL in males, < 12 g/dL in females
d.< 14 g/dL in males, < 13 g/dL in females
c.< 13.5 g/dL in males, < 12 g/dL in females
6.The subcutaneous route is the preferred route of administration of ESA in which population?
a.Patients not on dialysis
b.Peritoneal dialysis patients
c.Hemo-dialysis patients
d.Both a and b
d.Both a and b
7.If an Alzheimer’s patient is tolerating a 5mg daily dose of donepezil, at what point should you consider increasing the dose to 10mg daily?
a.1 to 2 weeks after therapy initiation
b.4 to 6 weeks after therapy initiation
c.8 to 12 weeks after therapy initiation
d.Never
b.4 to 6 weeks after therapy initiation
8.To help minimize GI side effects, the following cholinesterase inhibitor(s) is/are available as a patch?
a.Donepezil
b.Rivastigmine
c.Galantamine
d.All of the above
b.Rivastigmine
1.All of the following medications may lead to poor glycemic control EXCEPT:
a.Seroquel
b.Lisinopril
c.Bumex
d.All of the above may lead to poor glycemic control
b.Lisinopril
2.All of the following are true concerning thiazolidinediones EXCEPT:
a.It is contraindicated in patients with established Class III or IV heart failure
b.It is contraindicated in patients with LFT’s >2.5 times the upper limit of normal
c.Requires multiple daily dosing
d.Can cause hypoglycemia
c.Requires multiple daily dosing
1.
In the new 2012 update of the BEER’S list from the American Geriatrics Society, all of the following medications were added, EXCEPT:

a. Zolpidem
b. Glyburide
c. Glipizide
d. Prazosin
c. Glipizide
2.
If an elderly patient wanted to start taking a sleep-aid, which of the following would be most appropriate?

a. Ambien©
b. Rozerem©
c. Lunesta©
d. Unisom©
b. Rozerem©
1.
All of the following are pathophysiological changes that occur in CKD-BMD EXCEPT:

a. Hyperphosphatemia
b. Hypercalcemia
c. Secondary hyperparathyroidism
d. Vitamin D deficiency
b. Hypercalcemia
2.
All of the following medications could help a patient with hyperphosphatemia due to CKD-BMD EXCEPT:

a. Sevelamer
b. Calcium acetate
c. Lanthanum
d. Klor-con
d. Klor-con
All of the following are non-competitive cholinesterase inhibitors EXCEPT:
A. Donepezil
B. Rivastigmine
C. Galantamine
D. Tacrine
C. Galantamine
Which of the following has an FDA-approved indication specifically for the treatment of moderate – severe Alzheimer’s disease?
A. Galantamine
B. Rivastigmine (oral)
C. Rivastigmine (patch)
D. Memantine
D. Memantine
Many studies have shown an increase in mortality in heart failure patients who have digoxin levels greater than what value?

a. 0.5 ng/mL
b. 0.6 ng/mL
c. 0.8 ng/mL
d. 1.2 ng/mL
d. 1.2 ng/mL
2.
What is the target dose of metoprolol succinate in a heart failure patient?

a. 50mg/day
b. 100mg/day
c. 200mg/day
d. 400mg/day
c. 200mg/day
Which of the following beta-blockers is FDA approved for heart failure?
a.Carvedilol
b.Metoprolol tartrate
c.Nebivolol
d.Bisoprolol
a.Carvedilol

a. Cavedilol.Cavedilol is the only beta-blocker in the list that has an FDA-approved indication for heart failure. The other medications have been studied in heart failure and may be used off label for this indication.
2.What is the recommended sodium restriction in heart failure patients at this time?
a.≤5 grams/day
b.≤10 grams/week
c.≤ 2 grams/day
d.Just don’t add addition sodium to your food
c. 2 grams/day.At this time it is recommended that patients do not exceed 2 grams/day.
1.Which of the following is not an age related gastrointestinal change seen in geriatric patients?
a.Decreased blood flow
b.Delayed gastric emptying
c.Increased intestinal transit
d.Increased pH
Answer:c. Increased intestinal transit.Geriatric pts typically have decreased intestinal transit related to a multitude of factors.
2.Which of the following medications was recently added to the BEERS Criteria with its 2012 update?
a.Clonazepam
b.Amiodarone
c.Clonidine
d.Meloxicam
a.Clonazepam
Clonazepam was added to the list in 2012 independent of diagnosis.
3.Which of the following is not an American Diabetes Association (ADA) reason to have an A1c goal of <8%?
a.History of severe hypoglycemia
b.Geriatric patients
c.Limited life expectancy,
d.Advanced microvascular or macrovascular complications
b. Geriatric patients. Being geriatric is not a reason to raise the A1c goal, though many geriatric pts qualify for a high A1c goal of <8%.
Which anti-diabetic medications listed below has the greatest risk of causing hypoglycemia?
a.Metformin
b.Saxagliptin
c.Glipizide
d.Acarbose
c. Glipizide. Sulfonylureas are known to cause hypoglycemia in pts at a greater rate than metformin, DPP4I and -glucosidase inhibitors.
5.Which lipid value is typically increased in CKD patients?
a.LDL
b.Total cholesterol
c.Triglycerides
d.HDL
c.Triglycerides
c. Triglycerides.Typically normal LDL and total cholesterol are seen with a decreased HDL and increased triglyceride.
6.To which indication does the ESA REMS program APPRISE apply?
a.Oncology
b.Chronic Kidney Disease
c.Zidovudine induced anemia
d.Patients on dialysis
a.Oncology
7.Which of the following is not a reversible cause of dementia?
a.Vitamin B-12 deficiency
b.Thyroid dysfunction
c.Depression
d.Smoking
d. Smoking.Smoking is actually rumored to decrease your risk of dementia because of increase nicotinic receptors.
8.What is the definition of agnosia?
a.Poor coordination and unsteadiness due to the brain's failure to regulate the body's posture and regulate the strength and direction of limb movements
b.A person is unable to perform tasks or movements when asked, even though: The request or command is understood
c.An impairment of language ability
d.A loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss
d.A loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss
1.Concerning the stages of heart failure (HF)
A.Stage A represents those at risk for the development of HF
B.Stage B represents those at risk for the development of HF
C.Stage D represents refractory HF
D.All of the above
D.All of the above
2.The most reliable sign of volume overload is
A.Jugular venous distention
B.BNP >400 pg/mL
C.Serum Creatinine
D.BUN
A.Jugular venous distention
1.Different factors may represent hazards for prescription drugs to the elderly, which of the following is correct?
A.The most important pharmacokinetic changes in old age include a decrease in excretory capacity of the kidney more than a decline in the hepatic drug metabolism
B.Pharmacodynamic changes in the elderly are frequent and commonly ascribed to the alteration in the sensitivity to drugs.
C. May include immobility, co-morbid diseases, poor fluid intake, poor nutrition, confusion, forgetfulness, inability to self-care, lack of supervision, poor compliance.
D.All of the above
D.All of the above
2.The concept of “New Side Effect” vs “New Disease” involves:
A.A prescribing cascade model that involves the misinterpretation of an adverse reaction to 1 drug and the subsequent, potentially inappropriate prescription of a second drug
B.A side effect that causes a new disease
C.A disease that causes a new side effect
D.None of the above
A.A prescribing cascade model that involves the misinterpretation of an adverse reaction to 1 drug and the subsequent, potentially inappropriate prescription of a second drug
1.Concerning diabetes medications in the elderly
A.They may increase the risk for falls
B.There is a direct link between metformin and falls
C.There is a direct link for falls caused by neuropathy
D.Studies have shown insulin secretagogues are linked to falls
A.They may increase the risk for falls
2.Concerning pharmacologic options for the treatment of diabetes in the elderly
A.May be the same for the elderly as in younger adults
B.Treatment of diabetes in the elderly may differ due to changes in renal and hepatic function
C.Metformin may not be an appropriate treatment in older patients with CHF
D.All of the above
D.All of the above
1.
Concerning the TREAT (Trial to reduce cardiovascular events with Aranesp therapy) study

A.The goals for hemoglobin are 11-12 g/dL
B.Hemoblobin goal should be >13 g/dL
C.More caution is suggested when treating anemia with ESA (erythropoiesis-stimulating agents) therapy in patients with type 2 diabetes undergoing dialysis
D.The study’s findings provide new guidelines for treatment with ESA(erythropoiesis-stimulating agents)
A.The goals for hemoglobin are 11-12 g/dL
2.Which interventions are needed to avoid osteoporosis in CKD
A.Interventions to treat hyperphosphatemia
B.Interventions to treat hyperparathyroidism
C.Interventions to treat hypocalcemia
D.All of the above
D.All of the above
1.People with dementia who live alone are exposed to more risks than people with dementia who live with others, risks may include
A. inadequate self-care and malnutrition,
B. untreated medical conditions and falls
C. wandering from home unattended and accidental deaths
D. All of the above
D. All of the above
2.Concerning the use of antipsychotics for treatment of dementia behavioral symptoms
A.Are associated with greater mortality
B.The use of valproic acid for neuropsychiatric symptoms of dementia is not associated with the same risks as other antipsychotic medications
C.Haloperidol has been associated with the highest mortality rate
D.A and C
D.A and C
What class of drugs should not be used in systolic heart failure but can be used in diastolic heart failure?
a. angiotensin receptor blocker
b. non-dihydropyridine calcium channel blocker
c. dihydropyridine calcium channel blocker
d. alpha blockers
b. non-dihydropyridine calcium channel blocker
Which of the following angiotensin receptors blockers has an FDA indication for heart failure?
a. irbesartan
b. losartan
c. olmesartan
d. candesartan
d. candesartan
1.Nonbenzodiazepine hypnotics have been added the updated beers list as potentially inappropriate medications. If you were to use one of the agents in an elderly patient, what is the recommendation on the maximum duration of use?

a. 15 days
b.30 days
c. 90 days
d. 180 days
c. 90 days
What is a limitation to the Beers criteria?

a. evidence for recommendations can be lacking due to elderly underrepresented in drug trials
b. it recommends strict adherence to the outlined criteria
c. use of an expert consensus panel to create the guidelines
d. none of the above
a. evidence for recommendations can be lacking due to elderly underrepresented in drug trials
Which of the following atypical antipsychotics has the least effect on weight gain, hyperglycemia, and dyslipidemia?

a. Clozapine
b. Olanzapine
c. Aripiprazole
d. Quetiapine
c. Aripiprazole
Which sulfonylurea is not first choice in the elderly?
a. glipizide
b. glyburide
c. glimeperide
d. all of the above
b. glyburide
According to the FDA approved labeling for erythropoietin stimulating agents, what is a contraindication to starting therapy with one of these agents?
a. history of seizures
b. uncontrolled hypertension
c. history of stroke
d. cancer
b. uncontrolled hypertension
When a stage 3 or 4 CKD patient first presents with a low 25-hydroxyvitamin D level, which of the following agents would be recommended?
a. cholecalciferol
b. paricalcitol
c. ergocalciferol
d. Either A or C
d. Either A or C
In which of the following disease states would you be cautious when using a cholinesterase inhibitor?
a. Chronic kidney disease
b. Asthma
c. Peptic ulcer disease
d. Both B and C
d. Both B and C
Which of the following atypical antipsychotics has anticholinergic side effects?
a. risperidone
b. quetiapine
c. olanzapine
d. aripiprazole
c. olanzapine
1.Which of the following class medications have NOT shown decrease of mortality in patients with heart failure?
a.ARBs
b.Beta-blockers
c.Aldosterone antagonists
d.Combination of hydralazine & nitrate
b.Beta-blockers
2.Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. Which of the following are NOT associated with systolic heart failure?
a.Decreased EF less than 40%
b.EF greater than 40%
c.Impaired wall motion & dilated ventricle
d.Mainly due to Coronary artery diseases
b.EF greater than 40%
3.Diagnosing Alzheimer’s disease needs careful considerations since it has similar presentation to other illnesses, which of the following lab tests are NOT required before diagnosing Alzheimer’s disease?
a.Vitamin B 12 and Folate deficiency
b.Thyroid function tests, liver function tests
c.Blood cell counts, serum electrolytes
d.Serum creatinine
d.Serum creatinine
4.Dementia is accompanied with behavioral symptoms, which of the following measurement (s) are NOT used for determining these Behavioral Symptoms?
a.Neuropsychiatric Inventory (NPI)
b.Mini Mental Status Examination (MMSE)
c.Behavioral Pathology in Alzheimer’s Disease (BEHAVE-AD)
d.Cohen-Mansfield Agitation Inventory (CMAI)
b.Mini Mental Status Examination (MMSE)
5.Older diabetic patients of either sex with creatinine clearance that indicates reduced renal function should not use metformin because of the increased risk of lactic acidosis, which of the following is NOT a compelling reason to discontinue metformin in an elder patient?
a.Increase of half life of really eliminated drugs
b.CrCl ~60 ml/min
c.A serum creatinine of 1.5 mg/dL or greater in male patient
d.A serum creatinine of 1.4 mg/dL or greater in female patient
b.CrCl ~60 ml/min
6.Which of the following is an alarming concern in patient who has been taking metformin for long term, but he developed diabetic neuropathy despite his blood glucose level is controlled?
a.Normocytic anemia
b.Hypokalemia secondary to diarrhea
c.Decrease folate and vitamin B-12 absorption
d.leukocytoclastic vasculitis
c.Decrease folate and vitamin B-12 absorption
7.The secondary hyperparathyroidism and the consequent high-turnover bone disease of CKD are related to abnormal mineral metabolism, at what level of GFR decline these changes started?
a.GFR < 30 ml/min
b.GFR < 45 ml/min
c.GFR <50 ml/min
d.GFR < 60 ml/min
d.GFR < 60 ml/min
Malnutrition secondary to reduced oral nutrient intake frequently is evident when the glomerular filtration rate drops, which of the following indicate that CKD patient have moderate malnutrition?
a.ABW 70–79% IBW
b.Albumin of 3.4 g/dl
c.Prealbumin of 17 of mg/dl
d.All of the above
a.ABW 70–79% IBW
9.Second generation antipsychotic is considered safe and more effective than first generation. Which of the following medication has highest concern regarding anticholinergic burden and can cause agranulocytosis?
a.Clozapine (Clozaril)
b.Quetiapine (Seroquel)
c.Risperidone (Risperdal)
d.Aripiprazole (Abilify)
a.Clozapine (Clozaril)
10.Genes involved in a variety of dementia syndromes have been identified, which of the following gene testing is recommended for diagnosing dementia cases?
a.Apolipoprotein E4 (APOE4)
b.Amyloid precursor protein (APP) gene
c.Presenilin 1(PSEN1) & Presenilin 2 (PSEN2)
d.None of the above
d.None of the above
Which of the following is TRUE in regards to anticholinergic cognitive burden scale?a.The lower the anticholinergic cognitive burden scale score the more at risk the patient is for adverse effects
b.A medication score of 2 on the anticholinergic cognitive burden scale means a medication have possible anti anticholinergic effects but no evidence of clinically relevant anticholinergic effects
c.Each anticholinergic agent may increase the risk of cognitive impairment by 46% over 6 years
d.All of the above are true
c.Each anticholinergic agent may increase the risk of cognitive impairment by 46% over 6 years
When treating insomnia in the elderly, what are some acceptable treatment options?a.Short term use of a sleep agent such as zolpidem
b.Treatment of underlying pain with Tylenol
c.Teaching sleep hygiene techniques
d.All of the above are acceptable treatments
d.All of the above are acceptable treatments
Which of the following is not a common geriatric syndrome?
a.Osteoarthritis
b.Injurious falls
c.Incontinence
d.Cognitive impairment
a.Osteoarthritis
Which of the following are TRUE in regards to glycemic control in the elderly?a.They will benefit from tight glycemic control despite risks of hypoglycemia.
b.The benefits seen from tight glycemic control only requires 2-3 years to be seen
c.Due to highly variable life expectancies, glycemic control goals must be individualized
d.Tight glycemic control should take precedence over quality of life to achieve maximum benefits
c.Due to highly variable life expectancies, glycemic control goals must be individualized
2.Which of the following is true in regards to metabolic acidosis in CKD?
a.Commonly seen when GFR drops below 50mL/min
b.Occurs when pH is between 7.35-7.45
c.Can be treated with sodium bicarbonate
d.Occurs when [HCO3-] is between 22-25 mEq/L
c.Can be treated with sodium bicarbonate
1.Rivastigmine is NOT available in which formulation formulations
a.Patch
b.Capsule
c.ODT
d.Oral solution
c.ODT
2.Which of the following are effective interventions for wandering in Alzheimer’s?
a.Medic alert bracelet
b.Sewing/pining personal information to clothes
c.Involving the patient in daily activities
d.All of the above
d.All of the above
1.What is a common cause of heart failure?
a.CAD
b.MI
c.Atrial fibrillation
d.All of the above
d.All of the above
2.In which NYHA stage should you consider adding an ACEI?
a.Stage I
b.Stage II
c.Stage III
d.All stages
d.All stages
1.The American Geriatrics Society emphasizes treatment of which of the following comorbid conditions in patients with diabetes?
a.Depression
b.Polypharmacy
c.Cognitive impairment
d.All of the above
d.All of the above
2.The American Geriatrics Society guidelines on diabetes in the elderly state that an A1c goal of <8% is appropriate in certain patient subgroups. These subgroups include which of the following?
a.Life expectancy <10 years
b.Socially vulnerable older adults
c.Frail older adults
d.Those in whom the benefits of intensive glycemic control outweigh the risks
c.Frail older adults
1.Which of the following equations to estimate GFR account for race and BSA?
a.Cockcroft-Gault
b.MDRD
c.CKD-EPI
d.b and c
d.b and c
2.What is the goal hemoglobin when using ESAs in CKD anemia?
a.11-12 g/dl
b.12-16 g/dl
c.14-18 g/dl
d.>13 g/dl
a.11-12 g/dl
What is the most prevalent type of dementia?
a.Alzheimer’s disease
b.Vascular dementia
c.Lewy body dementia
d.Frontotemporal dementia
a.Alzheimer’s disease
2.Which of the following is not an assessment designed for evaluation of dementia symptoms?
a.MMSE
b.Clock drawing test
c.ADAS-Cog
d.AIMS
d.AIMS
1.Which of the following does not show improvement in mortality for any population?
a.Nitrates and hydralazine
b.Beta blockers
c.ACE Inhibitors
d.Digoxin
d.Digoxin
2.According to the ACC/AHA Heart Failure guidelines, which of the following therapies is recommended to initiate in Stage B Heart Failure patients?
a.ACE Inhibitor
b.Beta blocker
c.ACE Inhibitor + Beta blocker
d.Diuretic
c.ACE Inhibitor + Beta blocker
1.Which of the following drugs does NOT contribute to the anticholinergic burden of a patient?
a.Diazepam
b.Paroxetine
c.Oxybutynin
d.Gabapentin
d.Gabapentin
2.Which of the following antidepressants also has an FDA approved indication for treating diabetic neuropathic pain?
a.Fluoxetine
b.Nortriptyline
c.Duloxetine
d.Citalopram
c.Duloxetine
3.Although measuring fasting plasma glucose levels increases the detection of diabetes in the young, it may actually miss 31% of cases in the elderly. Which diagnostic test may be useful if there is a clinical uncertainty?
a.A1C > 6.5%
b.Signs and Symptoms alone
c.OGTT ≥200 mg/dl
d.Random plasma glucose
c.OGTT ≥200 mg/dl
4.Which of the following has the greatest potential to increase a patients glucose level?

a. Metoprolol
b. Quetiapine
b.Diltiazem
c.Citalopram
b. Quetiapine
d.If a patient was having ECG changes with hyperkalemia, what, other than sodium bicarbonate, could you use?
a.Insulin w/ dextrose
b.Albuterol
c.Kayexelate
d.Any of the above
d.Any of the above
Which of the following inhibit butyrylcholinesterase as part of their mechanism of action in Alzheimer’s Disease?
a.Rivastigmine
b.Galantamine
c.Donepezil
d.Memantine
a.Rivastigmine
3.Which of the following is associated with the symptom of visual hallucinations?
a.Alzheimer’s Disease
b.Vascular Dementia
c.Lewy body dementia
d.Fronto-temporal dementia (FTD)
c.Lewy body dementia
According to the AGS Beer’s Criteria, which of the following should be avoided regardless of disease state or precautions?a.Prasugrel
b.Diltiazem
c.Amiodarone
d.Vasodilators
c.Amiodarone
Which of the following is not a valid reason to not treat the patient’s anxiety?a.He’s only experienced anxiety acutely for 2 weeks
b.Anxiety is a normal part of the aging process
c.Lifestyle management may alleviate the patient’s causes of anxiety
d.The anxiety is likely secondary to high anticholinergic burden
b.Anxiety is a normal part of the aging process
1.Which of the following words is incorrectly matched with a description?
a.Agnosia: the inability to recognize objects by a particular sensory modality even though the sensory modality itself is intact
b.Aphasias: abnormalities of language functions that are not due to defects of vision or hearing or to motor paralysis
c.Apraxia: commands to perform a specific motor act or pantomime the use of a common tool in the absence of the real object cannot be followed
d.Ataxia: acute onset of severely impaired fluency (often mutism), which cannot be accounted for by corticobulbar, cerebellar, or extrapyramidal dysfunction
d.Ataxia: acute onset of severely impaired fluency (often mutism), which cannot be accounted for by corticobulbar, cerebellar, or extrapyramidal dysfunction
Which of the following alternative options have proven effective in delaying the progression of Alzheimer’s disease?
a.Coconut oil
b.Ginseng
c.Olive oil
d.Vitamin B12
a.Coconut oil
1.According to the new CHEST guidelines, how should patients with VKA-associated major bleeding be managed?
a.four-factor prothrombin complex concentrate
b.protamine sulfate
c.10 mg oral vitamin K
d.5 mg parenteral vitamin K infusion
a.four-factor prothrombin complex concentrate
2.Which of the following patients is not recommended to initiate warfarin at a starting dose of <5 mg according to the new CHEST guidelines?
a.Elderly
b.Renal dysfunction
c.Liver disease
d.Recent major surgery
b.Renal dysfunction
1.Which of the following is incorrect regarding ESA dosage adjustment?
a.If hemoglobin does not increase by >1 g/dL after 4 weeks: Increase dose by 25%
b.If hemoglobin increases >1 g/dL in any 4-week period: Reduce dose by ≥25%
c.If hemoglobin increases >1 g/dL in any 2-week period: Reduce dose by ≥25%
d.Inadequate or lack of response over a 12-week escalation period: Further increases are unlikely to improve response and may increase risks
b.If hemoglobin increases >1 g/dL in any 4-week period: Reduce dose by ≥25%
2.Which of the following is incorrect regarding goal parameters in a CKD patient?
a.Calcium: 8.4-9.5mg/dL
b.Phosphorus: 2.7-4.6 mg/dL
c.PTH: 150-300 pg/mL
d.Potassium: 3.5-5.5 mEq/L
d.Potassium: 3.5-5.5 mEq/L
1.Which combination medication is recommended to improve outcomes for Heart Failure patients self- described as African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics?
a.Diltiazem and Hydralazine
b.IsosorbideDinitrate and Verapamil
c.Hydralazine and IsosorbideDinitrate
d.Clonidine and Diltiazem
c.Hydralazine and IsosorbideDinitrate
2.Which Angiotensin-2 Receptor Blockers (ARB’s) are FDA approved for Heart Failure?
a.Irbesartan and Candesartan
b.Valsartan and Candesartan
c.Losartan and Telmisartan
d.Valsartan and Irbesartan
b.Valsartan and Candesartan
Which classification of dementia is appropriately matched up with it’s proposed pathophysiology?

a. Vascular Dementia:Pick bodies — abnormal protein-filled structures that
develop within brain cells
b. Dementia with LewyBodies:Evidence of B-amyloid deposits common
c. Frontotemporaldementia:Occlusion of cerebral blood vessel, Multi-infarct dementia
d. Vascular Dementia: Evidence of B-amyloid deposits common
b. Dementia with LewyBodies:Evidence of B-amyloid deposits common
What SE effect is most increased with the Aricept 23mg dose over the Aricept 5-10mg maintenance dose?

a. Gastrointestinal
b. Memory
c. Neuropathy
d. Hypoglycemia
a. Gastrointestinal
What is the dosing daily upper limit for digoxin recommended in the elderly according to the American Geriatrics Society 2012 Beers Criteria Update Expert Panel?

a. 0.075 mg/d
b. 0.125 mg/d
c. 0.175 mg/d
c. 0.215 mg/d
b. 0.125 mg/d
In heart failure, higher dosages associated with no additional benefit and may increase risk of toxicity; slow renal clearance may lead to risk of toxic effect.
When assessing an MMSE score, what range would be considered moderate dementia?

a. 13-20
b. 22-29
c. 27-34
d. 35-42
Answer: A.
During the MMSE, a health professional asks a patient a series of questions designed to test a range of everyday mental skills. The maximum MMSE score is 30 points. A score of 20 to 24 suggests mild dementia, 13 to 20 suggests moderate dementia, less than 12 indicates severe dementia.
1.All of the following are common characteristics of CKD-MBDEXCEPT:
a.Hyperphosphatemia
b.Hypercalcemia
c.Secondary hyperparathyroidism
d.Defective intestinal absorption of calcium
b.Hypercalcemia
2.According to the NKF-K/DOQIguidelines, for patients with Chronic Kidney Disease, what is the recommendedminimumTSAT and ferritin for both men and women?
a.TSAT >20 %; ferritin >80ng/mL
b.TSAT >30 %; ferritin >100 ng/mL
c.TSAT >20 %; ferritin >100 ng/mL
d.TSAT >30 %; ferritin >90ng/mL
c.TSAT >20 %; ferritin >100 ng/mL
1.According to the ADA Standards of Medical Care in Diabetes, what is the most reasonable recommended initial fasting blood glucose level in mg/dL upon waking up each day for a newly diagnosed nonpregnant diabetic adult if no other information is known about the patient?
a.40-100
b.70-130
c.70-150
d.90-150
b.70-130
If a patient is experiencing a hypoglycemic episode with a glucose of 62 mg/dL and symptoms of shaking and difficulty concentrating, the technique which will be the least appropriate in correcting this patient’s hypoglycemia is:

a. 2 tablespoons of raisins
b. 15 g of Glucose Tablets
c. 40 g Chocolate and Peanut Candy Bar
d. 12 ounce glass of non-diet soda
Answer: C. The significant fat content of a chocolate and Peanut candy bar will delay the absorption of sugars into the patient’s digestive system and will spike the patients blood glucose too high. Raisins, glucose tablets, and non-diet sodas are well-known to be excellent sources of quick fixes for hypoglycemia according to the American Diabetes Association.
1.Which of the following drugs can increase sodium and water retention, thus precipitating heart failure?
a.Ibuprofen
b.Pioglitazone
c.Prednisone
d.All of the above
d.All of the above
2.Which of the following medications has a U.S. Boxed Warning stating the drug is contraindicated in patients with heart failure?
a.Sertraline
b.Cilostazol
c.Levothyroxine
d.Hydralazine
b.Cilostazol
1.The 2012 Beers Criteria added which medication to Category 1 (potentially inappropriate medications and classes to avoid):
a.Dabigatran
b.Duloxetine
c.Prasugrel
d.Sliding-scale insulin
d.Sliding-scale insulin
2.Which of the following is NOT an FDA-approved indication for Cymbalta® (duloxetine HCl):
a.Anxiety
b.Insomnia
c.Diabetic peripheral neuropathy
d.Depression
b.Insomnia
1.Why does metformin have a contraindication in females with a serum creatinine ≥ 1.4 mg/dL and in males with a serum creatinine ≥ 1.5 mg/dL?
a.Increased risk of hypoglycemia
b.Increased risk of intolerable GI side effects (such as diarrhea, nausea, and vomiting)
c.Increased risk of lactic acidosis
d.Increased risk of myalgias/myopathies
c.Increased risk of lactic acidosis
2.Geriatric diabetic patients have higher rates of ____________ when compared to geriatric non-diabetic patients:
a.Hypertension
b.Chronic pain
c.Depression
d.All of the above
d.All of the above
1.The MDRD GFR equation utilizes which of the following parameters?
a.Gender
b.Age
c.Race
d.All of the above
d.All of the above
2.According to the 2007 NKF KDOQIupdated guidelines,what is the recommended hemoglobin target for dialysis and nondialysis patients receiving ESA therapy?
a.> 11.0 g/dL
b.11.0 – 12.0 g/dL
c.11.0 – 13.0 g/dL
d.>13.0 g/dL
b.11.0 – 12.0 g/dL
1.A lower ADAS-COG score correlates to _________ cognitive function, and a lower MMSE score correlates to _________ cognitive function.
a.Greater, greater
b.Greater, poorer
c.Poorer, greater
d.Poorer, poorer
b.Greater, poorer
2.Which cholinesterase inhibitor is FDA-approved for mild, moderate, and severe dementia?
a.Donepezil
b.Rivastigmine
c.Galantamine
d.All of the above
a.Donepezil
1.Even though it does not have an indication for heart failure, which unique property of Bystolic (nebivolol) makes it associated with less fatigue and may make it useful for patients undergoing cardiac rehab?
a.More beta1 selectivity
b.Shorter half-life
c.Nitrate like activity
d.All of the above
c.Nitrate like activity
2.Which of the following is the loop diuretic with the longest half-life, the least variability in bioavailability, and whose bioavailability is not affected by food?
a.Bumetanide
b.Torsemide
c.Furosemide
d.Metolazone
b.Torsemide
1.What new category of medications has been added to the updated 2012 Beers Criteria?
a.Potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes
b.Potentially inappropriate medications and classes to avoid in older adults
c.Medications to be used with caution in older adults
d.None of the above – there was not a new category added
c.Medications to be used with caution in older adults
3.Which of the following is the most common type of anemia found in CKD patients, due to decreased production of erythropoietin?
a.Normochromic, microcytic anemia
b.Normochromic, normocytic anemia
c.Normochromic, macrocytic anemia
d.None of the above
b.Normochromic, normocytic anemia
4.According to recent clinical trials and FDA recommendation, which of the following is the most appropriate hemoglobin goal for a CKD patient on an ESA, to avoid increased risk for cardiovascular events?
a.Normal range (ie. male 14-18g/dL, female 12-16g/dL)
b.11 – 12 g/dL
c.<11 g/dL
d.>12g/dL
c.<11 g/dL
5.The failure to recognize familiar objects is defined by which of the following terms?
a.Aphasia
b.Apraxia
c.Agnosia
d.Ataxia
c.Agnosia
6.Which of the following cholinesterase inhibitors requires a dose adjustment in moderate renal impairment and is not recommended in patients with CrCl <9ml/min?
a.Donepezil
b.Rivastigmine
c.Galatamine
d.B and C
c.Galatamine
1.Which drug showed superior efficacy compared with warfarin for stroke prevention in atrial fibrillation patients?
a.Aspirin and Plavix
b.Pradaxa
c.Xarelto
d.All The above
b.Pradaxa
Which of the following medications do NOT contribute to the anticholinergic burden?A.Oxybutynin
B.Benadryl
C.HCTZ
D.Clozapine
C.HCTZ
Which of the following drugs is NOT on the 2012 AGS criteria for potentially inappropriate medication use in older adults?
A.Metformin
B.Glyburide
C.Megestrol
D.Sliding Scale Insulin
A.Metformin
1.Which of the medications has the lowest risk of hypoglycemia?
a.Glyburide
b.Metformin
c.Chlorpropamide
d.Repaglinide
b.Metformin
2.According to AGS, what is the appropriate A1c goal for an elderly diabetic patient who is frail and has a life expectancy of less than 5 years?
a.A1c<6
b.A1c<7
c.A1c<8
d.A1c<9
c.A1c<8
1.All of the following are possible causes of macrocytic anemia EXCEPT:
a.Iron deficiency
b.Vitamin B12 deficiency
c.Folate deficiency
d.Iron excess
a.Iron deficiency
1.What drug is approved for mild-moderate alzheimer’s disease?
a.Aricept 23mg
b.Namenda
c.Exelon patch
d.Benztropine
c.Exelon patch
2.What class of drugs used to treat dementia in elderly patients has been issued a “Boxed Warning” for its increase risk of death?
a.Benzodiazepines
b.Antipsychotics
c.Anticholinergics
d.Anticonvulsants
b.Antipsychotics
1.What study has shown the benefits of BiDil in African American heart failure patients?
a.COMET
b.MERIT-HF
c.A-HeFT
d.CHARM
c.A-HeFT
2.What class of drugs can exacerbate the syndrome of heart failure?
a.NSAIDS
b.Antiarrhythmics
c.Calcium Channel Blockers
d.All The Above
d.All The Above
1.Which of the following angiotensin II receptor blocker(s) are FDA-approved for heart failure?
a.Losartan (Cozaar)
b.Candesartan (Atacand)
c.Valsartan (Diovan)
d.B & C only
D: Candesartan and valsartan of the only two ARBs FDA approved for treatment of NYHA Class II-IV heart failure. Source: CHARM trial (candesartan); Val-HeFT trial (valsartan).
2.Which of the followingwould not be appropriate as adjunctive therapy in heart failure patients?
a.Carvedilol (Coreg)
b.Diltiazem (Cardizem)
c.Spironolactone (Aldactone)
d.Bisoprolol (Zebeta)
Answer B: Carvedilol, bisoprolol and metoprolol succinate are the three beta-blockers recommended for heart failure patients. Spironolactone is an appropriate adjunctive therapy for Class IVHF patients with ejection fraction <30%. Diltiazem and other NDHP CCB agents are not appropriate as they have negative ionotropic effect that may worsen heart failure.
1.A high anticholinergic burden is associated with all of the following except:
a.Dilated pupils and blurry vision
b.Dry mouth
c.Excessive urination
d.Memory impairment
c.Excessive urination
Acetylcholine antagonism causes urinaryretention by blocking acetylcholine transmission on muscarinic 2 and muscarinic 3 receptors to decrease afferent activity and increase inhibitory control. This decreases sensitivity of the detrusor muscle that contributes to the overactive bladder, causing urinary retention rather than excessive urination.
2.Which of the following age-related changes contribute to the need of dosage-adjustments in medications for the elderly patient?
a.Increased total body weight and lean body mass affecting drug absorption.
b.Decreased GI blood flow and slowed intestinal transit cause the elderly population to be more sensitive to constipation from certain medications.
c.Increased brain volume allows leads to increased blood brain barrier permeability of drug molecules
d.Increased liver and renal blood flow
b.Decreased GI blood flow and slowed intestinal transit cause the elderly population to be more sensitive to constipation from certain medications.
The elderly patient tend to have:•Decreased total body weight, lean body mass that can affect absorption
•Decreased brain volume that decreases BBB permeability
•Decreased liver and renal blood flow that requires renal/hepatic adjustments
1.Which of the following medications can contribute to poor glycemic control of elderly diabetic patients?
a.Antipsychotic medications
b.Chronic corticosteroid therapy
c.Beta-blocker therapy
d.All of the above
Answer: D All of the above
Antipsychotic medications can worsen hyperglycemia, diabetic ketoacidosis and HHS. Corticosteroid therapy can aggravate diabetes mellitus4 times more frequently than control in susceptible patients. Beta-blocker blockade of B2 receptors on pancreatic islet cells would inhibit insulin secretion and can cause hyperglycemia.
2.Which of the following anti-diabetic agents have the least hypoglycemia effects?
a.Glyburide (Diabeta)
b.Repaglinide (Prandin)
c.Linagliptin (Tradjenta)
d.HumalogKiwkPen
Answer: C linagliptin (tradjenta) has low risk of hypoglycemia when used as monotherapy
1.Which of the following deficiencies is related to macrocytic anemia?
a.Folic Acid
b.Serum Iron
c.Vitamin B12
d.A & C
d.A & C
Answer D: FA and Vitamin B12 levels are usually within normal limits when there is normochromic and normocytic anemia. Low serum iron levels are usually seen in iron-deficiency anemia
2.Which of the following is consistent with the pathophysiology of mineral and bone disorder from chronic kidney disease?
a.Hyperphosphatemia as a result of decreased phosphorus elimination
b.Decreased serum calciumconcentrations promoting increased PTH secretion
c.Vascular and soft-tissue calcification eventually causing renal osteodystrophy
d.All of the above
Answer D: Decrease in phosphorus elimination leads to hyperphosphatemia, which leads to more binding of phosphorus by calcium. Hypocalcemia then stimulates secretion of PTH, which will increase calcium mobilization from bone.
3.What is the recommended duration of therapy according to available evidence for the use of antipsychotics in patients with dementia and Alzheimer’s Disease?
a.Lifelong
b.1-2 years
c.6-12 weeks
d.Antipsychotics should never be used in dementia patients.
Answer C: Evidence exist for modest short-term (6-12 weeks) benefits of antipsychotic treatment for the serious behavioral symptoms of Alzheimer’s. A previous Alzheimer’s Research Trust study also showed these benefits, which were not evident over longer periods of treatment.
4.Which of the following antipsychotic agents pose the highest risk of tardive dyskinesia for dementia patients?
a.Risperidone
b.Quetiapine
c.Haloperidol
d.Ziprasidone
Answer C: The newer generations of atypical antipsychotics are much safer than the older generation in regard to development of tardive dyskinesia. The first year incidence of TD with risperidone, olanzapine, quetiapine, and ziprasidone in young persons about 0.5%, which is ten-fold lower than with haloperidol. Similarly, the incidence of TD with atypical antipsychotics in the first year in geriatric patients is 2.5%, which is also ten-fold lower than with haloperidol. There is also growing evidence that the incidence is even lower in subsequent years of exposure to atypicals. The problem of TD has been significantly reduced with the advent and wide-spread use of atypical antipsychotics.
1.Which of the following cognitive function tests is used to stage Alzheimer's disease?
A.ADAS-cog
B.Mini Mental Status Exam
C.Clock Drawing Test
D.AIMs Test
B.Mini Mental Status Exam
2.Which of the following is NOT a physiologic change that occurs in the elderly that affects medication effects?
A.Decreased total body water
B.Decreased lean body mass
C.Increased Pgp activity
D.Decreased renal blood flow
C.Increased Pgp activity
Answer: C The elderly have decreased Pgp activity.
Which is used to highlight deposits of beta-amyloid during a PET scan?A. fluorodeoxyglucose
B.cysteine.
C.Flute
D.caesium
C.Flute
Which gene puts a patient at the strongest risk of Alzheimer’s?
a.APOE-e4
b.VKORC1
c.SLCO1B1
d.PKA13
a.APOE-e4
1.What side effect is more commonly seen with dabigatran (Pradaxa) than warfarin (Coumadin)?
a.Diarrhea
b.Dyspepsia
c.Headaches
d.Dizziness
b.Dyspepsia
2.When switching from warfarin (Coumadin) to rivaroxaban (Xarelto), at what point do you initiate therapy with rivaroxaban (Xarelto)?
a.Immediately upon discontinuation of warfarin (Coumadin)
b.When the INR < 4.0
c.When the INR < 3.0
d.When the INR < 2.0
Answer: c – when the INR < 3.0. When switching patients from warfarin to XARELTO, discontinue warfarin and start XARELTO as soon as the International Normalized Ratio (INR) is below 3.0 to avoid periods of inadequate anticoagulation. No clinical trial data are available to guide converting patients from XARELTO to warfarin. XARELTO affects INR, so INR measurements made during coadministration with warfarin may not be useful for determining the appropriate dose of warfarin. One approach is to discontinue XARELTO and begin both a parenteral anticoagulant and warfarin at the time the next dose of XARELTO would have been taken.
1.Which anticoagulant has an antidote in case of overdose?
a.Warfarin
b.Xarelto
c.Pradaxa
d. none of the above
a.Warfarin
2.What is the correct dose for Pradaxa if a patient has a CrCl of 20ml/min?
a.110mg BID
b.150mg Qdaily
c.75mg BID
d. none of the above
c.75mg BID
1.The CHADS2VASc score for estimating risk of stroke includes three more risk factors than the CHADS2 score. Which of the following is not one of these risk factors?
a.Female sex
b.Malignancy
c.Vascular disease
d.Age 65-74
Answer: B. Malignancy is not a risk factor in either the CHADS2VASc or CHADS2 score. Female sex, vascular disease and age 65-74 are the additional risk factors included in CHADS2VASc.
2.Genetic variations in which CYP enzyme are associated with a reduction in warfarin metabolism
a.3A4
b.2D6
c.2C9
d.1A2
Answer: C. Warfarin is metabolized primarily via oxidation in the liver by CYP2C9. The normal, or wild-type, variant is referred to as *1, and the two polymorphic versions are *2 and *3 which reduce warfarin metabolism by 30% and 90% respectively. Lower warfarin doses will be needed to achieve anticoagulation in patients with CYP2C9 polymorphisms.
Which is the recommendation for course of therapy for an A. fib patient who is anticoagulated with a Vitamin K antagonist, and is scheduled to undergo an invasive surgery?A.Continue warfarin therapy until the day of procedure, the use UFH or LMWH for 5 days before resuming warfarin.
B.Stop warfarin 5 days before surgery, and continue 12 to 24 hours after surgery.
C.Stop warfarin 5 days before surgery, bridge therapy with UFH or LMWH, and continue 12 to 24 hours after surgery.
D.Warfarin does not need to be stopped since it can be reversed with vitamin K.
C.Stop warfarin 5 days before surgery, bridge therapy with UFH or LMWH, and continue 12 to 24 hours after surgery.
When is it NOT recommended to give Vitamin K?
A.When INR is above 10 with no evidence of bleeding.
B.INR 4.5 to 10 with no evidence of bleeding.
C.INR 4.5 to 10 with evidence of bleeding.
D.Vitamin K antagonist related major bleeding event.
B.INR 4.5 to 10 with no evidence of bleeding.
1.To convert a patient from Pradaxa to warfarin with a CrCl of 29ml/min
a.Start warfarin 2 days before stopping Pradaxa
b.Start warfarin 3 days before stopping Pradaxa
c.Start warfarin 1 day before stopping Pradaxa
d.No recommendations
Answer: C Patient with a CrCl 15-30 ml/min, it is recommended to start warfarin 1 day before stopping Pradaxa; whereas in CrCl>50ml/min, start warfarin 3 days before and in CrCl 30-50ml/min, start warfarin 2 days before stopping Pradaxa
2.Increased bleeding risk is seen in patients taking warfarin in all the below given genotypes EXCEPT for ________
a.CYP 2C9*1
b.CYP2C9*2
c.CYP2C9*3
d.VKORC1 gene variation
Answer A: CYP2C9*1 is the wild type allele. Patients presenting with variations of CYP2C9 gene with 2/3 alleles and VKORC1 gene variations are associated with increased bleeding
1.How do you convert a patient from warfarin to Xarelto®?
a.Start Xarelto® and continue warfarin for 2 days before stopping.
b.Discontinue warfarin and initiate Xarelto® when INR is below 2.
c.Discontinue warfarin and initiate Xarelto® after 3 days regardless of INR.
d.Discontinue warfarin and initiate Xarelto® when INR is below 3.
Correct answer is D. You are supposed to start as long as INR is below 3.
2.When would you use 75mg BID of Pradaxa®?
a.Creatinine clearance below 50 mL/min
b.Creatinine clearance below 30 mL/min
c.Creatinine clearance below 15 mL/min
d.Never. Renal dosing for Pradaxa® is 75 mg once daily.
Correct answer is B. Pradaxa® is a twice daily drug. Renal impairment dosing begins at 30mL/min. It is not recommended for use below 15mL/min
Which of the following is an indication for an INR goal of 2.5-3.5?
A.Mechanical heart valve in the mitral position
B.Mechanical heart valve in the aortic position
C.Atrial fibrillation with previous history of stroke
D.Recurrent DVT/PE
A.Mechanical heart valve in the mitral position
2.Which of the following scenarios would necessitate the administration of oral vitamin K?
A.INR = 6, mild bruising
B.INR = 11, mild bruising
C.INR = 11, reported GI bleeding
D.INR = 6, reported GI bleeding
B.INR = 11, mild bruising
1.Warfarin is NOT FDA approved for the treatment of:
a.Prophylaxis and treatment of venous thrombosis and its extension, pulmonary embolism
b.Prophylaxis and treatment of thromboembolic complications associated with atrial fibrillation and/or cardiac valve replacement
c.Reduction in the risk of death, recurrent myocardial infarction, and thromboembolic events such as stroke or systemic embolization after myocardial infarction
d.For the treatment of hemorrhagic stroke.
d.For the treatment of hemorrhagic stroke.
2.Pradaxa(dabigatran) is indicated to:
a.reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation.
b.reduce the risk of stroke and nonsystemic embolism in patients with valvular atrial fibrillation.
c.reduce the risk of myocardial infarction.
d.Treat pulmonary embolism.
a.reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation.
According to the CHEST 9 guidelines when should a patient be given 2.5-5mg PO Vitamin K?
a. INR 4.5-10 with no significant bleeding
b. any INR with serious bleeding
c. INR >10 with no significant bleeding
d. INR >3 with life threatening bleeding
c. INR >10 with no significant bleeding
How often should a patient stabilized on warfarin be monitored?
a. every 2 weeks
b. every 4 weeks
c. every 8 weeks
d. every 12 weeks
d. every 12 weeks
1.Which of the following is the appropriate renal dose adjustment for Xarelto in nonvalvular atrial fibrillation?
a. CrCl < 30ml/min- avoid use
b. CrCl 30-50ml/min- decrease dose by 50%
c. CrCl 15-50- decrease dose by 50%
d. CrCl <15- avoid use
d. CrCl <15- avoid use
2.According to the 2012 CHEST Anticoagulation Guidelines, in which of the following patients would you NOT consider a warfarin starting dose less than or equal to 5mg?
a. patients with impaired nutrition
b. elderly patients
c. patients with liver disease
d. you would consider a lower starting dose for all of the above patients
d. you would consider a lower starting dose for all of the above patients
1.Which of the following is a metabolite of oral Vitamin K that is excreted in the urine?
a.Phylloquinone
b.Menaquinone
c.Phyllodione
d.Menadione
d.Menadione
2.Plant-derived vitamin K is also known as:
a.Phylloquinone (vitamin K1)
b.Menaquinones (vitamin K2)
c.Menadione (vitamin K3)
d.Phyllodione (vitamin K4)
a.Phylloquinone (vitamin K1)
1.If a newly diagnosed atrial fibrillation patient has a creatnine clearance of 41ml/min and the physician decides to place them on rivaroxaban, what should be the dose for the patient daily?
a.10 mg daily
b.15 mg BID
c.15 mg daily
d.20 mg daily
c.15 mg daily
2.If a patient came to have their INR checked. The level turns out to be 10 and the patient has no signs or symptoms of bleeding. What would be the best therapy for the patient?
a.Give oral vitamin K 2.5- 5 mg immediately
b.Give IV vitamin K 10mg over 30 minutes
c.Give fresh frozen plasma or PCC
d.Do not give vitamin K at this time, monitor for bleeding
d.Do not give vitamin K at this time, monitor for bleeding
1.All of the following are true disadvantages in regards to Dabigatran except
A.No reversal agent
B.Drug interactions with P-glycoprotein inhibitors and inducers
C.Cannot be dialyzed
D.Higher incidence of GI bleeding compared to warfarin
C.Cannot be dialyzed
2.All of the following are risk factors for bleeding with oral anticoagulation except
A.Age > 75 years
B.Concomitant use of antiplatelet drugs such as aspirin
C.History of bleeding
D.Previous anticoagulation therapy
D.Previous anticoagulation therapy
Which of the following is not evaluated to help determine the HAS-BLED risk score?
A. Hypertension (SBP> 160mmHg)
B. Anemia
C. Stroke
D. Labile INRs
B. Anemia
Which of the following best describes persistent atrial fibrillation?

A. A. fib that terminates spontaneously in less than 7 days
B. A. fib that does not terminate with attempts of cardioversion
C. Two or more episodes of atrial fibrillation
D. A. fib that lasts more than 7 days and does not terminate spontaneously
D. A. fib that lasts more than 7 days and does not terminate spontaneously
1.How long patient needs to get warfarin, prior and after cardioversion in patient without permanent A-Fib or recurrent Paroxysms?
a. 4 weeks prior and after
b.3 weeks prior and one month after
c.1 weeks prior and 2 weeks after
d.3 days prior and one week after
b.3 weeks prior and one month after
2.Which condition could cause auto-anticoagulation?
a.CHF
b.Liver impairment
c.Kidney impairment
d.HIV
b.Liver impairment
1.Which of the following statements is true?
a.In the RE-LY trial, dabigatran exhibited increased risk of GI bleeding but less intracranial hemorrhage compared to warfarin.
b.The RECORD trials compared the effectiveness of rivaroxaban versus warfarin for DVT prophylaxis in patients who have undergone hip and total knee replacement.
c.Apixaban is approved for stroke prevention in patients with atrial fibrillation.
d.The 2012 CHEST Guidelines recommend gradual tapering when discontinuing warfarin rather than abrupt discontinuation of warfarin
ANSWER: A – In the RE-LY trial (compared safety and efficacy of 110 mg and 150 mg dabigatran against warfarin), bleeding was reported in 16.6% of patients in the dabigatran 150 mg group compared to 18.4% in the warfarin group (HR 0.91, 95% CI 0.85—0.96). Intracranial bleeding was reported in 0.3% of patients taking 150 mg dabigatran compared to 0.8% of those taking warfarin (HR 0.41, 95% CI 0.28—0.60).
In clinical trials of patients who had undergone a total hip replacement (RECORD 1 and RECORD 2) or total knee replacement (RECORD 3), fewer patients who received rivaroxaban 10 mg PO daily had a venous thromboembolism compared to those who received enoxaparin 40 mg SC daily
Apixaban is not approved in the US.
Per the 2012 CHEST Anticoagulation guidelines, recommendation 5.0 “For patients eligible to discontinue treatment with VKA, we suggest abrupt discontinuation rather than gradual tapering of the dose to discontinuation (GRADE 2C).”
2.Which of the following genetic variations leads to decreased warfarin clearance?
a.CYP2C19*3
b.CYP2C9*3
c.CYP2C19*2
d.Both A & C
ANSWER: B – The variant alleles, CYP2C9*2 and CYP2C9*3, result in decreased hydroxylation of S-warfarin and decrease S-warfarin clearance; the presence of > 1 of the CYP2C9 variant alleles further decreases clearance.
Which clotting factor is not inhibited by warfarin?
A.I
B.II
C.IX
D.X
E.IV
A.I
Which clotting factor is responsible for hypercoaguable state when starting warfarin therapy?
a.D
b.B
c.C
d.G
c.C
1.Warfarin inhibits all of the following factors EXCEPT:
a.Factor II
b.Factor V
c.Factor VII
d.Factor IX
b.Factor V
2.Which of the following medications is NOT FDA-approved for postoperative thromboprophylaxis in patients who have undergone hip or knee replacement surgery?
a.Dabigatran
b.Rivaroxaban
c.Warfarin
d.All of the above have FDA approval
a.Dabigatran
Which of the following medications does NOT increase INR?
A. Acetaminophen
B. Levothyroxine
C. Levofloxacin
D. Metoprolol
D. Metoprolol
A patient comes to your anticoagulation clinic with an INR of 11 and no signs of bleeding. What would be the best treatment plan for this patient?
A. Continue warfarin and instruct patient to eat extra servings of green vegetables
B. Hold warfarin until therapeutic and administer oral Vitamin K 2.5-5mg
C. Decrease weekly dose of warfarin by 5%
D. Administer Vitamin K 10mg IV with FFP or PCC
B. Hold warfarin until therapeutic and administer oral Vitamin K 2.5-5mg
1.Which correctly correlates with the meaning of the acronym CHADS2?
a.CHF, Heart attack, Age > 75, Diabetes, Smoking
b.CHF, HTN, Age > 75, Diabetes, Stroke
c.CHF, HTN, Age > 55, Diabetes, Smoking
d.CHF, Heart attack, Age > 55, Diabetes, Stroke
b.CHF, HTN, Age > 75, Diabetes, Stroke
2.Which of the follow medications does NOT have an FDA approved indication for stroke prevention in patients with atrial fibrillation?
a.Warfarin
b.Rivaroxaban
c.Dabigatran
d.All of the above are indicated
d.All of the above are indicated
1.What would bethe CHADS2score for a 63 year old CongestiveHeart Failure patient with a prior history of a stroke one year ago and no history of diabetes or hypertension and what would you estimate the patient’s risk to be of suffering a future stroke (%) if the patient were not on coumadin?
a.2; 5.1%
b.3; 5.9%
c.4; 7.6%
d.5; 8.2%
b.3; 5.9%
2.What is the best description of the mechanism of action of Xarelto (rivaroxaban)?
a.Direct thrombin inhibitor
b.Specific Protein C + S Inhibition
c.ADP-induced platelet aggregation Inhibition
d.Factor Xa Inhibition
d.Factor Xa Inhibition
1.Choose the correctly matched warfarin dose and tablet color.
a.10mg - blue
b.2.5-mg - white
c.5mg - peach
d.None of the above are correct
c.5mg - peach
2.According to the 2012 CHEST guidelines for Anticoagulation Therapy in Atrial Fibrillation, what is the recommendation for patients with a CHADS2 score of 1?
a.Dual Anti-platelet therapy
b.Oral Anticoagulation Therapy
c.Warfarin
d.Aspirin Only
b.Oral Anticoagulation Therapy
Which of the following are the correct factors in the activity of warfarin?
A. Fribin
B. Xa
C.2A, 5A
D. 2,7,9,10
D. 2,7,9,10
If a patient’s INR is 5=< but less than =9, what is the correct reversal strategy?
A. Continue therapy
B. Hold 1-2 doses if no bleeding risk
C. Vit K 1-2.5mg PO Vit K x1
D. IV Bit K 10mg
B. Hold 1-2 doses if no bleeding risk
Which of the following is NOT a risk factor for bleeding?
A) Initiation of therapy
B) Age >55
C) Concurrent NSAID use
D) Malignancy
B) Age >55
Which of the following is NOT correct for the CHADS2 score?
A) C = CAD
B) H = HTN
C) A = Age >75
D) D = Diabetes
A) C = CAD
1.What is the loading dose of warfarin that is recommended in the CHEST 2012 guidelines?
a.5mg BID x 5 days
b.10mg Qday x 2 days
c.10mg Qday x 5 days
d.5mg BID x 2 days
e.None of the above
b.10mg Qday x 2 days
2.According to CHEST 2012 guidelines, what is the new recommended maximum time in between clinic visits for patients on warfarin?
a.4 weeks
b.6 weeks
c.12 weeks
d.18 weeks
e.None of the above
c.12 weeks
1.What is the best initial choice for stroke prevention therapy for a 70 year old white male with a past medical history of atrial fibrillation, dyslipidemia, and osteoarthritis?
a.Warfarin 10 mg PO daily
b.Warfarin 5 mg PO daily plus aspirin 81 mg PO daily
c.Dabigatran 150 mg PO twice daily
d.No oral anticoagulation therapy is necessary
d.No oral anticoagulation therapy is necessary
2.Which of the following are contraindications to anticoagulation therapy for an elderly patient diagnosed with atrial fibrillation?
a.History of gastrointestinal or genitourinary tract bleeding 12 months prior to diagnosis
b.Recurrent falls
c.Platelet count of 150,000/mm3
d.Heart failure
b.Recurrent falls
1.Which of the following is true in regard to Xarelto and Pradaxa therapy?
a.Both Xarelto and Pradaxa have evidence data supporting renally adjusted dosing.
b.Both Xarelto and Pradaxa are approved for use in stroke prophylaxis secondary to atrial fibrillation.
c.Both Xarelto and Pradaxa have equally long half-lives.
d.Both Xarelto and Pradaxa patients must be counseled on adverse GI effects and dyspepsia.
Answer B: Only Xarelto has evidence supporting renal dosing with CrCl<15-50 mL/min, whereas 75mg PO BID dose of Pradaxa for CrCl <30 mL/min was based on pharmacokinetic modeling. Xarelto has a shorter half-life (5-9 hours) than Pradaxa (12-17 hours). Pradaxa causes significantly more GI side effects (dyspepsia) than Xarelto as it is formulated with an acidic component whereas Xarelto does not have this issue.
2.Which of the following is true in regard to the new score system used to calculate stroke risk?
a.As incidence of hypertension has increased in this population, the new score system now assigns 2 points to this risk factor.
b.Younger patients (age 65-74) would receive a score of 2, while older patients (>75) will have a score of 1.
c.Higher risk for stroke is correlated with the female population.
d.As congestive heart failure (CHF) occurs more frequently in the elderly population, a score of 2 is now appointed to CHF patients.
Answer C: The new CHA2DS2-VASc score system used to calculate stroke risk assigns 2 points to age >75 as well as stroke/TIA history. In addition, the score now takes into account vascular disease, being of female gender, and differentiates between the “younger” elderly population and the “older” elderly population.
1.Which of the following doses is available for pradaxa in the U.S. for a CrCl< 30 ml/min?
a.150 mg PO BID
b.110 mg PO BID
c.75 mg PO BID
d.150 mg PO QD
c.75 mg PO BID
2.Pradaxa is contraindicated in CrCl< ___ ml/min?
a.50 ml/min
b.40 ml/min
c.30 ml/min
d.15 ml/min
d.15 ml/min
Which of the following statements is/are TRUE?a.Rivaroxaban dose should be reduced if CrCL<50mL/min.
b.Dabigatran dose should be reduced by 50% if CrCL<30mL/min.
c.There is no reversal agent for rivaroxaban.
d.All of the above
d.All of the above
Which of the following statements is/are TRUE?a.Bactrim can increase risk of bleeding in patients on warfarin.
b.Vitamin K is a reversal agent for warfarin.
c.CYP2C9*2 and CYP2C9*3 reduce clearance of S-warfarin.
d.All of the above.
d.All of the above.
Which of the following clotting factors has the shortest half life?

A. II
B. VII
C. IX
D. X
B. VII
Which of the following would be most appropriate for a 72 year old female with atrial fibrillation, a blood pressure of 110/82 and no significant past medical history?

A. No therapy
B. Warfarin
C. Apixiban
B. Dabigatran
A. No therapy