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402. The answer is b. (Fauci, 14/e, pp 148-149.) The best first test to evaluate changes in mental status in elderly patients is the Folstein minimental status examination (MMSE). A score of < 23 out of a possible 30 is consistent with dementia. The differential diagnosis for dementia includes Alzheimer's disease (the most common etiology), but other causes must be considered, such as multi-infarct dementia (stepwise decline), normal pressure hydrocephalus (NPH), hypothyroidism, vitamin B12 deficiency, folic acid deficiency, depression (pseudodementia), neurosyphilis, HIV, and subdural hematoma.

403. The answer is c. (Seidel, 4/e, p 195.) The grading for pressure ulcers is as follows:

Stage 1 = The skin is red but not broken Stage 2 = Damage through the epidermis and dermis Stage 3 = Damage through to the subcutaneous tissue Stage 4 = Muscle and possible bone involvement

404. The answer is b. (Goldman, 21/e, pp 20-22.) Delirium is a transient global disorder characterized by waxing and waning levels of consciousness, hallucinations, anxiety, restlessness, combative behavior, paranoia, short attention span, autonomic disturbances (tachycardia and diaphoresis), and decreased short-term memory. Patients often worsen in the evening hours ("sundowning"). Risk factors for delirium include Hypoxemia, Infection, Drugs, and Electrolyte abnormalities (HIDE); the mainstay of treatment is to treat the underlying cause.

405. The answer is b. (Berson, pp 40-55.) Glaucoma is a disorder that may occur without visual symptoms, and patients at risk for the disease should be screened carefully. Patients at risk include the elderly, African Americans, those with a family history of glaucoma, and those with a history of hypertension, diabetes mellitus, or myopia. Signs of glaucoma include asymmetry of the cup:disc ratios (even if normal), cup:disc ratio > 0.5, and flame hemorrhages at the edge of the disc. The disc of glaucoma is pale, not hyperemic. Macular degeneration, etiology unknown, is the leading cause of blindness in older persons. Patients complain of a progressive loss of vision, and funduscopic exam reveals drusen deposits (small, yellow-white) around the macula and posterior pole of the eye. Cataracts are opacities of the lens; patients often complain of glare and the inability to see well in reduced light (contrast sensitivity). Eye examination reveals a reduced red reflex. A pterygium is an abnormal triangular fold of membrane extending from the conjunctiva to the cornea that occurs because of irritation secondary to sand, dust, or ultraviolet light. Chemosis is conjunctival edema.

406. The answer is b. (Fauci, 14/e, pp 186, 1917, 2310.) Giant cell arteritis or temporal arteritis usually appears after the age of 55 and is more common in women than men. Patients typically present with severe headache, malaise, fever, and tenderness over the involved temporal artery. Patients may have ocular symptoms due to ischemic optic neuropathy (blindness is an irreversible complication) and complain of jaw pain when chewing (jaw claudication). Polymyalgia rheumatica (limb girdle stiffness and pain, weight loss, malaise) may be seen in up to 30% of patients with temporal arteritis. Patients suspected of having temporal arteritis require immediate corticosteroids; diagnosis is confirmed by temporal artery biopsy. Trigeminal neuralgia (tic douloureux) causes severe unilateral facial pain but is not associated with vision changes or claudication. Cluster headaches occur mostly in men and are characterized by periorbital or temporal pain lasting up to 2 h and accompanied by lacrimation and pto-sis. Patients complain of several attacks a day for several weeks followed by a period of remission.

407. The answer is d. (Fauci, 14/e, pp 2348-2355, 2449.) The patient has normal pressure hydrocephalus (NPH), which is a triad of dementia, incontinence, and ataxia in a patient with a past history of meningitis or subarachnoid hemorrhage. CT scan will show large ventricles. In Alzheimer's disease (dementia of the senile type), patients have motor signs and incontinence, but usually late in the disease. Mini-mental status examination (MMSE) score is typically 20 or less out of a possible score of 30. Patients with pseudodementia or depression have vegetative signs, such as sleep disturbances and lack of energy. Multi-infarct dementia (vascular dementia) causes a "stair-step" progression of symptoms; patients often have a history of hypertension, cardiac emboli, or atherosclerosis. Bin-swanger's disease is a specific kind of vascular dementia associated with demyelination of the cerebral white matter. Patients with Pick's disease have dementia with alterations in emotion and personality. CreutzfeldtJakob disease (spongiform encephalopathy) is due to a transmissible prion and is related to "mad cow disease." It is a rare disorder characterized by dementia, ataxia, myoclonus, and death within 6-12 mo of onset.

408. The answer is d. (Fauci, 14/e, p 40.) Physicians must determine the degree of functional incapacity of the elderly patient based on both medical and psychosocial evaluations. Determining the activities of daily living (ADLs), the instrumental activities of daily living (IADLs), and the socioeconomic circumstances and social support system (who will help the patient in case of illness or in an emergency) are integral in the functional assessment of an elderly patient. The ADLs are Dressing, Eating, Ambulating, Toileting, and Hygiene (DEATH). The IADLs are Shopping, Housekeeping, Accounting, Food preparation, and Transportation (SHAFT).

409. The answer is e. (Fauci, 14/e, p 2445.) Herpes zoster is due to reactivation of latent varicella virus; patients typically present with a history of pain, tingling, or itching of the affected area followed by an eruption of vesicles overlying an erythematous base. Although the disease can disseminate and produce diffuse eruptions, it typically presents with involvement of a single dermatome. The disease is not limited to adults or immuno-compromised patients and may be seen in children.

410. The answer is b. (Berson, pp 41, 50-54.) Macular changes include the formation of drusen, subretinal neovascularization, and degenerative changes (depigmentation and atrophy) of the retinal epithelium. Drusen are hyaline nodules or colloid bodies deposited in Bruch's membrane. Amsler grid testing is a method of evaluating the function of the entire macula. The patient looks at a square grid pattern; if he or she sees irregularities in the grid in the form of wavy or fuzzy lines, this indicates a sco-toma (due to macular involvement). Open-angle glaucoma is an insidious form of glaucoma whereby the chamber angle remains open. Acute angle-

closure glaucoma (also called narrow-angle glaucoma) is an ocular emergency in which the trabeculum suddenly becomes completely occluded by iris tissue. Patients complain of severe eye pain, nausea, and the presence of halos or rainbows around light. The pupil may be fixed and dilated secondary to the abrupt rise in intraocular pressure.

411. The answer is c. (Fauci, 14/e, pp 2356-2361.) Shy-Drager syndrome (also called multiple system atrophy or MSA) is parkinsonism associated with autonomic dysfunction; patients may present with anhidrosis, disturbance of sphincter control, impotence, and orthostatic hypotension. Patients typically have signs of LMN involvement (everything is "down" or "low" meaning flaccid paralysis, diminished reflexes, and flexor Babinski reflex). Parkinson's disease (PD) is a triad of resting, asymmetric tremor, rigidity (cogwheel in nature), and bradykinesia. Patients have difficulty getting out of a chair, and gait, which is slow at first, becomes faster (festination) with ambulation. The "get up and go" test (patient gets out of a chair, walks 10 ft, turns around, and returns to chair in under 15 s) is a good test for assessing gait and will be abnormal in patients with parkinsonism. PD is an idiopathic progressive disease in which there is Lewy body inclusion and degeneration of neurons in the substantia nigra. Benign essential tremor is also called senile tremor or familial tremor (autosomal dominant) and is reduced by alcohol use. Cerebellar tremor occurs with intention and is absent at rest. Patients usually have other signs of cerebellar disease, such as ataxia. Progressive supranu-clear palsy is a disorder of bradykinesia and rigidity with dementia and loss of voluntary control of eye movements. Creutzfeldt-Jakob disease is accompanied by parkinsonian features, but patients typically have dementia and myoclonic jerky movements.

412. The answer is e. (Seidel, 4/e, p 703.) Risk factors for osteoporosis include white, Asian-Pacific Islander, and Native American race, Northwestern European descent, blonde or red hair, freckles, thin body frame, nulli-parity, early menopause, family history of osteoporosis, postmenopause, constant dieting, calcium intake < 500 mg/day, scoliosis, rheumatoid arthritis, poor teeth, previous fractures, cigarette smoking, heavy alcohol use, medications (heparin, steroids, thyroxine), and metabolic disorders (diabetes, hyperthyroidism, hypercortisolism).

413. The answer is a. (Fauci, 14/e, pp 2388, 2455-2457.) The patient most likely has vitamin B12 deficiency due to pernicious anemia (lack of intrinsic factor). Patients show loss of posterior column sensation (vibration and position sense), positive Romberg test, mild spasticity, and bilateral extensor plantar reflexes (upper motor neuron). Patients may also present with mild dementia or psychiatric symptoms. The polyneuropathy associated with B6 (pyridoxine) deficiency is associated with isoniazid use. Lead poisoning causes a motor neuropathy (i.e., wristdrop, footdrop) and requires chronic exposure to lead as an adult. Tabes dorsalis due to tertiary syphilis causes progressive sensory loss, ataxia, and a positive Romberg test, but patients complain of severe lancinating leg pain. Patients are not spastic and do not have a positive Babinski sign. Vitamin E deficiency is seen in liver disease, cystic fibrosis, and other malabsorption syndromes; patients present with ataxia and peripheral neuropathy.

414. The answer is a. (Fauci, 14/e, pp 699-700.) The peripheral blood results are highly suggestive of chronic lymphocytic leukemia (CLL), which is primarily a clonal proliferation of B cells. Often smudge cells are seen in the peripheral blood smear. The life expectancy of this patient (stage 0 since he has no lymphadenopathy, hepatosplenomegaly, anemia, or thrombocytopenia) is greater than 10 years. Hypogammaglobulinemia with subsequent infections from encapsulated organisms is a late manifestation of CLL. Patients with CLL almost never undergo transformation into acute lymphoblastic leukemia.

415. The answer is e. (Goldman, 21/e, p 16. Tierney, 39/e, p 48.) Age-related physiologic changes include increase in body fat, decrease in total body water, decrease in thyroxine clearance and production, decrease in gastric acidity, decrease in colonic motility, and decrease in lean body mass. The process of aging produces important physiologic changes in the central nervous system, which cause age-related symptoms. The elderly may have the following changes:

Cognitive: Forgetfulness, declining processing speed, decreased verbal fluency

Reflexes: Decreased righting reflex, absent ankle reflexes, postural instability

Sensory: Presbyacusis or diminished high-frequency hearing Presbyopia due to decreased lens elasticity Olfactory system deterioration Vertigo

Decreased upward gaze Gait/balance: Stiffer, slower, forward flexed, unsteady, increased body sway

Sleep: Fatigue, insomnia, increased naps, decrease in sleep stages 3 and 4

416. The answer is b. (Fauci, 14/e, pp 2266-2268.) Paget's disease of bone (osteitis deformans) is a disorder in which normal bone is replaced by disorganized trabecular bone. Patients may be asymptomatic but may present with increased hat size (skull enlargement), hearing loss (involvement of the ossicles of the inner ear), facial pain, headache, backache, leg pain, growth of the lower extremities (one leg may be longer than the other), tibial bowing, and increased blood flow to the involved areas of bone growth. Alkaline phosphatase may be elevated and a bone scan will detect the lytic lesions. A complication of Paget's disease is osteosarcoma (<1%).

417. The answer is d. (Tintinalli, 5/e, p 1809.) Femoral neck fractures are common in the elderly and occur more frequently in women than men. Ninety percent are due to minor trauma secondary to falls. Displaced fractures cause pain and an inability to walk. The involved extremity is often shorter, slightly externally rotated, and abducted.

418. The answer is c. (Fauci, 14/e, pp 100-103. Sapira, p 342.) The patient most likely has cardiac syncope, which results from a sudden reduction in cardiac output usually caused by an arrhythmia. Patients with vasovagal or neurocardiogenic syncope (common fainting) present with bradycardia and hypotension due to activation of the parasympathetic nervous system. Patients with carotid sinus syncope initiate symptoms by turning the head to one side, wearing a tight shirt collar, or shaving over the carotid artery. The subclavian steal syndrome occurs with exercise of the upper extremities. When a subclavian artery is occluded and the patient exercises, blood is "stolen" from the ipsilateral vertebral artery and delivered first to the brain and then to the arm, bypassing the subclavian artery (reversal of flow). Patients may have a decreased radial pulse amplitude and lower blood pressure in the affected arm.

419. The answer is d. (Fauci, 14/e, pp 42-43.) Risk factors for falls in the elderly are reduced visual acuity, reduced hearing, vestibular dysfunction, peripheral neuropathy, dementia, musculoskeletal disorders, foot disorders (bunions, edema), postural hypotension, alcohol use, and medications (diuretics, sedatives, benzodiazepines, antidepressants, antihypertensives, antiarrhythmics, anticonvulsants).

420. The answer is a. (Fauci, 14/e, pp 1112-1116.) Secondary bacterial infection may be a complication of acute influenza. The common pathogens are Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. Often the patient experiences improvement in the influenza symptoms prior to the development of the bacterial pneumonia. A sputum gram stain or sputum culture is often helpful because patients may have a primary influenza viral pneumonia (the most common complication of influenza) or a mixed viral-bacterial pneumonia.

421. The answer is b. (Fauci, 14/e, p 40.) The patient most likely has depression. The mnemonic for depression is SIG E CAPS.

S = Sleep problems I = Decreased Interest in life G = Guilt feelings E = Lowered Energy level C = Decreased Concentration A = Decreased Appetite P = Psychomotor retardation/agitation S = Suicidal ideation

422. The answer is a. (Kochar, 3/e, p 510.) An elderly patient's decline in function in response to disease usually follows the same pattern. Hygiene or bathing are lost first, followed by dressing, toileting, ambulating (transferring), and eating. Recovery usually occurs in the reverse order. 423-425. The answers are 423-a, 424-a, 425-c. (Seidel, 4/e, pp 543, 571-572.) Normal postvoid residual urine volume (PVR) is <50 mL, and normal bladder capacity is 400-600 mL. The patients with stroke and BPH have urge incontinence or detrusor overactivity. Patients with parkinson-ism and dementia may also develop urge incontinence. Patients complain of urinary incontinence (sometimes of large volume) following a sudden urge to urinate. The patient senses the need to void at below normal volumes (<200 ml) and the bladder is unable to tolerate normal bladder capacity. Overflow incontinence is caused by (1) an acontractile bladder (diabetes or spinal cord injury), (2) anatomic obstruction (BPH), and (3) detrusor-sphincter dyssynergy or neurogenic bladder (multiple sclerosis and spinal cord lesions). Often a tense, smooth, and round mass (overdis-tended bladder) will be palpated on abdominal exam and the bladder can be percussed (a lower percussion note than the surrounding air-filled intestines). Patients with overflow incontinence often have leakage of small amounts of urine and calculated PVRs of >100 ml. Stress incontinence is characterized by the loss of small amounts of urine during activities that increase abdominal pressure, such as coughing, laughing, sneezing, and exercising. Functional incontinence is often due to the combination of cognitive impairment and immobility. The urinary tract is intact in functional incontinence.

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