Providing pharmaceutical care to geriatric patients is a crucial aspect of modern healthcare, representing a key “transcending concept” in patient safety and individualized therapy. Older adults are a specialized population with unique physiological changes that profoundly affect how drugs are absorbed, distributed, metabolized, and eliminated. A deep understanding of these age-related pharmacokinetic and pharmacodynamic shifts, coupled with knowledge of clinical tools like the Beers Criteria, is essential for safe and effective geriatric drug dosing. For PharmD students, mastering these principles is fundamental to minimizing adverse drug events, optimizing therapeutic outcomes, and promoting health and wellness in the elderly. This MCQ quiz will test your knowledge on the key principles of geriatric pharmacotherapy.
1. The most significant age-related pharmacokinetic change that affects the dosing of many medications in the elderly is:
- A. Increased hepatic blood flow
- B. Increased total body water
- C. A predictable decline in renal function, even with a normal serum creatinine
- D. Enhanced Phase I metabolism
Answer: C. A predictable decline in renal function, even with a normal serum creatinine
2. Age-related increase in body fat and decrease in total body water can affect drug distribution. For a lipophilic (fat-soluble) drug, this change can lead to:
- A. A decreased volume of distribution and shorter half-life.
- B. An increased volume of distribution and prolonged half-life.
- C. No change in drug distribution.
- D. Faster elimination of the drug.
Answer: B. An increased volume of distribution and prolonged half-life.
3. For a hydrophilic (water-soluble) drug, the age-related decrease in total body water can lead to:
- A. A lower initial plasma concentration for a given dose.
- B. A higher initial plasma concentration for a given dose, increasing the risk of toxicity.
- C. A longer elimination half-life.
- D. No change in drug distribution.
Answer: B. A higher initial plasma concentration for a given dose, increasing the risk of toxicity.
4. The Cockcroft-Gault equation is commonly used to estimate:
- A. Glomerular Filtration Rate (GFR)
- B. Creatinine Clearance (CrCl), as a surrogate for renal function to guide drug dosing
- C. Hepatic enzyme activity
- D. Body Mass Index (BMI)
Answer: B. Creatinine Clearance (CrCl), as a surrogate for renal function to guide drug dosing
5. Why can serum creatinine be an unreliable indicator of renal function in frail, elderly patients?
- A. Because older adults have increased muscle mass, leading to falsely elevated serum creatinine.
- B. Because older adults often have decreased muscle mass, leading to lower creatinine production and a potentially “normal” serum creatinine level despite significantly reduced renal function.
- C. Because serum creatinine is not filtered by the glomerulus.
- D. Because dietary protein does not affect serum creatinine levels.
Answer: B. Because older adults often have decreased muscle mass, leading to lower creatinine production and a potentially “normal” serum creatinine level despite significantly reduced renal function.
6. Age-related changes in hepatic metabolism primarily affect which type of metabolic reactions more significantly?
- A. Phase II reactions (conjugation, e.g., glucuronidation)
- B. Phase I reactions (oxidation, reduction, hydrolysis via CYP450 enzymes)
- C. Both Phase I and Phase II reactions are equally affected.
- D. Hepatic metabolism is generally increased in the elderly.
Answer: B. Phase I reactions (oxidation, reduction, hydrolysis via CYP450 enzymes)
7. The Beers Criteria is a clinical tool designed to help healthcare providers:
- A. Diagnose common geriatric syndromes.
- B. Calculate appropriate weight-based drug doses.
- C. Identify potentially inappropriate medications (PIMs) for older adults.
- D. Assess a patient’s cognitive function.
Answer: C. Identify potentially inappropriate medications (PIMs) for older adults.
8. Many drugs are included on the Beers Criteria list due to their strong anticholinergic properties. These properties can increase the risk of what in older adults?
- A. Improved memory and concentration
- B. Confusion, constipation, urinary retention, blurred vision, and falls
- C. Hypertension and tachycardia
- D. Weight loss and improved appetite
Answer: B. Confusion, constipation, urinary retention, blurred vision, and falls
9. Which of the following medication classes is a primary example of a potentially inappropriate medication for long-term use in most elderly patients due to increased risk of falls, fractures, and cognitive impairment?
- A. Statins
- B. ACE inhibitors
- C. Benzodiazepines and “Z-drugs” (e.g., zolpidem)
- D. Metformin
Answer: C. Benzodiazepines and “Z-drugs” (e.g., zolpidem)
10. “Polypharmacy” in geriatrics is generally defined as the concurrent use of multiple medications, often considered to be:
- A. 2 or more drugs
- B. 3 or more drugs
- C. 5 or more drugs
- D. 10 or more drugs
Answer: C. 5 or more drugs (though the exact number can vary).
11. A “prescribing cascade” occurs when:
- A. A new drug is prescribed to treat the side effect of another drug, which is misinterpreted as a new medical condition.
- B. A drug dose is slowly titrated upwards.
- C. A medication is discontinued without tapering.
- D. A generic medication is substituted for a brand-name medication.
Answer: A. A new drug is prescribed to treat the side effect of another drug, which is misinterpreted as a new medical condition.
12. The principle of “start low, go slow” in geriatric prescribing means:
- A. Always using sub-therapeutic doses indefinitely.
- B. Initiating therapy with a lower-than-usual adult dose and titrating upwards cautiously based on response and tolerance.
- C. Prescribing medications with a slow onset of action only.
- D. Delaying the initiation of all necessary medications.
Answer: B. Initiating therapy with a lower-than-usual adult dose and titrating upwards cautiously based on response and tolerance.
13. Which of the following is a pharmacodynamic change seen in older adults, leading to increased sensitivity?
- A. Decreased sensitivity of beta-adrenergic receptors to agonists and antagonists.
- B. Increased sensitivity to the sedative and respiratory depressant effects of opioids and benzodiazepines.
- C. Decreased sensitivity to the effects of warfarin.
- D. Enhanced baroreceptor reflex function.
Answer: B. Increased sensitivity to the sedative and respiratory depressant effects of opioids and benzodiazepines.
14. Decreased baroreceptor reflex sensitivity in older adults increases the risk of which adverse drug effect with antihypertensive agents?
- A. Rebound hypertension
- B. Orthostatic hypotension and subsequent falls
- C. Tachycardia
- D. Drug-induced lupus
Answer: B. Orthostatic hypotension and subsequent falls
15. “Deprescribing” is the systematic process of:
- A. Prescribing new medications to treat all existing symptoms.
- B. Identifying and discontinuing or reducing the dose of medications that are potentially inappropriate or no longer providing benefit.
- C. Switching all brand-name drugs to generics.
- D. Only prescribing medications on the Beers Criteria list.
Answer: B. Identifying and discontinuing or reducing the dose of medications that are potentially inappropriate or no longer providing benefit.
16. Which first-generation antihistamine is on the Beers Criteria list of drugs to avoid in older adults due to its potent anticholinergic effects?
- A. Loratadine
- B. Cetirizine
- C. Fexofenadine
- D. Diphenhydramine
Answer: D. Diphenhydramine
17. The use of NSAIDs (e.g., ibuprofen, naproxen) in older adults should be done with caution due to an increased risk of:
- A. Improved renal function.
- B. Gastrointestinal bleeding, renal toxicity, and exacerbation of heart failure.
- C. Bronchodilation.
- D. Lowering blood pressure.
Answer: B. Gastrointestinal bleeding, renal toxicity, and exacerbation of heart failure.
18. When dosing enoxaparin (a LMWH) in an elderly patient, it is crucial to:
- A. Use a fixed dose for all patients regardless of weight or renal function.
- B. Assess renal function (CrCl) and adjust the dose accordingly.
- C. Monitor INR daily.
- D. Administer it orally.
Answer: B. Assess renal function (CrCl) and adjust the dose accordingly.
19. Which of the following statements about digoxin use in the elderly is TRUE?
- A. Digoxin is a very safe drug with a wide therapeutic index in this population.
- B. Reduced renal clearance in the elderly increases the risk of toxicity; lower doses and careful monitoring are required.
- C. Digoxin dose does not need to be adjusted for renal function.
- D. Elderly patients are less sensitive to the effects of digoxin.
Answer: B. Reduced renal clearance in the elderly increases the risk of toxicity; lower doses and careful monitoring are required.
20. The STOPP (Screening Tool of Older People’s Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria are designed to:
- A. Only identify medications to stop.
- B. Only identify medications that should be started.
- C. Help clinicians identify both potentially inappropriate prescribing (STOPP) and potential prescribing omissions (START).
- D. Replace the need for clinical judgment.
Answer: C. Help clinicians identify both potentially inappropriate prescribing (STOPP) and potential prescribing omissions (START).
21. A decrease in serum albumin in a frail, malnourished elderly patient can lead to:
- A. Decreased effects of all drugs.
- B. An increased fraction of unbound (active) drug for highly protein-bound medications, potentially increasing their effects and toxicity.
- C. No change in the effects of protein-bound drugs.
- D. Increased metabolism of all drugs.
Answer: B. An increased fraction of unbound (active) drug for highly protein-bound medications, potentially increasing their effects and toxicity.
22. Which of the following drug classes has a high “anticholinergic burden” and should be used cautiously in the elderly?
- A. Statins
- B. ACE inhibitors
- C. Tricyclic antidepressants (e.g., amitriptyline), first-generation antihistamines, and some overactive bladder medications
- D. Beta-blockers
Answer: C. Tricyclic antidepressants (e.g., amitriptyline), first-generation antihistamines, and some overactive bladder medications
23. The pharmacist’s role in geriatric drug therapy is critical and includes:
- A. Only dispensing medications as quickly as possible.
- B. Performing medication reviews, assessing for polypharmacy, screening for potentially inappropriate medications, counseling on proper use, and collaborating with prescribers on dose adjustments.
- C. Discouraging all medication use in patients over 65.
- D. Making a definitive diagnosis of age-related diseases.
Answer: B. Performing medication reviews, assessing for polypharmacy, screening for potentially inappropriate medications, counseling on proper use, and collaborating with prescribers on dose adjustments.
24. Which of the following changes with aging generally has the least clinically significant impact on drug therapy?
- A. Decreased renal elimination
- B. Decreased hepatic metabolism (Phase I)
- C. Changes in drug absorption from the gastrointestinal tract
- D. Changes in body composition (fat vs. water)
Answer: C. Changes in drug absorption from the gastrointestinal tract (While some changes occur, the rate may be slowed, but the extent of absorption for most drugs is not significantly altered).
25. A “brown bag review,” where a patient brings all their medications (including OTCs and supplements) to an appointment, is a useful tool for:
- A. Assessing patient health literacy.
- B. Performing an accurate medication reconciliation and identifying potential problems like non-adherence, duplication, or inappropriate medication use.
- C. Determining the cost of the patient’s medications only.
- D. Checking for counterfeit medications.
Answer: B. Performing an accurate medication reconciliation and identifying potential problems like non-adherence, duplication, or inappropriate medication use.
26. Why might a long-acting sulfonylurea like glyburide be considered potentially inappropriate for many older adults with type 2 diabetes?
- A. It has a low risk of hypoglycemia.
- B. It has a high risk of prolonged hypoglycemia due to its long duration of action and active metabolites that are renally cleared.
- C. It causes significant weight loss.
- D. It is ineffective at lowering blood glucose.
Answer: B. It has a high risk of prolonged hypoglycemia due to its long duration of action and active metabolites that are renally cleared.
27. An older adult’s response to beta-blockers may be blunted due to an age-related:
- A. Increase in the number and sensitivity of beta-adrenergic receptors.
- B. Decrease in the number and sensitivity of beta-adrenergic receptors.
- C. Increase in baroreceptor reflex function.
- D. Decrease in hepatic metabolism of all beta-blockers.
Answer: B. Decrease in the number and sensitivity of beta-adrenergic receptors.
28. When considering a medication’s risk-benefit profile in a frail elderly patient with multiple comorbidities and a limited life expectancy, the focus may shift towards:
- A. Aggressively treating all conditions to prolong life at all costs.
- B. Prioritizing medications that improve quality of life and manage symptoms, while carefully considering the burden of other preventive medications.
- C. Withholding all medications.
- D. Using only medications with a very high risk of adverse effects.
Answer: B. Prioritizing medications that improve quality of life and manage symptoms, while carefully considering the burden of other preventive medications.
29. Which of the following is a key reason why older adults are more susceptible to adverse drug events (ADEs)?
- A. They take fewer medications than younger adults.
- B. Their physiological reserve is higher.
- C. They experience multiple pharmacokinetic and pharmacodynamic changes, and often have multiple comorbidities and polypharmacy.
- D. They have universally better medication adherence.
Answer: C. They experience multiple pharmacokinetic and pharmacodynamic changes, and often have multiple comorbidities and polypharmacy.
30. The Beers Criteria advises against using skeletal muscle relaxants (e.g., carisoprodol, cyclobenzaprine) in older adults due to:
- A. Their effectiveness in treating musculoskeletal pain.
- B. Their potent anticholinergic effects, sedation, and increased risk of falls and fractures, with questionable efficacy at tolerated doses.
- C. Their lack of drug interactions.
- D. Their low cost.
Answer: B. Their potent anticholinergic effects, sedation, and increased risk of falls and fractures, with questionable efficacy at tolerated doses.
31. When an older adult is prescribed a new medication, what is a crucial first step in dosing?
- A. Start with the maximum recommended dose.
- B. Assume no dose adjustment is needed.
- C. Assess their renal function (e.g., calculate CrCl) to determine if a dose adjustment is necessary for renally cleared drugs.
- D. Check their serum albumin level for all drugs.
Answer: C. Assess their renal function (e.g., calculate CrCl) to determine if a dose adjustment is necessary for renally cleared drugs.
32. What is a primary concern with using proton pump inhibitors (PPIs) for an extended duration in older adults, as noted in some guidelines/warnings?
- A. Increased risk of C. difficile infection, bone fractures, and micronutrient deficiencies.
- B. Severe hypertension.
- C. Improved absorption of calcium and vitamin B12.
- D. Lack of efficacy for treating GERD.
Answer: A. Increased risk of C. difficile infection, bone fractures, and micronutrient deficiencies.
33. The term “geriatric syndromes” (e.g., falls, delirium, incontinence) is important in geriatric pharmacotherapy because:
- A. These syndromes are never caused or exacerbated by medications.
- B. Medications are a common contributing factor to these syndromes, and medication review is key to their management.
- C. These syndromes only occur in hospitalized patients.
- D. These syndromes are a normal part of aging and require no intervention.
Answer: B. Medications are a common contributing factor to these syndromes, and medication review is key to their management.
34. For which of the following drugs is it most critical to perform renal dose adjustments in an elderly patient with reduced GFR?
- A. Warfarin (metabolized hepatically, but response can be sensitive in elderly)
- B. Propranolol (metabolized hepatically)
- C. Gabapentin (excreted renally)
- D. Atorvastatin (metabolized hepatically)
Answer: C. Gabapentin (excreted renally)
35. A “medication-related problem” in a geriatric patient is best identified through:
- A. Only checking their blood pressure.
- B. A comprehensive medication review that assesses indication, effectiveness, safety, and adherence for each medication.
- C. Asking the patient if they have any problems.
- D. Reviewing only the prescription medications.
Answer: B. A comprehensive medication review that assesses indication, effectiveness,safety, and adherence for each medication.
36. A decrease in first-pass metabolism in older adults can lead to ________ oral bioavailability for drugs that are normally extensively cleared by the liver on first pass (e.g., propranolol).
- A. Decreased
- B. Increased
- C. Unchanged
- D. Unpredictable
Answer: B. Increased
37. Which of the following represents an appropriate application of the STOPP criteria?
- A. Starting an NSAID for a patient with a history of peptic ulcer disease.
- B. Identifying that a patient on an ACE inhibitor and spironolactone with a K+ of 5.6 mEq/L should have their MRA stopped or dose reduced.
- C. Prescribing diphenhydramine for insomnia in an 85-year-old with cognitive impairment.
- D. Continuing a medication that has no valid indication.
Answer: B. Identifying that a patient on an ACE inhibitor and spironolactone with a K+ of 5.6 mEq/L should have their MRA stopped or dose reduced.
38. Which of the following represents an appropriate application of the START criteria?
- A. Identifying that an 80-year-old patient with atrial fibrillation and a CHA2DS2-VASc score of 4 is not on an anticoagulant, and one should be considered.
- B. Starting a benzodiazepine for anxiety in a patient with a history of falls.
- C. Adding another antihypertensive when the patient’s blood pressure is already at goal.
- D. Starting aspirin for primary prevention in a 90-year-old with no cardiovascular risk factors.
Answer: A. Identifying that an 80-year-old patient with atrial fibrillation and a CHA2DS2-VASc score of 4 is not on an anticoagulant, and one should be considered.
39. The anticholinergic cognitive burden (ACB) scale is a tool used to:
- A. Measure a patient’s cognitive function directly.
- B. Quantify the cumulative risk of cognitive impairment from all medications a patient is taking with anticholinergic effects.
- C. Diagnose dementia.
- D. Guide dosing for acetylcholinesterase inhibitors.
Answer: B. Quantify the cumulative risk of cognitive impairment from all medications a patient is taking with anticholinergic effects.
40. Why are drugs with long half-lives (e.g., long-acting benzodiazepines like diazepam) particularly problematic in older adults?
- A. They require more frequent dosing.
- B. They and their active metabolites can accumulate over time, leading to prolonged sedation, cognitive impairment, and increased risk of falls.
- C. They are less effective than short-acting agents.
- D. They have fewer drug interactions.
Answer: B. They and their active metabolites can accumulate over time, leading to prolonged sedation, cognitive impairment, and increased risk of falls.
41. An 80-year-old patient has a serum creatinine of 1.1 mg/dL. The pharmacist should interpret this value as:
- A. Definitively normal renal function.
- B. A sign of severe kidney damage.
- C. Potentially masking a significantly reduced creatinine clearance due to age-related low muscle mass; CrCl should be estimated.
- D. An indication to increase the dose of renally cleared drugs.
Answer: C. Potentially masking a significantly reduced creatinine clearance due to age-related low muscle mass; CrCl should be estimated.
42. The primary goal of geriatric pharmacotherapy is to:
- A. Use as many medications as possible to treat every symptom.
- B. Optimize quality of life and functional status by using medications appropriately to achieve therapeutic goals while minimizing adverse drug events.
- C. Only use medications that are on the Beers Criteria list.
- D. Avoid all medications in patients over the age of 80.
Answer: B. Optimize quality of life and functional status by using medications appropriately to achieve therapeutic goals while minimizing adverse drug events.
43. Which of the following is an example of a pharmacodynamic change in older adults?
- A. Slower metabolism of a drug by the liver.
- B. Reduced renal excretion of a drug.
- C. Increased brain sensitivity to the sedative effects of diphenhydramine.
- D. A larger volume of distribution for a lipophilic drug.
Answer: C. Increased brain sensitivity to the sedative effects of diphenhydramine.
44. A key principle when evaluating a new symptom in an elderly patient on multiple medications is to:
- A. Immediately assume it is a new disease and prescribe another medication.
- B. Consider whether the new symptom could be an adverse effect of one of their current medications.
- C. Ignore the symptom as it is likely just “old age.”
- D. Only investigate if the symptom is severe pain.
Answer: B. Consider whether the new symptom could be an adverse effect of one of their current medications.
45. Which of the following statements about warfarin use in the elderly is TRUE?
- A. Older adults often require higher doses of warfarin than younger adults.
- B. Older adults are often more sensitive to warfarin’s effects and may require lower doses and more frequent monitoring, especially at initiation.
- C. INR monitoring is not necessary for older adults on warfarin.
- D. Warfarin has no significant drug interactions in the elderly.
Answer: B. Older adults are often more sensitive to warfarin’s effects and may require lower doses and more frequent monitoring, especially at initiation.
46. When a pharmacist identifies a potentially inappropriate medication on a geriatric patient’s profile, the most appropriate next step is to:
- A. Tell the patient to stop the medication immediately.
- B. Contact the prescriber with the concern and offer alternative, safer therapeutic options.
- C. Dispense the medication without comment.
- D. Refuse to dispense all of the patient’s medications.
Answer: B. Contact the prescriber with the concern and offer alternative, safer therapeutic options.
47. Changes in body composition with aging (increased fat, decreased water) mean that a loading dose of a hydrophilic drug like gentamicin, if based on actual body weight, might lead to:
- A. Subtherapeutic levels
- B. Potentially toxic initial levels
- C. No change in levels
- D. A longer duration of action
Answer: B. Potentially toxic initial levels (as the Vd for the hydrophilic drug is smaller, the same mg/kg dose results in a higher plasma concentration).
48. What is the primary concern with using first-generation sulfonylureas (e.g., chlorpropamide, glyburide) in the elderly?
- A. They cause hyperglycemia.
- B. They have a long duration of action and/or active metabolites that are renally cleared, leading to a high risk of prolonged and severe hypoglycemia.
- C. They are ineffective in older adults.
- D. They must be administered intravenously.
Answer: B. They have a long duration of action and/or active metabolites that are renally cleared, leading to a high risk of prolonged and severe hypoglycemia.
49. The “prescribing cascade” for an elderly patient might look like:
- A. Patient takes an NSAID -> develops edema -> is prescribed a diuretic.
- B. Patient has hypertension -> is prescribed an ACE inhibitor.
- C. Patient has an infection -> is prescribed an antibiotic.
- D. Patient has high cholesterol -> is prescribed a statin.
Answer: A. Patient takes an NSAID -> develops edema -> is prescribed a diuretic. (Where the edema is a side effect of the NSAID, not a new disease).
50. An essential component of a medication management plan for any geriatric patient is:
- A. To ensure they are on at least five medications.
- B. To perform a comprehensive medication review regularly and incorporate patient-specific goals of care.
- C. To avoid all generic medications.
- D. To communicate only with the patient’s family members and not the patient.
Answer: B. To perform a comprehensive medication review regularly and incorporate patient-specific goals of care.