MCQ Quiz: Special Populations – Geriatrics

Caring for geriatric patients is a cornerstone of pharmacy practice, requiring specialized knowledge and a nuanced approach to medication management. Older adults are not simply “older adults”; they are a distinct patient population with unique physiological changes that significantly impact how drugs behave in their bodies. As covered extensively in the Patient Care and Drug Therapy Individualization curricula, age-related shifts in pharmacokinetics and pharmacodynamics, coupled with the high prevalence of polypharmacy and comorbidities, place this group at a heightened risk for adverse drug events. This quiz will test your understanding of key geriatric principles, including the application of the AGS Beers Criteria®, age-related dosing adjustments, and the management of common geriatric syndromes.

1. Which age-related pharmacokinetic change is considered the most significant and predictable, often requiring dose adjustments for many medications?

• a) Increased drug absorption
• b) Decline in renal function and glomerular filtration rate (GFR)
• c) Increased Phase I (CYP450) metabolism
• d) Increased total body water Answer: b) Decline in renal function and glomerular filtration rate (GFR)

2. The American Geriatrics Society (AGS) Beers Criteria® provides a list of Potentially Inappropriate Medications (PIMs) for older adults. Which of the following drug classes is prominently featured on this list due to its strong anticholinergic and sedative effects?

• a) Second-generation antihistamines (e.g., loratadine)
• b) First-generation antihistamines (e.g., diphenhydramine)
• c) Proton pump inhibitors (e.g., omeprazole)
• d) Statins (e.g., atorvastatin) Answer: b) First-generation antihistamines (e.g., diphenhydramine)

3. Due to an increase in body fat and decrease in total body water in older adults, how is the volume of distribution (Vd) for a highly lipophilic drug like diazepam affected?

• a) The Vd is decreased, leading to higher plasma concentrations.
• b) The Vd is increased, leading to a longer half-life.
• c) The Vd is unchanged by age.
• d) The drug cannot be distributed in older adults. Answer: b) The Vd is increased, leading to a longer half-life.

4. A “prescribing cascade” in a geriatric patient occurs when:

• a) A patient is prescribed too many medications at once.
• b) An adverse drug event from one drug is misinterpreted as a new medical condition, and another drug is prescribed to treat it.
• c) A medication is discontinued without a proper taper.
• d) A patient refuses to take a prescribed medication. Answer: b) An adverse drug event from one drug is misinterpreted as a new medical condition, and another drug is prescribed to treat it.

5. The concept of “deprescribing” in geriatrics involves:

• a) The systematic process of identifying and discontinuing medications when the harms outweigh the benefits.
• b) Refusing to prescribe any new medications for an older adult.
• c) Replacing all brand-name drugs with generics.
• d) Lowering the dose of every medication by 50%. Answer: a) The systematic process of identifying and discontinuing medications when the harms outweigh the benefits.

6. As taught in the “Geriatric Dosing” transcending concept lecture, older adults often exhibit increased sensitivity to the CNS effects of which drug class?

• a) Antibiotics
• b) Benzodiazepines
• c) Beta-blockers
• d) Diuretics Answer: b) Benzodiazepines

7. Which of the following is NOT a reason older adults are at a higher risk for adverse drug events?

• a) Polypharmacy
• b) Multiple chronic comorbidities
• c) Increased efficiency of Phase I metabolism
• d) Age-related changes in pharmacokinetics and pharmacodynamics Answer: c) Increased efficiency of Phase I metabolism

8. According to the AGS Beers Criteria®, sliding scale insulin is considered potentially inappropriate in older adults due to its higher risk of:

• a) Hyperglycemia
• b) Hypoglycemia
• c) Weight gain
• d) Dehydration Answer: b) Hypoglycemia

9. The use of which OTC pain medication should be done with extreme caution in an older adult with chronic kidney disease or heart failure?

• a) Acetaminophen
• b) Ibuprofen
• c) Capsaicin cream
• d) Lidocaine patch Answer: b) Ibuprofen

10. What is a primary goal of glaucoma management in geriatric patients?

• a) To cure the disease completely
• b) To lower intraocular pressure (IOP) to prevent further optic nerve damage and vision loss
• c) To improve the patient’s distance vision
• d) To reverse existing vision loss Answer: b) To lower intraocular pressure (IOP) to prevent further optic nerve damage and vision loss

11. Polypharmacy is most accurately defined as:

• a) The use of any more than one medication.
• b) The use of multiple pharmacies to fill prescriptions.
• c) The use of multiple medications, or the administration of more medications than are clinically indicated.
• d) The use of only generic medications. Answer: c) The use of multiple medications, or the administration of more medications than are clinically indicated.

12. An older adult’s medication list includes amitriptyline for sleep. Why is this considered a potentially inappropriate medication according to the Beers Criteria®?

• a) It is not effective for sleep.
• b) It has strong anticholinergic effects, increasing the risk of confusion, constipation, and falls.
• c) It is too expensive.
• d) It must be taken with food. Answer: b) It has strong anticholinergic effects, increasing the risk of confusion, constipation, and falls.

13. When initiating a new medication in an older adult, the common prescribing mantra is:

• a) “Start high, go fast.”
• b) “Start low, go slow.”
• c) “Never change the dose.”
• d) “The higher the dose, the better.” Answer: b) “Start low, go slow.”

14. A decrease in serum albumin in some frail older adults can lead to:

• a) Higher concentrations of free, active drug for highly protein-bound medications.
• b) Lower concentrations of free, active drug.
• c) Faster renal elimination of all drugs.
• d) No change in pharmacokinetics. Answer: a) Higher concentrations of free, active drug for highly protein-bound medications.

15. What is the most important question for a pharmacist to ask an older adult during a medication review, as covered in the “OTC and Herbal Product Use in the Geriatric Community” lecture?

• a) “Do you like the color of your pills?”
• b) “Are you taking any over-the-counter medications, vitamins, or herbal supplements?”
• c) “Do you have any children?”
• d) “What is your favorite food?” Answer: b) “Are you taking any over-the-counter medications, vitamins, or herbal supplements?”

16. The Cockcroft-Gault equation is often used to estimate what parameter in older adults to guide drug dosing?

• a) Liver function
• b) Cardiac output
• c) Creatinine clearance (as an estimate of GFR)
• d) Body Mass Index (BMI) Answer: c) Creatinine clearance (as an estimate of GFR)

17. What is a key reason that benzodiazepines are on the AGS Beers Criteria® list to avoid in older adults?

• a) They are associated with an increased risk of cognitive impairment, delirium, and falls.
• b) They are not effective for anxiety.
• c) They cause severe hypertension.
• d) They are difficult to obtain. Answer: a) They are associated with an increased risk of cognitive impairment, delirium, and falls.

18. An 80-year-old patient is prescribed nitrofurantoin for a urinary tract infection. The pharmacist notes their eGFR is 25 mL/min. This medication is likely inappropriate due to:

• a) Lack of efficacy and increased risk of toxicity in poor renal function.
• b) The high cost of the medication.
• c) The risk of a disulfiram-like reaction.
• d) Its strong anticholinergic properties. Answer: a) Lack of efficacy and increased risk of toxicity in poor renal function.

19. A common challenge in managing hypertension in geriatric patients is:

• a) The lack of effective medications.
• b) The risk of orthostatic hypotension and falls.
• c) The fact that older adults never have high blood pressure.
• d) The need to use much higher doses than in younger adults. Answer: b) The risk of orthostatic hypotension and falls.

20. When counseling a geriatric patient, it is most effective to:

• a) Use complex medical jargon to sound knowledgeable.
• b) Speak very quickly to save time.
• c) Use plain language, provide written instructions in large print, and use a “teach-back” method.
• d) Assume the patient’s family member will handle everything. Answer: c) Use plain language, provide written instructions in large print, and use a “teach-back” method.

21. Zolpidem is a sedative-hypnotic on the AGS Beers Criteria® due to its association with:

• a) Improved memory and cognition.
• b) Delirium, falls, and fractures in older adults.
• c) Weight loss.
• d) Increased bone density. Answer: b) Delirium, falls, and fractures in older adults.

22. “Beers Criteria medication” refers to a drug that is:

• a) Only available over-the-counter.
• b) Potentially inappropriate for use in most older adults.
• c) Always safe for older adults.
• d) Used to treat alcoholism. Answer: b) Potentially inappropriate for use in most older adults.

23. The “Advanced Topics in Pediatrics” lecture highlights key differences from adults; similarly, the “Advanced Topics in Geriatrics” lecture stresses that older adults have unique considerations. What is a primary pharmacodynamic change in the elderly?

• a) Increased number of drug receptors
• b) Decreased sensitivity to anticholinergic effects
• c) Impaired homeostatic regulation (e.g., blood pressure control)
• d) Faster recovery from CNS depressant effects Answer: c) Impaired homeostatic regulation (e.g., blood pressure control)

24. The concurrent use of multiple anticholinergic medications in an older adult significantly increases the risk of:

• a) Improved cognition
• b) Constipation, urinary retention, blurred vision, and confusion.
• c) Weight loss
• d) Reduced fall risk Answer: b) Constipation, urinary retention, blurred vision, and confusion.

25. A key role for a pharmacist on a multidisciplinary geriatric team is:

• a) Performing a comprehensive medication review to identify and resolve drug therapy problems.
• b) Diagnosing new medical conditions.
• c) Prescribing all new medications.
• d) Acting as the team’s scribe. Answer: a) Performing a comprehensive medication review to identify and resolve drug therapy problems.

26. Why might a standard adult dose of a water-soluble drug like lithium result in higher plasma concentrations in an older adult?

• a) Due to increased total body water.
• b) Due to decreased total body water, leading to a smaller volume of distribution.
• c) Due to faster kidney elimination.
• d) Due to increased protein binding. Answer: b) Due to decreased total body water, leading to a smaller volume of distribution.

27. Skeletal muscle relaxants like cyclobenzaprine and carisoprodol are generally poorly tolerated in older adults due to their:

• a) Anticholinergic effects and risk of sedation and falls.
• b) Tendency to cause hypertension.
• c) High cost.
• d) Lack of efficacy for muscle spasms. Answer: a) Anticholinergic effects and risk of sedation and falls.

28. An 82-year-old patient’s medication list includes glimepiride, a long-acting sulfonylurea. This is a PIM on the Beers Criteria® due to the high risk of:

• a) Severe and prolonged hypoglycemia.
• b) Weight gain.
• c) Pancreatitis.
• d) Hyperkalemia. Answer: a) Severe and prolonged hypoglycemia.

29. The “START/STOPP” criteria are another evidence-based tool used in geriatric pharmacy practice to:

• a) Determine when to start and stop CPR.
• b) Identify potential prescribing omissions (START) and potentially inappropriate prescriptions (STOPP).
• c) Manage pharmacy inventory.
• d) Schedule pharmacist breaks. Answer: b) Identify potential prescribing omissions (START) and potentially inappropriate prescriptions (STOPP).

30. Which of the following statements is true regarding medication adherence in the geriatric population?

• a) It is never a problem.
• b) It can be complex due to factors like polypharmacy, cognitive impairment, and cost.
• c) Older adults always have better adherence than younger adults.
• d) Adherence aids like pill boxes are not helpful. Answer: b) It can be complex due to factors like polypharmacy, cognitive impairment, and cost.

31. The Beers Criteria® recommend avoiding the use of proton pump inhibitors (PPIs) for longer than 8 weeks in older adults, unless there is a clear indication, due to concerns about increased risk of:

• a) Clostridium difficile infection and bone fractures.
• b) Weight gain and edema.
• c) Hypertension and tachycardia.
• d) Hair loss and skin rash. Answer: a) Clostridium difficile infection and bone fractures.

32. A pharmacist’s role in geriatric care extends to non-prescription products. Recommending against the use of OTC diphenhydramine for sleep is an application of knowledge from which core geriatric resource?

• a) The Orange Book
• b) The Red Book
• c) The AGS Beers Criteria®
• d) The Sanford Guide Answer: c) The AGS Beers Criteria®

33. The principle of “start low, go slow” for geriatric dosing is a direct response to what physiological reality?

• a) Older adults are generally less adherent to medications.
• b) Older adults have more reliable and faster drug clearance.
• c) Older adults often have reduced drug clearance and/or increased sensitivity to drug effects.
• d) Medications are more expensive for older adults. Answer: c) Older adults often have reduced drug clearance and/or increased sensitivity to drug effects.

34. A decline in Phase I (oxidative) metabolism in the elderly can lead to a longer half-life for drugs like:

• a) Acetaminophen (which primarily undergoes Phase II conjugation)
• b) Lorazepam (which undergoes Phase II conjugation)
• c) Diazepam (which undergoes Phase I oxidation)
• d) Morphine (which undergoes Phase II conjugation) Answer: c) Diazepam (which undergoes Phase I oxidation)

35. A key element of the “Advanced Topics in Geriatrics” unit is understanding that chronological age is often a poor predictor of an individual’s physiologic function and medication tolerance. It is more important to assess:

• a) The patient’s date of birth only.
• b) Their functional status, comorbidities, and overall frailty.
• c) The number of children they have.
• d) Their favorite color. Answer: b) Their functional status, comorbidities, and overall frailty.

36. Digoxin has a narrow therapeutic index and is cleared by the kidneys. It is on the Beers Criteria® to use a lower dose (e.g., ≤0.125 mg/day) in older adults due to:

• a) The high risk of toxicity associated with decreased renal clearance.
• b) Its tendency to cause rapid weight gain.
• c) Its anticholinergic side effects.
• d) The fact that it is not effective in older adults. Answer: a) The high risk of toxicity associated with decreased renal clearance.

37. When an older adult is hospitalized, what is a crucial role for the pharmacist during transitions of care (admission and discharge)?

• a) To make sure the patient has a ride home.
• b) To perform a thorough medication reconciliation to prevent errors.
• c) To order the patient’s meals.
• d) To only focus on the new medications started in the hospital. Answer: b) To perform a thorough medication reconciliation to prevent errors.

38. Which statement best reflects an appropriate ethical and clinical approach to the AGS Beers Criteria®?

• a) The criteria are absolute rules, and these medications must never be used.
• b) The criteria identify medications that may be inappropriate and require the clinician to assess the risk vs. benefit for the individual patient.
• c) The criteria are only for research and should not be used in clinical practice.
• d) The criteria only apply to patients under the age of 65. Answer: b) The criteria identify medications that may be inappropriate and require the clinician to assess the risk vs. benefit for the individual patient.

39. Non-benzodiazepine hypnotics like zolpidem are on the Beers list because they:

• a) Are the safest possible sleep aids for older adults.
• b) Have similar risks to benzodiazepines regarding falls, fractures, and delirium.
• c) Are not effective for insomnia.
• d) Are known to improve memory. Answer: b) Have similar risks to benzodiazepines regarding falls, fractures, and delirium.

40. A patient’s family reports that an older adult has become suddenly confused and is seeing things. Which medication class on their profile would be the most likely culprit to investigate?

• a) Statins
• b) Vitamins
• c) Anticholinergics
• d) Calcium supplements Answer: c) Anticholinergics

41. The primary concern with the use of NSAIDs in an older adult with hypertension treated with an ACE inhibitor is the increased risk of:

• a) Acute kidney injury
• b) Improved blood pressure control
• c) Severe weight loss
• d) Hypoglycemia Answer: a) Acute kidney injury

42. Which of these beta-blockers used for glaucoma is a beta-1 selective agent, making it potentially safer for patients with asthma?

• a) Timolol
• b) Carteolol
• c) Betaxolol
• d) Levobunolol Answer: c) Betaxolol

43. The “Geriatric Dosing” lecture emphasizes that creatinine production decreases with age due to reduced muscle mass. This means that a “normal” serum creatinine level in an older adult may actually reflect:

• a) Significantly impaired renal function.
• b) Supranormal renal function.
• c) That the patient is a bodybuilder.
• d) That the patient does not need any dose adjustments. Answer: a) Significantly impaired renal function.

44. A patient-centered approach to geriatric care involves:

• a) Making all decisions for the patient.
• b) Ignoring the patient’s goals of care.
• c) Involving the patient and their caregivers in shared decision-making about medications.
• d) Focusing only on extending life, regardless of quality of life. Answer: c) Involving the patient and their caregivers in shared decision-making about medications.

45. Which of the following is a common challenge when managing pain in older adults?

• a) They do not experience pain.
• b) They are at a higher risk for adverse effects from analgesics like opioids and NSAIDs.
• c) They always over-report their pain levels.
• d) Pain is a normal part of aging and should not be treated. Answer: b) They are at a higher risk for adverse effects from analgesics like opioids and NSAIDs.

46. A frail, 85-year-old woman is started on oxybutynin for overactive bladder. The pharmacist should be most concerned about which potential adverse effect?

• a) Weight loss
• b) Increased energy
• c) Worsening cognitive function and falls
• d) Improved memory Answer: c) Worsening cognitive function and falls

47. According to the Patient Care VII curriculum, the management of geriatric patients is a dedicated module because:

• a) This population has unique needs and high medication-related risks.
• b) No other course discusses older adults.
• c) It is the easiest patient population to manage.
• d) Geriatric patients use very few medications. Answer: a) This population has unique needs and high medication-related risks.

48. Why is it important to simplify medication regimens for geriatric patients whenever possible?

• a) To make the pharmacist’s job harder.
• b) To improve adherence and reduce the risk of medication errors.
• c) Because older adults can only take one medication per day.
• d) To increase the cost of therapy. Answer: b) To improve adherence and reduce the risk of medication errors.

49. The use of multiple drugs with cumulative anticholinergic effects is known as:

• a) Polypharmacy
• b) Anticholinergic burden
• c) A prescribing cascade
• d) Deprescribing Answer: b) Anticholinergic burden

50. The ultimate goal of geriatric pharmacotherapy is to:

• a) Prescribe as many medications as possible.
• b) Stop all medications in every patient over 65.
• c) Optimize the patient’s quality of life and functional status while minimizing medication-related harm.
• d) Ensure the patient lives to be 100, regardless of their health state. Answer: c) Optimize the patient’s quality of life and functional status while minimizing medication-related harm.