MCQ Quiz: Advanced Topics in Geriatrics

The pharmaceutical care of older adults requires more than just knowledge of drugs; it demands a sophisticated understanding of the complex interplay between aging physiology, multiple chronic conditions, and the unique challenges of polypharmacy. Advanced topics in geriatrics, a key component of the Patient Care curriculum , push students beyond basic principles to master concepts like deprescribing, managing geriatric syndromes, and applying evidence-based tools like the AGS Beers Criteria®. This quiz will test your knowledge on these advanced topics, preparing you to provide safe, effective, and patient-centered care to this growing and vulnerable population.

1. The systematic process of identifying and discontinuing medications where existing or potential harms outweigh existing or potential benefits is known as:

• a) Polypharmacy
• b) A prescribing cascade
• c) Deprescribing
• d) Medication reconciliation Answer: c) Deprescribing

2. The American Geriatrics Society (AGS) Beers Criteria® are designed to identify what for use in older adults?

• a) The most cost-effective medications
• b) The only medications that can be used for patients over 65
• c) Potentially Inappropriate Medications (PIMs)
• d) The first-line treatment for every geriatric syndrome Answer: c) Potentially Inappropriate Medications (PIMs)

3. A “prescribing cascade” is a key advanced topic in geriatrics. Which of the following is a classic example?

• a) Prescribing a statin for a patient with high cholesterol.
• b) Prescribing metformin for a new diagnosis of type 2 diabetes.
• c) Prescribing a calcium channel blocker for hypertension, which causes peripheral edema that is then treated with a diuretic.
• d) Prescribing an antibiotic for a confirmed bacterial infection. Answer: c) Prescribing a calcium channel blocker for hypertension, which causes peripheral edema that is then treated with a diuretic.

4. According to the AGS Beers Criteria®, benzodiazepines should be avoided in older adults due to an increased risk of:

• a) Hypertension and tachycardia
• b) Cognitive impairment, delirium, falls, and fractures
• c) Weight loss and improved appetite
• d) Hair growth Answer: b) Cognitive impairment, delirium, falls, and fractures

5. Which of the following statements about using serum creatinine to estimate renal function in frail, older adults is true?

• a) It is always a reliable indicator of kidney function.
• b) A “normal” serum creatinine may mask a significantly reduced GFR due to decreased muscle mass.
• c) It consistently overestimates actual kidney function.
• d) It is only useful for patients under the age of 70. Answer: b) A “normal” serum creatinine may mask a significantly reduced GFR due to decreased muscle mass.

6. The “start low, go slow” principle of geriatric dosing is a direct response to what age-related physiological changes?

• a) Increased drug metabolism and faster renal clearance.
• b) The fact that older adults prefer lower doses of medication.
• c) Reduced drug clearance and/or increased pharmacodynamic sensitivity.
• d) Insurance company mandates for all new prescriptions. Answer: c) Reduced drug clearance and/or increased pharmacodynamic sensitivity.

7. Delirium, a common geriatric syndrome, is characterized by:

• a) A chronic, progressive decline in memory.
• b) An acute change in mental status with a fluctuating course and inattention.
• c) A normal part of the aging process that should not be treated.
• d) A symptom that is never caused by medications. Answer: b) An acute change in mental status with a fluctuating course and inattention.

8. First-generation antihistamines like diphenhydramine are listed as PIMs on the Beers Criteria® due to their strong:

• a) Beta-blocking properties
• b) Anticholinergic properties
• c) Antiplatelet properties
• d) ACE-inhibiting properties Answer: b) Anticholinergic properties

9. The use of sliding scale insulin (SSI) as the sole method of diabetes management is discouraged in older adults due to its high risk of:

• a) Dehydration
• b) Hypoglycemia without improvement in overall glycemic control
• c) Severe weight gain
• d) Pancreatitis Answer: b) Hypoglycemia without improvement in overall glycemic control

10. “Frailty” is a geriatric syndrome best defined as:

• a) A state of decreased physiologic reserve, leading to increased vulnerability to stressors.
• b) Having more than five chronic medical conditions.
• c) Being over the age of 85.
• d) The need for a walking aid. Answer: a) A state of decreased physiologic reserve, leading to increased vulnerability to stressors.

11. The STOPP/START criteria are another tool used in geriatric care. The “START” portion of the tool aims to identify:

• a) Potentially inappropriate medications to stop.
• b) Medications that have a high risk of drug-drug interactions.
• c) Potentially indicated medications that are being omitted.
• d) The correct starting dose for all new medications. Answer: c) Potentially indicated medications that are being omitted.

12. An older adult has an increased percentage of body fat and a decreased percentage of lean body mass. This will most significantly increase the volume of distribution and half-life of which type of drug?

• a) A highly water-soluble (hydrophilic) drug
• b) A highly fat-soluble (lipophilic) drug
• c) A drug that is eliminated only by the kidneys
• d) A drug administered intravenously Answer: b) A highly fat-soluble (lipophilic) drug

13. The Beers Criteria® recommend avoiding the chronic use of proton pump inhibitors (PPIs) without a clear indication due to an increased risk of:

• a) Clostridioides difficile infection and bone fractures
• b) Improved blood pressure
• c) Weight loss
• d) Alopecia Answer: a) Clostridioides difficile infection and bone fractures

14. A key objective of the “Advanced Topics in Geriatrics” unit is to understand that medication management in older adults should focus on:

• a) Maximizing the number of prescribed medications.
• b) Achieving perfect laboratory values regardless of side effects.
• c) The patient’s functional goals and quality of life.
• d) Extending life at all costs. Answer: c) The patient’s functional goals and quality of life.

15. Which of the following pain medications is generally considered the safest first-line option for chronic musculoskeletal pain in an older adult?

• a) Ketorolac
• b) Cyclobenzaprine
• c) Acetaminophen
• d) Meperidine Answer: c) Acetaminophen

16. The anticholinergic cognitive burden refers to the cumulative risk of cognitive impairment resulting from:

• a) Taking a single anticholinergic medication.
• b) Taking multiple medications with anticholinergic properties.
• c) A diet high in choline.
• d) A diagnosis of Alzheimer’s disease. Answer: b) Taking multiple medications with anticholinergic properties.

17. What is a key pharmacodynamic change in older adults that increases their risk of orthostatic hypotension with antihypertensive agents?

• a) Increased baroreceptor reflex sensitivity
• b) Decreased baroreceptor reflex sensitivity
• c) Increased number of alpha-adrenergic receptors
• d) Decreased number of beta-adrenergic receptors Answer: b) Decreased baroreceptor reflex sensitivity

18. When counseling an older adult on self-care, as discussed in the Patient Care VII curriculum, it is crucial to ask about:

• a) Only their prescription medications.
• b) Their political beliefs.
• c) Their use of all OTC products, herbal supplements, and vitamins.
• d) Their favorite television shows. Answer: c) Their use of all OTC products, herbal supplements, and vitamins.

19. Skeletal muscle relaxants (e.g., carisoprodol, cyclobenzaprine) are on the Beers Criteria® because of their high risk for causing sedation and falls, and because:

• a) They are highly effective with few side effects.
• b) Their efficacy at tolerated doses is questionable.
• c) They are the only option for treating muscle spasms.
• d) They are inexpensive. Answer: b) Their efficacy at tolerated doses is questionable.

20. A “brown bag review” is an advanced technique in geriatric care where the patient:

• a) Brings in a bag of brown-colored pills.
• b) Brings all of their medications, including OTCs and supplements, to an appointment for review.
• c) Receives their lunch in a brown bag.
• d) Is taught how to properly store medications in a brown bag. Answer: b) Brings all of their medications, including OTCs and supplements, to an appointment for review.

21. Digoxin is recommended to be avoided as first-line therapy for heart failure in older adults and requires lower dosing due to its narrow therapeutic index and:

• a) Dependence on hepatic metabolism, which is increased in the elderly.
• b) Dependence on renal clearance, which is often decreased in the elderly.
• c) Tendency to cause significant weight gain.
• d) Lack of available monitoring parameters. Answer: b) Dependence on renal clearance, which is often decreased in the elderly.

22. Which of the following is an example of a drug-disease interaction highlighted by the Beers Criteria®?

• a) Using metformin in a patient with diabetes.
• b) Using a statin in a patient with hyperlipidemia.
• c) Using NSAIDs in a patient with heart failure.
• d) Using an albuterol inhaler in a patient with asthma. Answer: c) Using NSAIDs in a patient with heart failure.

23. The pharmacist’s role in transitions of care for a geriatric patient moving from hospital to home is critical for:

• a) Ensuring the hospital food was satisfactory.
• b) Performing a final medication reconciliation to prevent discharge-related errors.
• c) Packing the patient’s belongings.
• d) Driving the patient home. Answer: b) Performing a final medication reconciliation to prevent discharge-related errors.

24. Which statement BEST describes the clinical application of the AGS Beers Criteria®?

• a) They are absolute contraindications and can never be violated.
• b) They are a list of PIMs to be used as a guide, requiring clinical judgment and consideration of the individual patient.
• c) They are only applicable to patients in nursing homes.
• d) They replace the need for a pharmacist’s professional judgment. Answer: b) They are a list of PIMs to be used as a guide, requiring clinical judgment and consideration of the individual patient.

25. An older adult taking warfarin is prescribed trimethoprim/sulfamethoxazole. This combination is a PIM due to the high risk of:

• a) Decreased warfarin effect, leading to blood clots.
• b) Increased bleeding due to a significant drug-drug interaction.
• c) A disulfiram-like reaction.
• d) Worsening renal function. Answer: b) Increased bleeding due to a significant drug-drug interaction.

26. Incontinence is a common geriatric syndrome. The use of which drug class for other indications can worsen stress incontinence?

• a) Alpha-agonists
• b) Alpha-antagonists (e.g., prazosin)
• c) Beta-blockers
• d) ACE inhibitors Answer: b) Alpha-antagonists (e.g., prazosin)

27. The primary reason long-acting sulfonylureas like glyburide are considered potentially inappropriate for older adults is:

• a) Their high cost
• b) Their prolonged duration of action, which increases the risk of severe, delayed hypoglycemia
• c) Their lack of efficacy
• d) Their need for twice-daily dosing Answer: b) Their prolonged duration of action, which increases the risk of severe, delayed hypoglycemia

28. An “advanced topic in geriatrics” is understanding that not all problems require a drug. For insomnia, a non-pharmacologic first-line approach would be:

• a) A shot of whiskey at bedtime.
• b) Cognitive behavioral therapy for insomnia (CBT-I) and sleep hygiene education.
• c) Prescribing a high-dose benzodiazepine.
• d) Recommending OTC diphenhydramine every night. Answer: b) Cognitive behavioral therapy for insomnia (CBT-I) and sleep hygiene education.

29. The term “iatrogenesis” in geriatrics refers to:

• a) Any illness caused by a genetic disorder.
• b) Any harm or illness caused by medical treatment or diagnosis.
• c) The normal process of aging.
• d) A type of physical therapy. Answer: b) Any harm or illness caused by medical treatment or diagnosis.

30. Which of the following is a key patient-centered question to ask when considering deprescribing a medication?

• a) “Does this medication come in a color you like?”
• b) “What does this medication help you with, and what is most important to you for your health?”
• c) “Do you want to stop all of your medications today?”
• d) “Is this the most expensive medication you take?” Answer: b) “What does this medication help you with, and what is most important to you for your health?”

31. The Beers Criteria® advise against using peripherally acting alpha-1 blockers (e.g., doxazosin) as an antihypertensive because:

• a) They are not effective.
• b) They cause severe bradycardia.
• c) They have a high risk of causing orthostatic hypotension.
• d) They are only approved for use in young men. Answer: c) They have a high risk of causing orthostatic hypotension.

32. What is a key challenge in managing chronic pain in older adults?

• a) They under-report pain because they believe it is a normal part of aging.
• b) They are at higher risk for adverse effects from both opioids and NSAIDs.
• c) Cognitive impairment can make pain assessment difficult.
• d) All of the above. Answer: d) All of the above.

33. The use of tertiary amine tricyclic antidepressants (TCAs) like amitriptyline is discouraged in the elderly primarily due to:

• a) Their high cost
• b) Their potent anticholinergic and sedating properties
• c) Their lack of efficacy for depression
• d) Their stimulating properties Answer: b) Their potent anticholinergic and sedating properties

34. A pharmacist is reviewing medications for a new nursing home resident. The most appropriate first step is:

• a) To discontinue all medications started by the previous doctor.
• b) To conduct a comprehensive medication review, assessing each drug for appropriateness, safety, and efficacy.
• c) To double the doses of all pain medications.
• d) To order a new set of laboratory tests without reviewing the current regimen. Answer: b) To conduct a comprehensive medication review, assessing each drug for appropriateness, safety, and efficacy.

35. Which of the following OTC sleep aids is the most inappropriate for an older adult due to its anticholinergic effects?

• a) Melatonin
• b) Valerian root
• c) Diphenhydramine (e.g., ZzzQuil, Tylenol PM)
• d) Chamomile tea Answer: c) Diphenhydramine (e.g., ZzzQuil, Tylenol PM)

36. A significant reduction in Phase I (oxidative) metabolism in the liver of older adults primarily affects drugs that are substrates of:

• a) UDP-glucuronosyltransferase (UGT)
• b) Cytochrome P450 (CYP) enzymes
• c) N-acetyltransferase (NAT)
• d) Thiopurine S-methyltransferase (TPMT) Answer: b) Cytochrome P450 (CYP) enzymes

37. When applying the Beers Criteria®, it’s important to remember that they are intended for which population?

• a) All adults
• b) Pediatric patients
• c) Adults aged 65 years and older
• d) Patients in the intensive care unit only Answer: c) Adults aged 65 years and older

38. The concept of “functional status” in a geriatric assessment refers to:

• a) How well the patient’s kidneys are working.
• b) The patient’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
• c) The patient’s employment status.
• d) The patient’s marital status. Answer: b) The patient’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

39. What is the primary safety concern with using spironolactone in an older adult with a CrCl < 30 mL/min, especially if they are also on an ACE inhibitor?

• a) Hypoglycemia
• b) Hypertension
• c) Hyperkalemia
• d) Hypokalemia Answer: c) Hyperkalemia

40. An advanced practice pharmacist in geriatrics often focuses on:

• a) Selling the most profitable supplements.
• b) Minimizing patient interaction.
• c) Comprehensive medication management and leading deprescribing initiatives.
• d) Dispensing medications as quickly as possible. Answer: c) Comprehensive medication management and leading deprescribing initiatives.

41. The rationale for avoiding drugs like diazepam (long half-life) in favor of lorazepam (shorter half-life) in older adults is due to:

• a) The risk of accumulation and prolonged sedation with long-acting agents.
• b) Diazepam being more expensive.
• c) Lorazepam being more effective for anxiety.
• d) Diazepam having more anticholinergic effects. Answer: a) The risk of accumulation and prolonged sedation with long-acting agents.

42. Which of the following is a key barrier to successful deprescribing?

• a) Lack of time during appointments
• b) Patient or caregiver resistance to stopping a long-term medication
• c) Fear of adverse withdrawal events or the return of a treated condition
• d) All of the above Answer: d) All of the above

43. A pharmacist’s recommendation to switch an older adult from glyburide to glipizide is based on the fact that glipizide:

• a) Has a shorter duration of action and lower risk of hypoglycemia.
• b) Is a more potent sulfonylurea.
• c) Causes less weight gain.
• d) Is a newer medication. Answer: a) Has a shorter duration of action and lower risk of hypoglycemia.

44. The medication reconciliation process is especially critical for geriatric patients because:

• a) They are more likely to be on multiple medications prescribed by multiple providers.
• b) They never make mistakes with their medications.
• c) They enjoy talking about their pills.
• d) Their insurance requires it for all refills. Answer: a) They are more likely to be on multiple medications prescribed by multiple providers.

45. Which of the following is an example of an “instrumental activity of daily living” (IADL)?

• a) Bathing
• b) Dressing
• c) Toileting
• d) Managing finances Answer: d) Managing finances

46. The risk of adverse drug events in geriatrics is not just about the number of drugs, but also the:

• a) Color of the pills.
• b) Appropriateness and complexity of the regimen.
• c) Shape of the tablets.
• d) Time of day the pharmacy opens. Answer: b) Appropriateness and complexity of the regimen.

47. The primary learning objective of the “Special Populations – Geriatrics” module is to equip pharmacists to:

• a) Treat all older adults the same way.
• b) Individualize pharmacotherapy to maximize benefits and minimize harm in older adults.
• c) Specialize in pediatric medicine.
• d) Avoid interacting with patients over the age of 65. Answer: b) Individualize pharmacotherapy to maximize benefits and minimize harm in older adults.

48. Why is it important to explicitly discuss a medication’s indication with an older adult?

• a) To test their memory.
• b) To help identify medications that may no longer be necessary (therapeutic orphans).
• c) It is not important.
• d) To bill for a higher level of service. Answer: b) To help identify medications that may no longer be necessary (therapeutic orphans).

49. An older patient with new-onset urinary incontinence should first be assessed for:

• a) The need for a urinary catheter.
• b) Potentially causative medications (e.g., diuretics, alpha-blockers).
• c) Surgical options.
• d) The need to restrict all fluid intake. Answer: b) Potentially causative medications (e.g., diuretics, alpha-blockers).

50. The ultimate principle guiding all advanced topics in geriatrics is:

• a) Ensuring the patient is on at least 10 medications.
• b) Patient-centered care that respects the individual’s goals and preferences.
• c) The “one-size-fits-all” model.
• d) A “drug for every ill” prescribing philosophy. Answer: b) Patient-centered care that respects the individual’s goals and preferences.