MCQ Quiz: Special Populations – Geriatric Dosing

Dosing medications for geriatric patients is one of the most complex and critical responsibilities in pharmacy. Older adults are not just “older”; they experience a cascade of physiological changes that alter drug pharmacokinetics and pharmacodynamics, making them uniquely susceptible to adverse events. The mantra “start low, go slow” is just the beginning. A deep understanding of age-related changes in renal function, body composition, and drug sensitivity is required to truly optimize therapy. This quiz, based on key principles from the Patient Care and Drug Therapy Individualization curricula, will test your knowledge on the nuances of geriatric dosing, from applying the AGS Beers Criteria® to adjusting doses based on organ function.

1. What is the most common reason for medication dose adjustments in the geriatric population?

• a) Increased hepatic metabolism
• b) Reduced renal clearance
• c) Increased drug absorption
• d) Increased protein binding Answer: b) Reduced renal clearance

2. The common geriatric prescribing principle “start low, go slow” refers to:

• a) Starting with the lowest effective dose and titrating slowly based on response and tolerance.
• b) Only prescribing low-potency medications.
• c) Prescribing medications that have a slow onset of action.
• d) Driving slowly to the pharmacy. Answer: a) Starting with the lowest effective dose and titrating slowly based on response and tolerance.

3. Why can a “normal” serum creatinine level be a misleading indicator of kidney function in a frail, older adult?

• a) Because older adults have higher muscle mass, which elevates creatinine.
• b) Because decreased muscle mass leads to lower creatinine production, masking a reduced GFR.
• c) Because serum creatinine is not related to kidney function.
• d) Because older adults metabolize creatinine faster. Answer: b) Because decreased muscle mass leads to lower creatinine production, masking a reduced GFR.

4. The AGS Beers Criteria® recommends avoiding or using a lower dose of digoxin (>0.125 mg/day) in older adults primarily due to:

• a) Increased risk of toxicity from reduced renal clearance.
• b) Its potent anticholinergic side effects.
• c) Its tendency to cause weight gain.
• d) Its ineffectiveness in the geriatric population. Answer: a) Increased risk of toxicity from reduced renal clearance.

5. Due to an age-related increase in body fat, a highly lipophilic drug like diazepam will have:

• a) A decreased volume of distribution and shorter half-life.
• b) An increased volume of distribution and longer half-life.
• c) No change in its pharmacokinetic profile.
• d) Increased renal clearance. Answer: b) An increased volume of distribution and longer half-life.

6. A water-soluble drug like lithium will have a higher initial plasma concentration in an older adult given the same mg/kg dose as a younger adult because of:

• a) Increased total body water in the elderly.
• b) Decreased total body water in the elderly, leading to a smaller volume of distribution.
• c) Faster metabolism.
• d) Slower absorption. Answer: b) Decreased total body water in the elderly, leading to a smaller volume of distribution.

7. Which phase of hepatic metabolism is generally preserved in older adults compared to the other?

• a) Phase I (oxidation, reduction) metabolism is preserved.
• b) Phase II (conjugation) metabolism is relatively preserved.
• c) Both phases are equally and significantly reduced.
• d) Neither phase is affected by age. Answer: b) Phase II (conjugation) metabolism is relatively preserved.

8. The “LOT” benzodiazepines (Lorazepam, Oxazepam, Temazepam) are often preferred in older adults because they:

• a) Are more potent than other benzodiazepines.
• b) Primarily undergo Phase II metabolism, which is less affected by age and liver disease.
• c) Have no sedative effects.
• d) Are not controlled substances. Answer: b) Primarily undergo Phase II metabolism, which is less affected by age and liver disease.

9. A geriatric patient is more sensitive to the CNS depressant effects of opioids. This is an example of an age-related:

• a) Pharmacokinetic change
• b) Pharmacodynamic change
• c) Formulation issue
• d) Adherence problem Answer: b) Pharmacodynamic change

10. According to the AGS Beers Criteria®, nitrofurantoin is potentially inappropriate in older adults with a CrCl < 30 mL/min because of:

• a) Increased risk of hypertension.
• b) Lack of efficacy for urinary tract infections and increased risk for pulmonary toxicity.
• c) The high cost of the medication.
• d) Its strong anticholinergic effects. Answer: b) Lack of efficacy for urinary tract infections and increased risk for pulmonary toxicity.

11. Which of the following is an example of an appropriate geriatric dosing adjustment?

• a) Doubling the standard starting dose of warfarin.
• b) Using the same dose of gabapentin for a patient with a CrCl of 25 mL/min as for a patient with a CrCl of 90 mL/min.
• c) Starting an 85-year-old on a lower initial dose of an opioid analgesic.
• d) Using a long-acting sulfonylurea like glyburide for diabetes management. Answer: c) Starting an 85-year-old on a lower initial dose of an opioid analgesic.

12. The impaired baroreceptor reflex in many older adults increases the risk of what adverse effect when using antihypertensive agents?

• a) Orthostatic hypotension and falls
• b) Rebound hypertension
• c) Severe bradycardia
• d) Anaphylaxis Answer: a) Orthostatic hypotension and falls

13. When choosing a medication, considering if an older patient can physically swallow a large tablet or open a specific container is a practical application of which course’s principles?

• a) Drug Delivery Systems
• b) Population Health
• c) Principles of Law & Ethics
• d) Pharmacy Practice Management Answer: a) Drug Delivery Systems

14. An older adult with decreased serum albumin will have a higher free fraction of which type of drug, potentially leading to toxicity?

• a) A drug that is highly water-soluble
• b) A drug that is highly protein-bound (e.g., phenytoin, warfarin)
• c) A drug that is not metabolized
• d) A drug with low protein binding Answer: b) A drug that is highly protein-bound (e.g., phenytoin, warfarin)

15. The Beers Criteria® advise against using which class of drugs for insomnia due to their high anticholinergic burden and limited efficacy?

• a) First-generation antihistamines (e.g., diphenhydramine)
• b) Melatonin
• c) Trazodone at low doses
• d) Ramelteon Answer: a) First-generation antihistamines (e.g., diphenhydramine)

16. The concept of simplifying medication regimens (e.g., changing to once-daily formulations) is a key geriatric dosing strategy aimed at improving:

• a) Medication cost
• b) Adherence
• c) The drug’s potency
• d) The drug’s half-life Answer: b) Adherence

17. What is the primary safety concern with prescribing a tricyclic antidepressant like amitriptyline to an older adult?

• a) Its high cost.
• b) Its potent anticholinergic and sedating effects, leading to confusion and falls.
• c) Its lack of efficacy for depression.
• d) It is not available in a generic form. Answer: b) Its potent anticholinergic and sedating effects, leading to confusion and falls.

18. A key learning objective of the “Principles of Drug Therapy Individualization” course is understanding how patient-specific factors, such as age-related renal decline, require medication individualization. This is MOST critical for drugs that are:

• a) Primarily cleared by the kidneys and have a narrow therapeutic index.
• b) Primarily cleared by the liver.
• c) Available over-the-counter.
• d) Highly lipophilic. Answer: a) Primarily cleared by the kidneys and have a narrow therapeutic index.

19. Why might the dose of a pro-drug that requires hepatic activation need to be re-evaluated in an older adult?

• a) Reduced Phase I metabolism may lead to less conversion to the active metabolite, decreasing efficacy.
• b) Activation is always increased in the elderly.
• c) Prodrugs are not affected by hepatic metabolism.
• d) The dose should always be doubled. Answer: a) Reduced Phase I metabolism may lead to less conversion to the active metabolite, decreasing efficacy.

20. A pharmacist recommending a lower starting dose of zolpidem for an 80-year-old female is following dosing guidance from:

• a) The patient’s preference
• b) The AGS Beers Criteria® and FDA labeling
• c) A television commercial
• d) The Sanford Guide Answer: b) The AGS Beers Criteria® and FDA labeling

21. When dosing medications for older adults, it’s important to differentiate between side effects and:

• a) Symptoms of a new disease.
• b) The desired therapeutic effect.
• c) The normal aging process.
• d) The patient’s personality. Answer: a) Symptoms of a new disease.

22. Which factor is LEAST likely to require a dose adjustment in a typical geriatric patient?

• a) Renal function (eGFR)
• b) Comorbid conditions
• c) Drug absorption rate
• d) Presence of interacting medications Answer: c) Drug absorption rate

23. The Beers Criteria® recommend avoiding the combination of opioids, benzodiazepines, and gabapentinoids in older adults due to the significantly increased risk of:

• a) Severe respiratory depression and sedation-related falls.
• b) Hypertension.
• c) Hyperglycemia.
• d) Liver failure. Answer: a) Severe respiratory depression and sedation-related falls.

24. For which of the following drugs would a pharmacist most likely need to recommend a dose adjustment in an 85-year-old with an eGFR of 20 mL/min?

• a) Warfarin
• b) Atorvastatin
• c) Dabigatran
• d) Lorazepam Answer: c) Dabigatran

25. The principle of geriatric dosing is not just about avoiding harm, but also about preventing:

• a) Undertreatment of conditions like pain or hypertension.
• b) The patient from asking too many questions.
• c) Polypharmacy at all costs.
• d) The use of any new medications. Answer: a) Undertreatment of conditions like pain or hypertension.

26. Which formulation might be preferred for an older adult with dysphagia (difficulty swallowing)?

• a) A very large, unscored tablet
• b) An extended-release capsule that cannot be opened
• c) An oral liquid, chewable tablet, or orally disintegrating tablet
• d) An enteric-coated tablet Answer: c) An oral liquid, chewable tablet, or orally disintegrating tablet

27. The clinical focus of geriatric dosing should always be on:

• a) The number of prescriptions a patient takes.
• b) The individual patient’s goals of care, functional status, and risk vs. benefit profile.
• c) The chronological age of the patient only.
• d) The cost of the medications above all else. Answer: b) The individual patient’s goals of care, functional status, and risk vs. benefit profile.

28. An increased sensitivity to the QT-prolonging effects of some medications in older adults is an example of what kind of age-related change?

• a) Pharmacokinetic
• b) Pharmacodynamic
• c) Pharmaceutical
• d) Pharmacoeconomic Answer: b) Pharmacodynamic

29. The AGS Beers Criteria® are updated periodically to:

• a) Reflect new evidence and research in geriatric pharmacotherapy.
• b) Remove drugs from the list to make prescribing easier.
• c) Add more expensive drugs to the list.
• d) Comply with a government mandate. Answer: a) Reflect new evidence and research in geriatric pharmacotherapy.

30. Why is the chronic use of NSAIDs, such as ibuprofen or naproxen, generally avoided in older adults?

• a) They are not effective for pain.
• b) They have a high risk of causing GI bleeding and worsening renal function or heart failure.
• c) They have strong anticholinergic effects.
• d) They are all controlled substances. Answer: b) They have a high risk of causing GI bleeding and worsening renal function or heart failure.

31. When should a pharmacist recommend a dose adjustment for a renally cleared drug?

• a) Only when the patient reports side effects.
• b) Proactively, based on the patient’s estimated renal function and the drug’s properties.
• c) Never, as it is solely the prescriber’s responsibility.
• d) When the patient’s serum creatinine is exactly 1.5 mg/dL. Answer: b) Proactively, based on the patient’s estimated renal function and the drug’s properties.

32. The “Geriatric Dosing” transcending concept lecture in the PharmD curriculum is designed to prepare students to:

• a) Memorize a list of doses for every drug.
• b) Apply principles of aging physiology to safely and effectively individualize drug therapy.
• c) Avoid caring for older adult patients.
• d) Focus only on the pediatric population. Answer: b) Apply principles of aging physiology to safely and effectively individualize drug therapy.

33. An older adult with benign prostatic hyperplasia (BPH) and hypertension is at a higher risk of falls if treated with:

• a) A beta-1 selective blocker
• b) An ACE inhibitor
• a) A non-selective alpha-1 blocker like doxazosin
• d) A thiazide diuretic Answer: c) A non-selective alpha-1 blocker like doxazosin

34. The primary reason for the “start low, go slow” approach is that the consequences of ________ are often worse than the consequences of ________ in the geriatric population.

• a) Undertreating; overtreating
• b) Overtreating; undertreating
• c) Adherence; non-adherence
• d) Cost; efficacy Answer: b) Overtreating; undertreating

35. A decrease in hepatic blood flow with age can significantly reduce the first-pass metabolism of:

• a) Drugs with low hepatic extraction.
• b) Drugs with high hepatic extraction (e.g., propranolol, morphine).
• c) Drugs that are not metabolized by the liver.
• d) Drugs administered intravenously. Answer: b) Drugs with high hepatic extraction (e.g., propranolol, morphine).

36. Dosing of which antidiabetic drug class needs to be carefully considered in older adults, with long-acting agents like glyburide being avoided?

• a) Biguanides (metformin)
• b) Thiazolidinediones (e.g., pioglitazone)
• c) DPP-4 inhibitors (e.g., sitagliptin)
• d) Sulfonylureas Answer: d) Sulfonylureas

37. Which statement best reflects the goal of geriatric dosing?

• a) To use the minimum number of medications possible.
• b) To find the optimal dose of each necessary medication to maximize benefit and minimize risk.
• c) To stop all medications after age 80.
• d) To use the same doses as in younger adults to ensure efficacy. Answer: b) To find the optimal dose of each necessary medication to maximize benefit and minimize risk.

38. When dosing dabigatran in a patient over 75 years old, what must be considered?

• a) Their liver function
• b) Their renal function and risk of bleeding
• c) Their weight
• d) Their height Answer: b) Their renal function and risk of bleeding

39. The most accurate way to assess a patient’s medication-taking behavior and need for simplified dosing is to:

• a) Assume they are perfectly adherent.
• b) Ask them directly in a non-judgmental way.
• c) Look at pharmacy refill records alone.
• d) Ask a family member without the patient’s permission. Answer: b) Ask them directly in a non-judgmental way.

40. An advanced geriatric dosing strategy may involve “drug holidays” or structured interruptions of therapy to:

• a) Assess the continued need for the medication and reduce long-term side effects.
• b) Increase pharmacy profits.
• c) Punish the patient for non-adherence.
• d) Confuse the patient’s homeostatic mechanisms. Answer: a) Assess the continued need for the medication and reduce long-term side effects.

41. Which class of antidepressants generally has a more favorable side effect profile in the elderly compared to TCAs?

• a) MAOIs
• b) SSRIs
• c) Amphetamines
• d) Barbiturates Answer: b) SSRIs

42. Even with SSRIs, dosing for geriatrics often starts at what level compared to the usual adult dose?

• a) Double the usual dose
• b) The same as the usual dose
• c) Half the usual starting dose
• d) One-tenth of the usual dose Answer: c) Half the usual starting dose

43. A pharmacist’s key role in geriatric dosing during transitions of care includes:

• a) Packing the patient’s suitcase.
• b) Ensuring dose adjustments made in the hospital are appropriate for the outpatient setting.
• c) Ordering meals for the patient.
• d) Taking the patient’s vital signs. Answer: b) Ensuring dose adjustments made in the hospital are appropriate for the outpatient setting.

44. What is a key consideration for dosing pain medications in older adults?

• a) They do not feel pain, so analgesics are not needed.
• b) They are more sensitive to the CNS and respiratory depressant effects of opioids.
• c) NSAIDs are completely safe and are the first choice for all types of pain.
• d) Higher doses of opioids are always required. Answer: b) They are more sensitive to the CNS and respiratory depressant effects of opioids.

45. Before recommending an OTC product to an older adult, it is essential for the pharmacist to:

• a) Recommend the most expensive option.
• b) Assume it is safe because it is available without a prescription.
• c) Screen for comorbidities and check for potential interactions with their prescription medications.
• d) Sell the product without asking any questions. Answer: c) Screen for comorbidities and check for potential interactions with their prescription medications.

46. Which drug used for BPH is also on the Beers Criteria® as a PIM due to its potent anticholinergic effects?

• a) Tamsulosin
• b) Finasteride
• c) Oxybutynin (used for OAB, but can be confused)
• d) First-generation antihistamines (if used off-label) Answer: d) First-generation antihistamines (if used off-label)

47. When a new medication is added for a geriatric patient, a follow-up should be scheduled to assess:

• a) Efficacy
• b) Tolerability and side effects
• c) Adherence
• d) All of the above Answer: d) All of the above

48. The practice of using one medication to treat the side effects of another medication is known as a:

• a) Prescribing cascade
• b) Drug holiday
• c) Deprescribing event
• d) Therapeutic interchange Answer: a) Prescribing cascade

49. The Beers Criteria® recommend avoiding skeletal muscle relaxants in older adults because:

• a) Most have questionable efficacy at doses tolerated by the elderly and they have high rates of anticholinergic side effects.
• b) They cause hypertension.
• c) They are known to improve cognitive function.
• d) They are not covered by insurance. Answer: a) Most have questionable efficacy at doses tolerated by the elderly and they have high rates of anticholinergic side effects.

50. The ultimate goal of mastering geriatric dosing principles is to:

• a) Stop all medications for patients over 75.
• b) Individualize therapy to optimize quality of life and function while minimizing harm.
• c) Pass the pharmacy board exam.
• d) Treat every older adult with the same standard doses. Answer: b) Individualize therapy to optimize quality of life and function while minimizing harm.