Which of the Following Is Most Helpful in Establishing the Diagnosis of Delirium?

GPSAP Questions

Medical Evaluation

1) A 84 year old man is evaluated because nurses are concerned about his agitation, which is markedly increased in the evenings. He underwent emergency hip replacement 3 days ago after he fell and fractures his hip. He requires antipsychotic agents to control his agitation at night: he yells “help me” constantly and is determined to get out of bed alone and walk. In the year before his fall, he had stopped working and driving; the reasons are unclear. History includes hypertension, benign prostatic hyperplasia, and osteoarthritis. There is no history of dementia. On examination, he appears confused and is disoriented to time and place. He has some pain with hip movements. Neurologic findings are nonfocal.

Which of the following is most helpful in establishing the diagnosis of delirium?

A) Order electrolytes, BUN, glucose, and thyrotropin

B) Determine why the patient stopped working and driving

C) Perform the digit-span memory test.

D) Order CT of the brain

E) Review the patient’s medication list.

Answer: C

Rationale

The patient appears delirious, which is common in hip fracture patients. Delirium is diagnosed on the basis of change in cognitive function and attentional deficit. The digit span memory test- asking the patient to repeat a series of numbers-is a useful assessment for attention. Cognitive assessment can include detailed orientation questions or formal cognitive screening tests, such as the Montreal Cognitive Assessment (MOCA) or Confusion Assessment Method (CAM). The sensitivity and specificity of CAM in acute medical patient are approximately 95% and 90%, respectively. The Delirium Rating Scale-Revised 98 is another commonly used tool.

Because dementia is the strongest risk for developing delirium, establishing the baseline cognitive status of the patient is useful. The patient may have preexisting cognitive deficits: he recently stopped driving and working. Further history is required to determine whether these events were due to cognitive deficits. However, evaluation for risk factors would not substitute for tests for delirium.

CT of the brain may be performed to determine the cause of delirium, but it does not diagnose delirium. It is most useful in the presence of new focal neurologic symptoms or falls. Determining primary and contributing causes of the delirium requires reviewing all medications and conducting laboratory and other tests as indicated by the patient’s history and findings on examination.

References:

1) Inouye SK. Delirium in older persons. N Engl J Med. 2006; 354(11):1157-1165.

2) Wei LA, Fearing MA, Sternberg EJ, et al. the Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc. 2008;56(5):823-830.

2) A 68-yr old Chinese-American man comes to the office because he has widespread maculopapular eruption with formation of flaccid bullae and erosions. For 2 days before the rash, he had fever, odynophagia, and eye pain. Over the next few days, the rash evolved to extensive sloughing and peeling of the skin. History includes hypertension, diabetes, and peripheral neuropathy. Two weeks ago, he began carbamazepine at 200mg q12h for peripheral neuropathy. Other medications include glipizide, felodipine, simvastatin, and enteric-coated aspirin.

On examination, the sloughing and peeling involve 45% of the patient’s body surface. His oral mucosa has erosions and exudates. He also has bilateral conjunctivitis.

The patient is admitted to a burn unit.

Which of the following is the most likely diagnosis?

A) Bullous pemphigoid

B) Staphylococcal scalded skin syndrome

C) Disseminated herpes zoster

D) Toxic epidermal necrolysis Answer: D

Rationale

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severity variants of the same disease, characterized by epidermal detachment. In SJS, skin detachment affects <10% of the body surface; in TEN, detachment affects >30% of the body. When skin detachment is between 10% and 30%, the syndrome is considered overlap SJS/TEN. The mortality for SJS is between 1% and 3%; mortality is 30% for TEN. Often, fever and mucosal involvement overlap days before the rash appears. Initial lesions are macular and can form target lesions with purpuric centers. These lesions can coalesce and progress to superficial flaccid bullae. Usually at least two mucous surfaces are involved. Epidermal necrosis is pathognomonic for SJS and TEN.

SJS and TEN are rare reactions to medications. More than 200 medications have been implicated, but the most common are antibiotics, NSAIDS, and anticonvulsants. The risk of SJS or TEN from carbamazepine is significantly increased in patients who have the HLA-B*1502allele, which is found in individuals with ancestry from across broad areas of Asia, including South Asian Indians.

In 2007, the FDA alerted healthcare professionals of changes to the prescribing information, including a new boxed warning for carbamazepine: “Patients with ancestry in at-risk populations should be screened for the HLA-B*1502 allele prior to starting carbamazepine. Patients who test positive for the HLA-B*1502 should not be treated with carbamazepine unless expected benefit clearly outweighs the increased risks of SJS/TEN” Given the Chinese ancestry of this patient, he should not have been given carbamazepine without genetic testing.

Bullous pemphigoid is a bullous disorder mainly found in older adults. The bullae are tense, not flaccid, because they are subepidermal. Oral involvement is seen in about 20% of cases and is rare in drug-induced pemphigoid.

Staphylococcal scalded skin syndrome is caused by exfoliative exotoxins released by group 2 staphylococci. It presents as a generalized, superficial exfoliative dermatitis without mucosal involvement. Because the exotoxins are cleared renally, it usually affects neonates and infants, due to their immature renal clearance, and in adults with renal insufficiency or immunodeficiency.

Pemphigus vulgaris also presents with flaccid, easily ruptured bullae. Oral involvement is present in 60%, but is less common in drug-induced pemphigus. Histopathologic examination is essential for definitive diagnosis of bullous disorders. The lesions of herpes zoster are small vesicles, or blisters, on an erythematous base. They appear in clusters and in various stages of healing, and distributed along a single dermatome. New lesions appear every few days and heal with crusting over 1-2 wk. Although there can be mucosal involvement, the lesions are clearly different from those of TEN on appearance.

References:

1) Carr DR, Houshmand E, Hefferman, MP. Approach to the acute, generalized, blistering patient. Semin Cutan Med Surg. 2007;26(3):139-146

2) Cotliar J. Approach to the patient with suspected drug eruption. Semin Cutan Med Surg. 2007;26(3):139-146.

3) Information on Carbamazepine (marketed as Carbatrol, Equetro, Tegretol, and generics). http://www.fda.gov/Drugs/Drugsafety/PostmarketDrugSafetyInformationforPatientsa ndProviders/ucm107834.htm (assessed Nov 2009).

3) A 82-yr-old male smoker has a history of hypertension, dyslipidemia, diabetes mellitus, and nonvalvular atrial fibrillation.

Which of the following most increases his risk of stroke?

A) Cigarette smoking

B) Hypertension

C) Dyslipidemia

D) Atrial fibrillation

Answer: D

Rationale Among men, the incidence of stroke is about 4.5 per 1,000 between ages of 65 and 74 year, and 9.3 per 1,000 between 75 and 84 yr. The contribution of factors to a person’s stroke risk varies by age. For a 70-yr-old man, the relative risk from a nonvalvular atrial fibrillation is the relative risk from hypertension is 2; from cigarette smoking, 1.8; and from dyslipidemia, 2.

The high prevalence of hypertension makes it the largest overall contributor to stroke risk in the population, with a population-attributable risk of 30%. This relationship in true in all age groups, except in adults >80 yr old, in whom the increased prevalence of nonvalvular atrial fibrillation results in a population-attributable risk of 23%, while that of hypertension is 20%.

References:

1) Goldstein LB, Adams R, Alberts MJ, et al. Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2006:113(24):e873-e923.

4) Which of the following should be undertaken first in an initial evaluation to determine if a new patient is at risk of falls?

A) Check vision

B) Ask about previous falls

C) Examine feet

D) Check for arrhythmia

E) Perform a mental status examination.

Answer: B Rationale

Fall prevention is important to incorporate in the care of all older adults. Risk assessment and management reduce the incidence of falls, and in primary care setting, can reduce the incidence of emergency treatment for fall I juries. The first step in assessing is to ask about previous falls. Patients who have fallen previously are at high risk of future falls, especially if they have impaired mobility. Older adults often will not mention previous falls unless specifically asked about them. According to published guidelines, if a patient has fallen more than once in the past year, or has fallen once and has impaired gait or balance, fall risk should be fully assessed. The evaluation should identify factors that can be modified or eliminated to reduce fall risk. Modifiable factors include problems with balance and gait, use of more than four medications, postural hypotension, and home environmental hazards. Additional factors are sensory deficits, especially vision, and problems with feet and unsupportive footwear. Cardiac examination, including checking for arrhythmia, is indicated, especially if there are symptoms of lightheadedness or a history of syncope. Patients with dementia are at increased risk of falls, and a mental status screening test is an important part of the evaluation.

References:

1. American Geriatric Society and British Geriatrics Society. Clinical Practice Guideline for the Prevention of Falls in Older Persons. New York: American Geriatrics Society; 2009 (http://www.americangeriatrics.org/)

2. Tinetti ME, Baker DI, king M, et al. Effect of dissemination of evidence in reducing injuries from falls. N Engl J Med. 2008;359(3):252-261

3. Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007;297(1):77-86.

5) A 72-year-old Caucasian woman with a history of mild cognitive Impairment and obsessive-compulsive disorder is seen in the office along with her daughter. Her daughter reports that her mother has been getting more confused over the past 2 weeks. Her daughter also reports that the “pill box” which she fills for her mother every week has been getting empty soon. The patient tells you that she is happy that she does not have to urinate frequently, but reports constipation and blurred vision over the last 3 days.

On examination you notice that her oral mucosa is dry, her bladder appears distended, and her skin is warm to touch. The patient is not oriented to date, day and place. She is unable to perform digits backwards and unable to perform serial sevens. Her medications include hydrochlorothiazide 25 mg and Lisinopril 20 mg for hypertension, Atorvastatin 20 mg for hyperlipidemia, a multivitamin and Clomipramine 100 mg for obsessive compulsive disorder. You suspect anticholinergic overdose and delirium. What would you expect to find on the EKG?

A) Sick sinus syndrome

B) Increased PR interval

C) Short R waves

D) Decreased QT interval

E) No change on EKG

Answer B

Rationale

Cardiac conduction abnormalities occur during TCA poisoning because TCAs inhibit the fast sodium channels in the His-Purkinje system and myocardium. This inhibition decreases conduction velocity, increases the duration of repolarization, and prolongs absolute refractory periods. These effects are similar to those of the class IA antiarrhythmic drugs such as quinidine. Mechanisms that contribute to hypotension during overdose include decreased contractility from reduced calcium influx into ventricular myocytes, blockade of rapid sodium channels, and peripheral vasodilatation from blockade of alpha 1 adrenergic receptors.

Sinus tachycardia is common in TCA overdose, likely due to anticholinergic (vagolytic) effects and hemodynamic decompensation causing a reflex tachycardia. Hypotension is common following significant TCA poisoning, and mortality from TCA overdose is due largely to refractory hypotension. Cardiac conduction abnormalities may contribute to hypotension. Ventricular tachycardia and ventricular fibrillation (VT and VF) occur in approximately 4 percent of TCA overdose cases. VT and VF are more common in severe poisonings (eg, severe acidosis, hypotension), particularly those involving extreme QRS prolongation.

References:

1) Roose SP: Considerations for the use of antidepressants in patients with cardiovascular disease. Am Heart J 140:S84-S88, 2000

2) Alessi CA, Cassel CJ. Medical evaluation and common medical problems of the geriatric psychiatry patient. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive Textbook of Geriatric Psychiatry. 3rd ed. New York: WW Norton; 2004: 281-314.

3) Fleming KC, Rummans TA, Maletta GJ. Medical assessment of the elderly psychiatric patient. In: Agronin M, Maletta GJ, eds. Principles and Practice of Geriatric Psychiatry. New York: Lippincott Williams & Wilkins; 2006: 59-71.

4) Resnick NM, Dosa D. Geriatric medicine. In: Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw- Hill; 2005: 43-52.

6) An 82-year-old female admitted with 42-pound weight loss over 1 year was found to have normal labs, imaging scans and exams. Psychiatry was consulted for evaluation of depression. Patient found to be eating happily in bed, denying any mood symptoms. MMSE is 29/30. Four days later, the patient develops confusion and the lab tests reveal hypokalemia. The complete blood count and urinalysis is within normal limits. What is the most likely cause of the patient’s confusion?

A) Refeeding syndrome

B) Acute renal failure

C) Seizure

D) Paraphrenia

E) Pneumonia Answer A

Rationale:

Severe electrolyte abnormalities and fluid shifts can occur when patients with severe malnutrition are reinitiated on a regular diet. Psychiatric patients with dementia, depression, neglect, alcohol abuse, and anorexia are particularly at risk.

The pathophysiology includes that under carbohydrate deficient conditions, energy is produced from lipolysis. Insulin secretion is suppressed. Serum concentrations of electrolytes are maintained at the expense of low intracellular concentrations. When carbohydrates are reintroduced, insulin levels rise, causing increased cellular uptake of not only glucose, but also of potassium, magnesium, and phosphate as well. If carbohydrate load is too great, depletion of serum electrolytes may lead to confusion, ataxia, cardiac arrhythmias and sudden death. The increased cellular utilization of thiamine may also precipitate Wernicke’s encephalopathy. The treatment involves a gradual titration of calories, and monitoring of electrolytes and cardiac rhythms.

References:

A. Kuwahara T, Asanami S, Tamura T, Kaneda S. Effects of pH and osmolality on phlebitic potential of infusion solutions for peripheral parenteral nutrition. J Toxicol Sci 1998; 23:77. B. Kuwahara T, Asanami S, Tamura T, Kubo S. Dilution is effective in reducing infusion phlebitis in peripheral parenteral nutrition: an experimental study in rabbits. Nutrition 1998; 14:186. C. Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore) 2002; 81:466. D. DeLegge MH, Borak G, Moore N. Central venous access in the home parenteral nutrition population-you PICC. JPEN J Parenter Enteral Nutr 2005; 29:425. E. O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002; 51:1. F. Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenteral nutrition. JPEN J Parenter Enteral Nutr 2004; 28:S39. G. Naylor CJ, Griffiths RD, Fernandez RS. Does a multidisciplinary total parenteral nutrition team improve patient outcomes? A systematic review. JPEN J Parenter Enteral Nutr 2004; 28:251. 7) A 68-year-old Caucasian woman comes in with her daughter for an office visit. The daughter reports that she has been complaining of dull-intermittent headaches over the past three weeks and is accompanied with some lightheadedness and some confusion. She also reports lack of motivation and feels “sleepy” all the time. The daughter recalls that about four weeks ago she slipped and fell down in the toilet and hit her head on the sink. She was confused and lightheaded for a few hours, but began to feel better. She took some ibuprofen, which helped. There was no loss of consciousness reported by the daughter.

Since her last visit to your office about 6 months ago, when she was diagnosed with mild cognitive impairment, the patient began to take an over the counter medication for memory and cognitive enhancement besides her other medications which includes warfarin, Zoloft and omeprazole.

Which of the following over-the-counter prescriptions used to enhance cognition is associated with coagulation dysfunction as a side-effect?

A) Vitamin E

B) Gingko biloba

C) Estrogen

D) Fish oils

E) Coconut oil

Answer B

Rationale:

Gingko biloba extract is widely used as a herbal preparation for dementia and other cognitive difficulties. Gingko has a significant effect on prostaglandin metabolism and it antagonizes the platelet aggregating factor. As a result platelet function may be compromised especially when other anticoagulants like warfarin and medications that affect platelet aggregration like proton pump inhibitors and selective serotonin reuptake inhibitors are co-administered. Many cases of internal bleeding and postoperative bleeding have been attributed to Gingko. Monitoring bleeding time may be an option in high-risk patients, but this is only a crude measure of platelet dysfunction.

References:

1) Fong KCS and Kinnear PE. Retrobulbar hemorrhage associated with chronic Gingko biloba ingestion. Postgraduate Medical journal 2003;79:531-532

2) Bent S, Goldberg H, Padula A, Avins AL. Spontaneous bleeding associated with ginkgo biloba: a case report and systematic review of the literature: a case report and systematic review of the literature. J Gen Intern Med 2005; 20:657.

3) Rowin J, Lewis SL. Spontaneous bilateral subdural hematomas associated with chronic Ginkgo biloba ingestion. Neurology 1996; 46:1775.

4) Vale S. Subarachnoid haemorrhage associated with Ginkgo biloba. Lancet 1998; 352:36.

5) Pedroso JL, Henriques Aquino CC, Escórcio Bezerra ML, et al. Ginkgo biloba and cerebral bleeding: a case report and critical review. Neurologist 2011; 17:89.

6) Köhler S, Funk P, Kieser M. Influence of a 7-day treatment with Ginkgo biloba special extract EGb 761 on bleeding time and coagulation: a randomized, placebo- controlled, double-blind study in healthy volunteers. Blood Coagul Fibrinolysis 2004; 15:303.

7) Destro MW, Speranzini MB, Cavalheiro Filho C, et al. Bilateral haematoma after rhytidoplasty and blepharoplasty following chronic use of Ginkgo biloba. Br J Plast Surg 2005; 58:100.

8) Which one of the following statements regarding vitamin B deficiency in older adults 12 is true? Vitamin B deficiency generally can be treated with a three-month course of A. 12 intramuscular injections

Central nervous system manifestations of vitamin B deficiency always occur after B. 12 hematologic manifestations

Older adults with a low-normal vitamin B level still may have a vitamin B C. 12 12 deficiency

The anemia of vitamin B deficiency usually is microcytic D. 12

The most frequent cause of vitamin B deficiency in the elderly is dietary E. 12 insufficiency

ANSWER C

Rationale: Atrophic gastritis is the most common cause of vitamin B deficiency. 12 Hematologic abnormalities frequently develop before neurologic disease except in up to 25% of cases. The anemia of vitamin B deficiency is macrocytic. Current laboratory 12 norms may miss those individuals with early preclinical deficiency. When vitamin B is 12 <350 pg/ml, measuring metabolic markers of vitamin B deficiency such as 12 methylmalonic acid and homocysteine levels should be considered. Treatment is life-long and typically is via injections or, in some cases, oral supplements.

Reference:

3) Sullivan DH, Johnson LE. Nutrition and aging. In: Hazzard WR, Blass JP, et al., eds. Principles of Geriatric Medi- cine and Gerontology. 5th ed. New York: McGraw-Hill; 2003: 1163-1164.

4) Taylor WD, Doraiswamy PM. Use of the laboratory in the diagnostic workup of older adults. In: Blazer DG, Stef- fens MD, Busse EW, eds. The American Psychiatric Publishing Textbook of Geriatric Psychiatry. 3rd ed. Washington, DC: American Psychiatric Publishing, Inc.; 2004: 179-188.

9) You are considering electroconvulsive therapy (ECT) for a 75-year-old man with depression. The patient is concerned about rumors he has heard about ECT. In explaining the risks of ECT to this patient, which one of the following statements is true?

1 A) Brain tumor is an absolute contraindication to ECT therapy

2 B) Cardiac events are the major cause of mortality reported from ECT

3 C) Pacemaker patients cannot receive ECT therapy

4 D) Pretreatment with atropine prevents post-ECT tachycardia

5 E) Stroke is an absolute contraindication to ECT therapy

ANSWER: B

Rationale: The efficacy of ECT is as high as 90%. Although there are very few contraindications to ECT, the presence of increased intracranial pressure from a tumor or other space- occupying lesion presents a considerable risk. Despite this risk, ECT can be performed safely in stroke patients after neurological status has stabilized, or even in patients with brain tumors who are carefully monitored throughout the procedure. While ECT is a safe procedure, patients over the age of 80 are at greatest risk for cardiovascular complications and falls. Clearly, cardiac events are the major cause of mortality from ECT. Pretreatment of cardiac patients with atropine or glycopyrrolate provides a cholinergic blockade that reduces the risk of asystole and bradycardia. ECT may be performed safely in patients who have implanted pacemakers.

Reference:

1) Alessi CA, Cassel CJ. Medical evaluation and common medical problems of the geriatric psychiatry patient. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive Textbook of Geriatric Psychiatry. 3rd ed. New York: WW Norton; 2004: 281-314. 2) Kellner CH, Coffey EC, Greenberg RM. Electroconvulsive therapy. In: Sadavoy J, Jarvik LF, Grossberg GT, Meyers BS, eds. Comprehensive Textbook of Geriatric Psychiatry. 3rd ed. New York: WW Norton; 2004: 845-902.

3) Kennedy G. Depression and other mood disorders. In: Pompei P, Murphy JB, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 6th ed. New York: American Geriatrics Society; 2006: 269-280.

10) You are choosing a hypnotic medication for short-term use in an 80-year-old woman with osteoporosis and a history of vertebral compression fractures. Which one of the following is the best predictor of postural hypotension occurring with antidepressant therapy?

A) A history of falls

B) A history of hypertension

C) A history of vertebral compression fractures

D) An abnormal electrocardiogram (ECG)

E) Preexisting orthostatic hypotension

ANSWER : E

Rationale:

It is very difficult to predict who will develop postural hypotension, a serious concern that increases the risk of falls in the older patient. A history of falls is a significant risk factor for future falls. Prior history of hypothyroidism, hypertension, or even of compression fractures is not necessarily predictive of orthostatic hypotension. An abnormal ECG also will not provide the predictive information; however, preexisting orthostatic hypotension is a good indicator of an underlying risk that may be exacerbated with antidepressants associated with this side effect. It is important to check for preexisting orthostatic hypotension in an older patient for whom you are considering using an antidepressant that is known to have this side effect.

3) Resnick NM, Dosa D. Geriatric medicine. In: Kasper DL, Braunwald E, Fauci AS, et al., eds. Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005: 43-52.

11) A 79-year-old man comes to you with complaints of episodes of dizziness and several falls since he was discharged from the geriatric psychiatry unit two weeks ago. He was admitted to the hospital because of an episode of major depressive disorder with psychotic features. During admission, medications were utilized to treat his condition with excellent results. His medical history also includes hypertension, benign prostatic hyperplasia, and osteoarthritis. His medications on admission included amlodipine 10 mg, hydrochlorothiazide 25 mg, finasteride 5 mg, and sertraline 100 mg, once daily. In addition, he was taking aceta- minophen 500 mg four times per day. On discharge, he continued on the same regimen with the addition of risperidone 2 mg twice daily. Which one of the following interventions most likely will improve his symptoms?

A) Discontinue risperidone and prescribe quetiapine 50 mg daily

B) Monitor his blood pressure and adjust medications for hypertension if needed

C) Prescribe meclizine 25 mg every six hours as needed for dizziness

D) Refer him to physical therapy for gait training

E) Refer him to an otolaryngologist (ENT) for evaluation and treatment of vertigo ANSWER : B

Rationale:

Falls are one of the most common geriatric syndromes that threaten the independence of older adults. Many falls are the result of an adverse drug reaction and/or a drug-drug interaction. Medication use is one of the most modifiable risk factors for falls. Psychotropic medications appear to produce a two-fold increase in the risk of falling. Risperidone and quetiapine may induce orthostatic hypotension associated with dizziness, tachycardia, and, in some patients, syncope, especially during the initial titration. Clinically significant hypotension has been observed with concomitant use of antipsychotics and anti- hypertensive agents. This patient’s symptoms most likely are related to hypotension secondary to a drug-drug interaction. There is no indication for referral to an ENT for evaluation and treatment of vertigo. The management of orthostatic hypotension by correcting adverse drug reactions should be performed before referral to physical therapy for gait training.

Reference:

12) An 85-year-old woman who you have been treating for mild Alzheimer’s dementia and depression comes to your office with a chief complaint of two falls over the last month. You become very concerned because the patient lives alone and has no social support system. Which one of the following statements is correct regarding this situation?

A) Cognitive impairment has not been identified as a risk factor for falls

B) Falls are one of the most common geriatric syndromes threatening the independence of older persons

C) In patients over the age of 75, fractures of the upper extremities are twice as common as fractures of the lower extremities

D) Less than 10% of fallers are unable to get up without help after a fall with potentially hazardous consequences

E) The effectiveness of exercise in reducing falls in the older adult is unclear

ANSWER: B

Rationale:

H. Falls increase with age and cognitive impairment has been recognized as a significant risk factor. Fractures of the lower extremities are about twice as common as fractures of the upper extremities. Fifty percent of older persons who fall are unable to get up without help, with potentially hazardous consequences even in the absence of serious injuries. Falls are one of the most common geriatric syndromes that threaten the independence of older adults. There is a strong association between the use of psychotropic medications, falls, and hip fractures. Strength and balance training are effective in increasing lower extremity strength and will decrease the risk of falls.

Reference: