Mock Geriatrics Module 3

A 58-year-old man with metastatic colorectal cancer is admitted with worsening abdominal pain. He has been taking sustained-release morphine 60 mg twice daily for three months.

Over the past two weeks his pain has become increasingly diffuse and severe despite dose escalation to 120 mg twice daily, and he now reports that light touch to his abdomen provokes pain.

Examination reveals generalised hyperalgesia and allodynia disproportionate to imaging findings. A CT abdomen shows stable disease burden compared with imaging one month prior.

Which of the following best explains the underlying mechanism responsible for this patient’s worsening pain?

A 65-year-old man is admitted with an acute-on-chronic flare of non-specific lumbar back pain.

His regular medications include codeine/paracetamol 30/500 mg (eight tablets daily), pregabalin 300 mg twice daily, escitalopram 10 mg daily, oxycodone immediate-release 5 mg (20 tablets per month) and diazepam 5 mg as required (20 tablets per month). Red flags have been excluded.

CT lumbar spine demonstrates no canal or foraminal stenosis, no acute disc protrusion, and no neurological deficit is found.

On further history, his dog recently died, he is socially isolated with low mood, and he increasingly relies on his wife for domestic and personal tasks, which is straining their relationship.

Which of the following best characterises the predominant contributor to this patient’s current presentation?

A 72-year-old woman is recovering from type 2 respiratory failure that required non-invasive ventilation during a COPD exacerbation. She has chronic lumbar back pain and the physiotherapist reports difficulty progressing mobilisation and chest physiotherapy because of severe pain.

Her regular medications are tramadol 50 mg twice daily, paracetamol 1 g three times daily and duloxetine 30 mg daily. Celecoxib 100 mg twice daily has been added for five days. Oxycodone 5 mg every four hours had been prescribed as required.

CT shows severe bilateral L5/S1 facet joint degeneration without canal or foraminal stenosis. Arterial blood gas on admission demonstrated pH 7.28, PaCO₂ 68 mmHg, HCO₃⁻ 30 mmol/L.

Which of the following is the most appropriate adjustment to her breakthrough analgesia?

A 74-year-old woman is being discharged after an admission for an acute exacerbation of chronic mechanical low back pain.

She was commenced on oxycodone sustained-release 20 mg twice daily during admission, in addition to her long-standing tramadol 100 mg twice daily. She has been taking opioids for two years.

Investigations, including MRI lumbar spine, show only mild multilevel degenerative change without nerve root compression.

Her total oral morphine equivalent daily dose is now approximately 130 mg.

Which of the following is the most appropriate discharge strategy regarding her opioid therapy?

A 50-year-old man has been maintained on sustained-release oxycodone 40 mg twice daily for 18 months following a workplace back injury. He reports persistent pain, has not returned to work, and complains of low libido, erectile dysfunction and fatigue. His wife notes loud snoring with witnessed pauses in breathing during sleep.

Examination shows central adiposity.

Investigations reveal: morning total testosterone 4.2 nmol/L (8.3–29.0), LH 1.8 IU/L (1.7–8.6), FSH 2.1 IU/L (1.5–12.4), and a bone mineral density scan demonstrating a lumbar spine T-score of −2.6.

Which of the following best explains the constellation of endocrine and metabolic findings in this patient?

An 82-year-old woman presents with a 6-month history of urinary urgency, frequency, and occasional urge incontinence. She voids up to 12 times per day and twice overnight. She has hypertension and osteoarthritis. Post-void residual volume on bladder scan is 30 mL (normal <50 mL). Urinalysis is negative for nitrites and leukocytes. Urine culture is sterile.

Urodynamic studies demonstrate involuntary detrusor contractions during the filling phase at a bladder volume of 180 mL.

Which of the following best explains the mechanism underlying her presentation?

A 74-year-old woman reports vaginal dryness, dyspareunia, urinary urgency, and recurrent lower urinary tract symptoms. She has had three culture-positive urinary tract infections in the past year. On examination, the vaginal mucosa is pale, thin, and friable with loss of rugae. Vaginal pH is 6.5 (premenopausal reference <4.5). Urinalysis today is negative. She has no history of vaginal bleeding.

Which of the following investigations or findings most strongly supports the underlying diagnosis?

A 78-year-old man presents with hesitancy, weak stream, terminal dribbling, and nocturia. Digital rectal examination reveals a smoothly enlarged, non-tender prostate. Serum PSA is 3.2 ng/mL (age-adjusted reference <6.5). Post-void residual volume is 220 mL. Renal function shows creatinine 145 µmol/L (60–110) with eGFR 42 mL/min/1.73m².

Renal tract ultrasound demonstrates bilateral mild hydronephrosis and a trabeculated bladder wall.

Which of the following is the most appropriate next step in management?

An 84-year-old woman with mild cognitive impairment was recently commenced on amitriptyline for insomnia and low mood. She now presents with urinary retention and overflow incontinence (post-void residual 480 mL).

Over the same period, her family report that she has become increasingly confused, drowsy, and disorientated.

On examination she is afebrile, her mucous membranes are dry, her pupils are mildly dilated, and she has a distended, palpable bladder. Urinalysis is negative.

Her Mini-Mental State Examination has fallen by 5 points compared with a recent baseline.

In addition to urinary retention, which of the following complications is most likely to be attributable to this medication?

An 87-year-old nursing home resident with advanced dementia develops new urinary and faecal incontinence over two weeks. She has been passing frequent small amounts of loose stool and small volumes of urine. Abdominal examination reveals a palpable mass in the left iliac fossa. Rectal examination demonstrates a large volume of hard stool in the rectum.

Abdominal radiograph shows extensive faecal loading throughout the colon with rectal distension.

Which of the following best explains the mechanism of her overflow incontinence?

A 68-year-old woman reports leakage of urine when coughing, sneezing, and lifting. She has had four vaginal deliveries. There is no urgency or nocturia. Post-void residual is 20 mL. Urinalysis is negative.

On examination, there is demonstrable leakage of urine from the urethra on coughing and reduced pelvic floor muscle tone.

Urodynamic studies confirm urinary leakage coincident with raised intra-abdominal pressure in the absence of detrusor contraction.

Which of the following is the most appropriate first-line management?

A 79-year-old man with congestive cardiac failure (NYHA II), obstructive sleep apnoea, and mild cognitive impairment reports troublesome urinary urgency and nocturia (4 times per night). Post-void residual is 40 mL.

Investigations:

• Echocardiogram shows an ejection fraction of 40%.
• Overnight polysomnography confirms moderate obstructive sleep apnoea.
• Bladder diary shows nocturnal polyuria.
• Urinalysis is negative.

Which of the following interventions is most appropriate to address his nocturia?

A 81-year-old woman presents with a sensation of vaginal bulging, incomplete bladder emptying, and recurrent urinary tract infections.

On examination, there is a stage III anterior vaginal wall prolapse (cystocele) extending 2 cm beyond the hymen. Post-void residual is 250 mL. Renal tract ultrasound reveals bilateral mild hydronephrosis. Creatinine is 130 µmol/L (45–90).

Which of the following is the most likely explanation for her renal findings?

A 83-year-old man with Parkinson’s disease and severe knee osteoarthritis is admitted to hospital. He develops urinary incontinence, leaking a full bladder volume before reaching the toilet. He reports normal urinary sensation and no urgency at home where his commode is beside his bed. Post-void residual is 25 mL. Urinalysis and urine culture are negative. Cognitive assessment is normal. His mobility is severely limited by pain and bradykinesia.

Which of the following is the most likely type of incontinence?

A 72-year-old man reports continuous dribbling of urine that worsens on standing and physical activity, occurring since a radical prostatectomy for prostate cancer 14 months ago. He denies urgency. Post-void residual is 15 mL. Urinalysis is negative. Urodynamic studies demonstrate leakage with increased abdominal pressure and a low Valsalva leak point pressure, with no detrusor overactivity. Cystoscopy shows an incompetent external urethral sphincter.

Which of the following is the most appropriate definitive management for persistent, bothersome symptoms after failed conservative therapy?

An 82-year-old woman is being assessed prior to elective right hemicolectomy for caecal adenocarcinoma.

She lives independently but has noticed reduced exercise tolerance over 2 years.

On assessment, her resting heart rate is 74 bpm, blood pressure 148/72 mmHg.

Investigations reveal:

• Haemoglobin: 108 g/L (115–165)
• Creatinine: 92 µmol/L (45–90)
• eGFR: 48 mL/min/1.73m² (>60)
• Albumin: 32 g/L (35–50)
• ECG: sinus rhythm, left ventricular hypertrophy by voltage criteria
• Transthoracic echocardiogram: LV ejection fraction 62%, grade II diastolic dysfunction, left atrial enlargement, aortic valve sclerosis (peak velocity 1.8 m/s)

Which of the following age-related physiological changes best explains her widened pulse pressure and diastolic dysfunction?

A 79-year-old man is referred for pre-operative assessment prior to elective open abdominal aortic aneurysm repair (AAA 6.2 cm). He walks with a stick, has lost 4 kg unintentionally over 6 months, and reports exhaustion most days. Grip strength is 18 kg. His gait speed over 4 metres is 1.1 m/s. He lives with his wife who assists with shopping.

Investigations:

• Haemoglobin: 118 g/L (130–170)
• Albumin: 30 g/L (35–50)
• eGFR: 54 mL/min/1.73m²
• CT: infrarenal AAA 6.2 cm, no rupture

Which of the following is the most appropriate next step to inform shared decision-making regarding surgical risk?

An 84-year-old woman with mild cognitive impairment (MMSE 24/30) presents with a symptomatic 90% left carotid stenosis after a transient ischaemic attack.

The vascular surgeon recommends carotid endarterectomy.

During your assessment, she can describe that she had “a mini stroke,” states she wants “to not have another one,” but when asked about the operation, says “the doctor knows best.”

She cannot explain the risks of stroke or death associated with surgery despite repeated explanations.

Which of the following best describes her decision-making capacity?

A 76-year-old man is scheduled for elective open sigmoid colectomy for recurrent diverticulitis. He has type 2 diabetes on insulin, hypertension, and prior MI (5 years ago). He can climb one flight of stairs slowly but stops due to dyspnoea (approximately 3 METs).

• ECG: Q waves in inferior leads, sinus rhythm, HR 68 bpm
• Haemoglobin: 122 g/L
• Creatinine: 148 µmol/L, eGFR 42 mL/min/1.73m²
• HbA1c: 8.4%
• NT-proBNP: 780 ng/L (<125)

Which of the following is the most appropriate next investigation prior to surgery?

An 81-year-old woman is admitted for elective total hip replacement. She has hypertension, osteoarthritis, and lives independently. Medications: perindopril, oxycodone SR 10 mg BD, temazepam 10 mg nocte, and diphenhydramine PRN for sleep. MoCA is 24/30. She reports 2 falls in the past year.

Which of the following interventions is most likely to reduce her risk of postoperative delirium?

A 78-year-old man is scheduled for elective laparoscopic cholecystectomy in 7 days.

His medications include:

• Apixaban 5 mg BD (for AF, CHA₂DS₂-VASc 4)
• Metformin 1 g BD
• Empagliflozin 10 mg daily
• Perindopril 5 mg daily
• Atorvastatin 40 mg nocte
• Prednisone 7.5 mg daily (for polymyalgia rheumatica, 2 years)

Investigations: eGFR 58 mL/min/1.73m², HbA1c 7.2%, Hb 132 g/L.

Which of the following medication management plans is most appropriate?

An 85-year-old man underwent emergency laparotomy 5 days ago for perforated sigmoid diverticulitis (Hartmann’s procedure).

Pre-operatively, he was CFS 5 (mildly frail) with mild cognitive impairment.

Post-operatively he developed hyperactive delirium on day 2, aspiration pneumonia on day 3, and now has an eGFR fall from baseline 62 to 28 mL/min/1.73m². He is refusing oral intake and mobilisation.

Investigations today:

• Hb: 88 g/L
• Albumin: 22 g/L
• CRP: 180 mg/L
• Troponin I: 68 ng/L (<26) — trending down from peak 145
• ECG: sinus tachycardia, no ischaemic changes
• Chest X-ray: right lower lobe consolidation, improving

Which of the following statements about his prognosis and management is most accurate?

A 79-year-old man is 24 hours post-operative from an open right hemicolectomy for colon cancer. He has moderate CKD (eGFR 38 mL/min/1.73m²), ischaemic heart disease, and mild frailty (CFS 4). Weight 62 kg.

Observations: HR 96, BP 108/64, RR 14, drowsy but rousable, MoCA baseline unknown.

He is reporting pain 7/10 despite regular paracetamol 1 g QID and PRN oxycodone IR 10 mg 4-hourly (has received 5 doses in 24 hours). The surgical team asks your advice.

Which of the following is the most appropriate analgesic strategy?

An 84-year-old woman is 2 days post-operative from a right total hip arthroplasty for osteoarthritis. Weight 58 kg. She has AF on apixaban 2.5 mg BD (dose-reduced for age and creatinine), previous GI bleed 3 years ago, and CKD (eGFR 34 mL/min/1.73m²). Apixaban was ceased 3 days pre-operatively.

Post-op Hb 96 g/L (was 118 pre-op), platelets 210, INR 1.1, wound drainage minimal.

Which of the following is the most appropriate thromboprophylaxis strategy?

An 87-year-old woman presents to the ED after a mechanical fall at her nursing home. She has an intracapsular fractured neck of femur on X-ray. Background: dementia (MMSE 18/30), AF on warfarin (INR today 2.6), heart failure with preserved EF, CKD stage 3b, previous stroke with mild residual hemiparesis. CFS 6 (moderately frail).

Bloods:

• Hb 104 g/L
• Na 138
• K 4.2
• urea 12
• creatinine 138
• troponin I 42 ng/L (<26)
• NT-proBNP 1,850 ng/L.

Which of the following management principles is best supported by current evidence for optimal outcomes?

A 74-year-old retired engineer underwent elective CABG 3 months ago. His family reports persistent difficulties with memory, planning, and word-finding since surgery. Pre-operatively, he was functioning independently and working part-time.

Neuropsychological testing today confirms decline of >1 SD from population norms in executive function and memory domains. He denies mood symptoms; PHQ-9 is 4.

MRI brain: mild small vessel ischaemic changes, no acute infarct. TSH, B12, folate normal.

Which of the following statements about his condition is most accurate?

An 82-year-old woman is day 8 post-hemiarthroplasty for a fractured neck of femur. Pre-fracture: lived alone in a single-storey home with a niece visiting weekly, mobilised with a stick, independent ADLs, CFS 4. Post-op course complicated by delirium (now resolved), UTI treated, and mild anaemia (Hb 92 g/L). She now mobilises with a 4-wheel frame under supervision, can transfer with one-person assist, and needs help with dressing lower half.

MoCA now 21/30 (baseline unknown but daughter reports “she was sharp before this”).

The surgical team asks about discharge planning.

Which of the following is the most appropriate discharge pathway?

A 78-year-old man is admitted to a geriatric evaluation and management (GEM) unit following a left middle cerebral artery ischaemic stroke 2 weeks ago. He has residual right-sided hemiparesis (MRC grade 3/5 upper limb, 4/5 lower limb), mild expressive dysphasia, and dysphagia now resolving. Pre-morbidly he lived alone, mobilised independently, and managed all self-care.

On assessment today:

• Requires moderate assistance with bathing and dressing upper body
• Requires maximal assistance with dressing lower body and toileting
• Transfers with one-person assist
• Ambulates 10 metres with a 4-wheel frame and supervision
• Continent of urine but has occasional faecal urgency
• Feeds himself with a modified diet
• Communication improving but requires prompts

The multidisciplinary team wishes to track his rehabilitation progress with a validated tool that captures both motor and cognitive/communication domains, is sensitive to change, and is widely used in inpatient rehabilitation settings.

Which of the following is the most appropriate assessment tool?

An 80-year-old woman presents to a falls clinic after two falls in the past 6 months. She has hypertension, osteoarthritis of both knees, and cataracts. Medications: amlodipine, paracetamol, and temazepam (recently ceased). She lives with her husband and mobilises independently indoors without an aid but uses a stick outdoors.

You perform a Timed Up and Go (TUG) test as part of her assessment. She takes 16 seconds to rise from a standard armchair, walk 3 metres, turn, return, and sit down. She uses her arms to push off from the chair and appears unsteady during turning.

Which of the following statements about the TUG test and this patient’s result is most accurate?

A 76-year-old man attends a geriatric outpatient clinic prior to elective total knee replacement for severe osteoarthritis. He lives independently but reports slowing over the past year. He denies falls. His medications include perindopril, atorvastatin, and paracetamol.

You perform the Short Physical Performance Battery (SPPB):

• Standing balance (side-by-side, semi-tandem, tandem): 3/4
• 4-metre gait speed: 0.7 m/s (score 2/4)
• 5-times sit-to-stand: 16 seconds (score 2/4)
• Total SPPB score: 7/12

His grip strength is 24 kg, and he reports unintentional weight loss of 3 kg over the past year.

Which of the following statements about physical performance measurement and its clinical implications is most accurate?