NMS Q&A Family Medicine

282 NMS Q&A Family Medicineclinicians. Early diagnosis of AD alerts the primary carephysician to avoid anticholinergic medications, as theseare agents that worsen dementia. Among the serious mentalillnesses to be found in elderly individuals, dementia isthe most prevalent, with the others being depression,delirium, schizophrenia, and bipolar disorder. Anothergood reason for early diagnosis of dementia is the unearthingof reversible causes of dementia in elderly persons,such as anemia, urinary tract infection, chronic pain, and,sometimes, simply radical change of environment.9. The answer is C. 40%. Actually, the official figure forthe false-positive rate in the Folstein Mini-Mental StateExamination is 39.4%, that is, somewhere in the rangeof 30% to 50% of elderly persons older than the age of85 years, they suffer from a degree of dementia, but thevast majority do not qualify for a diagnosis of AD. Thisshould lend a note of sobriety to the administration of theFolstein test. Elderly persons may fail the test because offatigue, motivation, or anxiety. Dementia, of which AD isthe most common form among elderly individuals,involves (a) at least one language-impairment problem(word finding, later difficulty following a conversation, ormutism); (b) apraxia (inability to perform certain previouslylearned manual tasks, such as cutting a loaf of breadby using both hands despite manifesting no sensory ormotor abnormalities); and (c) impaired organization(sometimes called executive ability) such as poor mentalflexibility, planning, and judgment. Subsets in screeningregarding the foregoing categories are in play. In the verbalcategory, including attention and concentration, thepatient may be asked to recite name, address, and phonenumbers; to recall three unrelated words such as “tulip,umbrella, scar” or parts of objects such as lapel and cuff;and follow a mildly complex command such as “point tothe ceiling before you point to the floor.” A corollary topraxis functioning is visuospatial organization such asdrawing a clock with a prescribed time indicated. Regardingorganizational ability, there may be questions involvinglogic, such as “how is a peach like a pear?”10 . The answer is A. The incorrect statement is that mostfalls among elderly persons occur outside of the homeenvironment. Thus, most falls among elderly personsoccur in or around the home. Falls in the home may beindirectly caused by conditions that would be viewed asrelatively benign for agile and mentally competent people,such as slippery or warped floors, shag carpet, or thickrugs, which present opportunities for elderly individualsto trip. Risk of falls is directly related to the number ofmedications the elderly patient is taking, obviously especiallythose involving sedatives, antihypertensives, alcohol,antidepressants, or neuroleptics, or overdosage withbeta-adrenergic blocking agents. The most common injuriesincurred in falls among elderly individuals are wrist,hip, and vertebral fractures. Hip fractures will occur inone-third of women and one-sixth of men in the “oldelderly” age group. Hip fractures carry a 20% first-yearmortality rate. Another significant risk from trauma inelderly individuals is subdural hematoma. Falls oftenoccur in mentally competent elderly people. These are thefrail elderly, often victims of osteoporosis or malnutrition,the former more often among women and the latteramong men.11. The answer is D. They allow the individual to communicatethe desire for or against specific life-supportmeasures in the event that the individual’s health status atsome point makes him or her unable to do so. Living willshave been honored by courts and do not require the useof an attorney. Catastrophic illness, which leaves the individualunable to communicate wishes, can occur withanyone, but particularly with elderly persons. Living willsgive them a mechanism to convey their wishes.ReferencesBross MH , Tryon AF . Preventive care of the older adult ( 65years) . In: Rudy DR , Kurowski K , eds. Family Medicine: HouseOfficer Series . Baltimore : Williams & Wilkins ; 1997 : 741 – 750 .Dickman R . Care of the elderly . In: Rakel RE , ed. Textbook ofFamily Practice . Philadelphia : WB Saunders ; 2002.Family Medicine Review . Kansas City , Missouri ; May 3–10;2009.McPhee SJ , Papadakis MA . Current Medical Diagnosis and Treatment. 49th ed . New York/Chicago : Lange, McGraw-Hill ;2010 .Rudy DR. Endocrinology . In: Rakel RE , ed. Textbook of FamilyPractice . 6th ed . Philadelphia : WB Saunders ; 2002 .The Guide to Preventive Services 2009. Recommendations ofthe U.S. Preventive Services Task Force.