Medicare Housing health
Depression and Anxiety
What is the average lifespan in the US? 76.1 years;
What Public Program establishes benefits for victim of work accidents? Social Security Act 1935
What Public program establishes benefits for the unemployed? Social Security Act 1935
What Public Program is a federally managed health insurance to people are entitled to these benefits
after contributing a certain amount? Medicare
What public program is a welfare program of the state, where the eligible depends on need and poverty?
Medicaid
mothers and children blind and handicapped? Social Security Act 1935
When do insured workers become eligible for social security? 62 years old
When does Medicare start? Age 65
Medicare covers about what percentage of healthcare expenses of those enrolled? Half
How is Medicare funded? Combo of payroll tax, beneficiary premiums and surtaxes from beneficiaries, co
pays, deductibles and US Treasury
What are the 4 parts of Medicare and what do each cover? Part A -D
What does Part A cover? Hospital, skilled nursing, hospice service,
Part B covers: Outpatient services, office visits, lab work, outpatient procedures,
Part C: Alternative to Medicare called Managed Medicare which allows patient to choose health
plants
Part D: Prescription drug benefits
What is the difference between a Copay and a deductible? A small, fixed amount outlined in the policy
that you pay each time a covered service is provided. Deductible is the amount you must pay out of
pocket for covered expenses before the insurance company will cover the remaining costs.
What is inflation Reduction Act 2022?
This act helps lower prescription drug costs for people with Medicare and reduce spending by
federal government.
What does Patient Protection and Affordable Care Act do? Expand eligibility and federal funding for
Medicaid which improves coverage, access and financial security (Medicaid)
Can a non citizen receive Medicaid? Yes if they qualify
Can low income disabled who already receives social security income receive Medicaid? Yes
What population are considered higher in risk for food insecurity? Hispanic/ AA/ Rural/ live
alone/Southern US or those that live with children/ chronic dx/ functional or cognitive impairment
What are some Federal and Local Programs that help with Food Insecurity :
Supplemental Nutrition Assessment Program
Meals on Wheels
Congregate Meal programs
Medically tailored meal program
T/F : To qualify for PACE (Programs for All inclusive Care of the Elderly) you must be 65 years or older, be
able to live safe in a community and are not eligible for nursing care. False, they must be eligible for
nursing care.
T/F Programs for all-inclusive care of the Elderly include Adult day care, dentistry, meals but does not
include emergency services.
T/F: Home Health does not require physician certification, it is a personal care service.
False, it is service provided by skilled personnel: nursing PT, OT, SLP, social worker and needs
physician certification
T/F: Long Term care is the same as Home health.
Fill in the blank: Skilled Nursing facilities are a post hospital care service.
Fill in the blank: Most long term care is not medical care, but assistance with basic personal tasks of
everyday life.
T/F: Private home- assisted living facilities do require monthly skilled nursing care. False, do not require
skilled nursing care
T/F: Combative behavior (from the patient) is not a risk factor for abuse. (false)
T/F: both close and distant relationships with the patient are risk factors for abuse
T/F: Self neglect is a not a form of abuse. False!
What are the top 3 forms of abuse on the elderly?
Verbal
Financial
Psychological/emotional
T/F: Elongated (long) toenails are not a sign of elderly abuse. False, this can be a possible sign of poor
hygiene
Fill in the blank: Victim of financial exploitation often have diminished mental capacity.
T/F: Increased confusion/agitation is not a sign of psychological emotional abuse. False
T/F: Neglect can be active, passive, intentional but NOT unintentional. False
What types of labs would you order for physical exam? Electrolytes, liver function tests,
hemoglobin/hematocrit
What is the American Rescue Plan? Plan signed by Biden to invest 276 millions to the Elder Justice Act
for the next 2 years.
When is world elder abuse awareness day? June 15
T/F The Older American Act program provides only nutritional Services. False
Provides Supportive services such as Vaccine outreach, Caregiver Support, health promotion,
Native American outreach programs, and programs for individuals living in nursing homes (LTC
Ombudsman Program)
1. Fill in the blanks:
a. Older Adults have a higher rate of physical and cognitive comorbidities, social isolation,
polypharmacy, age-related pharmacodynamics.
2. Name the 3 Risk Factors (general categories) that may lead to depression in the geriatric
population?
a. Medical/Biological factors (such as Parkinson’s, MI, stroke, cancer)
b. Psychological factors (loss of control of body/mind)
c. Social factors (isolation, loneliness) due to change in social network
3. What are two features that distinguish geriatric depression from other late life mood
disturbances:
a. Anhedonia
b. Hopelessness
4. Fill in the blank:
a. DSM-5 criteria for major depressive episode:
i. At least 5 of the 9 symptoms are present nearly every day during the same 2
week period as reported by the patient or observed by others, these symptoms
represent a change in distress, impairment in social, occupational or other
important areas of functioning. At least one symptom must be low mood or
anhedonia.
5. What are the different screening questionnaires used as diagnostic tools for depression in the
geriatric population?
a. Geriatric Depression scale, patient health questionnaire (PHQ-2 & PHQ-9)
6. When do you use PHQ-2 vs PHQ-9?
a. PHQ-2 is administered first, if patient screening indicates a possibility of depression (this
only screens for feeling of anhedonia and hopelessness) then patient should be followed
up with PHQ-9 questionnaire.
7. What are possible differential diagnosis If patient comes in with the following complaints?
a. Memory loss/dementia  depression, bereavement and cognition
b. Delirium  infection, comorbid illness
c. Fatigue/weight loss  diabetes, thyroid issue, malignancy, anemia
d. Sleep disturbances  insomnia, nocturia, sleep apnea
e. Medication Side effects (list drugs that are notorious for AE)  Benzodiazepines,
opioids, glucocorticoids)
8. Fill in the blank: Depression is a major risk factor for suicide in the elderly, most are white males
greater than 85 years old. Risk factors are comorbid illness, pain, social isolation, prior suicide
attempt, FMHx of suicide, ETOH abuse.
9. What is the first line for mild depression? What is emphasized during this time?
a. Education and psychotherapy
b. Sleep hygiene, physical activity and social support
10. Under the Suicide/Safety Risk Factor checklist, what are the 4 categories under the Suicidal
Items (hint: these are 4 questions we ask to determine if patient has thoughts of committing
suicide)
a. Thoughts, Intent, Plan, Behavior
11. T/F Firearm Form Status is found in the Suicide/Safety Risk factor Checklist.
12. What is Audit C in the Suicide/Safety Risk Factor Checklist?
a. Screening for Alcohol
13. ( this is a gimmie question, just so we know what an AUDIT C screening is- it was only mentioned
in class and might help us with a question) Fill in the blank : The higher the AUDIT-C score the
more likely it is that the patient’s drinking is affecting his or her health and safety. Score of 4 or
more is positive in men while a score of 3 or more is positive in women.
14. What are the 7 different types/components of depression treatment?
a. Education to the patient & family
b. Social support
c. Exercise
d. Pharmacotherapy
e. ECT
f. Integrative therapy
15. What are some examples of social support that can help with depression?
a. Senior centers
b. Adult day health centers
c. Support Groups
d. Friendly visitor programs
e. Friendship line
f. Local meal delivery services
g. Transportation programs
16. Adult Day Services programs offer a safe, positive, caring alternative to nursing home care for
those who do not need 24-hour skilled nursing.
17. What are the two types of antidepressants are used for moderate to severe depression?
a. SSRI and SNRI
18. What SSRI is avoided due to long half life?
a. Fluoxetine
19. Fluoxetine is the only antidepressant approved for treatment of?
a. Bulimia
20. Why are TCAs and MAOIs are generally avoided for depression in the geriatric patients?
a. TCAs are known to cause confusion or hallucinations in the elderly population along
with anticholinergic symptoms
i. Also if you OD it can cause the 3 “C’s”
1. Cardiotoxicity as it is a Na channel blocker
2. Convulsions
3. Coma
b. MAOIs:
i. Causes hypertensive crisis as it prevents the breakdown of tyramine leading to
hypertension and causes orthostatic hypotension (SNRI are also known to cause
hypertension but NOT hypertensive crisis – taken from PPP, reference pg 571
and 573)
21. What anti-depressant would be best for the following scenarios:
22.
23.
24.
25.
a. Patient has depression and has trouble gaining weight or lost significant weight from
depression?
i. Mirtazepine
b. Patient has depression and would like to quit smoking?
i. Bupropion
c. Patient has neuropathic pain and has been diagnosed with depression?
i. Nortriptyline
d. Patient has trouble with sleep and has been diagnosed with depression?
i. Mirtazapine or Nortriptyline
How does antidepressant dosing differ for the geriatric patient vs the general adult population?
a. Usually has a lower dosing
Fill in the blank:
a. Regarding antidepressant medication, if no “older adult” dosing is given give ½ of
manufacturer recommended starting dose for antidepressant dosing
How long do you wait to titrate antidepressants for the geriatric patient?
a. 4-6 weeks
Fill in the blank: (cautions & interactions of antidepressants)
a. Cardiac arrhythmias  Citalopram (Class: SSRI; give 20 mg )
b. Hypertension  Venlafaxine and desvenlafaxine (SNRIs)
c. Hyponatremia  SSRI
d. Seizure Disorders  Bupropion (and TCA if OD)
e. Hepatic Disease  Nefazodone
f. Bleeding risk  SSRI (and Warfarin)
g. Suicide Risk  TCAs
h. Cognitive impairment  TCAs and SSRI’s
i. Serotonin Syndrome  SSRI, Tramadol (not mentioned in notes but don’t forget also
SNRI, MAOI, Triptans, TCAs ** or combo with St John wort, Ecstasy, cocaine or
amphetamines)
i. **(most likely will give you anticholinergic syndrome instead of Serotonin
Syndrome due to muscarinic receptor blocker effects)
j. What symptoms would you expect in a patient with Serotonin Syndrome?
i. Cognitive effects: agitation, Altered mental status, confusion, hallucinations,
hypomania
ii. Autonomic instability: hyperthermia, tachycardia, diaphoresis, blood pressure
changes
iii. GI serotonin effects: nausea/vomiting, increased bowel sounds & diarrhea
iv. Neuromuscular hyperactivity: spontaneous or inducible clonus, hypertonia,
tremors
v. Dilated pubils, dry mucous membranes and flushed skin
vi.
26. When do you consider switching antidepressant medication?
a. If patient is experiencing intolerable side effects or adequate trial of medication
27. T/F: When switching between SSRI antidepressants, you need to wait at least 2 weeks before
initiating the new SSRI- also known as a “washout period”. False no washout period is required
however Fluoxetine is an exception!
28. T/F Abruptly stopping medications with short half-life result in vertigo, tinnitus, paresthesia.
29. What antidepressants might cause tinnitus, paresthesia, vertigo?
a. Citalopram
b. Paroxetine
c. Sertraline
d. Venlafaxine
e. ** Note these are SNRI & SSRI
30. How long should you continue medication if remission of depression is achieved?
a. 6 months
31. What is the time span for tapering antidepressants once remission is achieved and has been
continued for at least 6 months?
a. 2-3 months
32. What are some possible cardio, pulm and endo differential diagnosis with patient displaying
anxiety-like symptoms?
a. Cardiac arrhythmias, acute coronary syndrome, bronchospasm, hyperthyroidism
33. Fill in the blank: According to the DSM5, patient with excessive anxiety about events/ activities
must present with these symptoms for at least 6 months.
34. What is the first line treatment for anxiety? What is second line? What drug is considered an
“adjunct” for anxiety?
a. First line: cognitive behavioral therapy
b. SSRI/SNRI such as paroxetine (SSRI), extended Venalfaxine (SNRI), Sertraline (SSRI),
Escitalopram (SSRI)
c. Adjuvant (to SSRI): Buspirone
35. When do you give Benzodiazepines ?
a. For patient with anxiety, used for short term only- until long term therapy takes effect
36. What anxiolytic medication (also used for depression) can cause arrhythmias?
a. Venlafaxine (SNRI)
37. What anxiolytic medication can cause respiratory depression, confusion, ataxia, somnolence,
falls, increased risk for memory loss?
a. Benzodiazepines
38. Fill in the blank: All depressed and anxious patients should be assessed for suicide risk.
Driving as an Older Adult:
39. T/F: Older adult population has greater “absolute” yearly crash rates than younger drivers.
False, only a smaller subset (of 75 y/o and greater) have a greater crash set
40. Drivers > 75 y/o are less likely to get into few accidents as they drive fewer miles then their
younger counterparts. False they average more crashes/mile driven
41. Match the leading cause of injury with age bracket:
a. 65- 74 y/o
1. Falls
b. 75 -84 y/o
2. Motor Vehicle Collision
42. What are the 3 life “aspects” that former drivers say have been negatively impacted with
cessation of driving?
a. Physical well being
b. Mental well being
c. Social well being
43. What are 5 physiologic changes caused by aging that may negatively impact elderly drivers?
a. Agility/flexibility to rotate head and trunk
b. Reaction time
c. Cognition
d. Vision deterioration
e. Muscular weakness and mobility
44. What is UFOV?
a. The useful field of view (UFOV) is the area from which information can be extracted with
one glance, without head or eye movements (speed of processing information from
your visual field)
45. What is the minimal visual acuity requirement for licensure for most states?
a. Minimum best corrected visual acuity requirement at 20/40 in the better eye
46. T/F: Malnutrition can lead to cognitive impairment and ultimately negatively impact on driving.
a. True
47. T/F: Patients with early dementia can no longer drive
a. False, patients can drive “as long as their cognition allows”
48. How often should you assess drivers with early dementia?
a. You should reassess every 6 months
49. T/F: Drivers with moderate stage dementia can still drive as long as they are reassessed every 6
months.
a. False, they are deemed unsafe to drive, some may need to cease driving immediately
50. What are two different assessment Tool that are used for assessing Mental cognition?
a. Montreal Cognitive Assessment
b. Mini Mental State Examination
51. T/F A score of 10-17 or lower on Montreal Cognitive Assessment is considered severe cognitive
impairment.
a. False; its considered moderate cognitive impairment
52. What is the cutoff “score” (for both Montreal Cognitive Assessment and Mini Mental State
Examination) you need to able to drive ?
a. MoCA: has to be greater than 18
b. MMSE: has to be greater than 24
53. How does MoCA (Montreal Cognitive Assessment) and MMSE (Mini Mental State Examination)
differ? (Yes, I know we don’t really to know this for the test, however you might need to know
this for life- you’ll thank me later, in an email like Dr. Catalano)
a. Because it tests for executive function, the MoCA is more sensitive in this regard than
the (MMSE). This means the MoCA is better at detecting mild disease than the MMSE.
b. For this reason, the MoCA may be a better choice for people with mild symptoms, while
the MMSE is a good option for people with more pronounced symptoms.
c. Fun fact, MoCA tests your ability to recognize a camel, rhino and a lion
54. Can Sleep apnea impair driving? What about COPD? Yes, both conditions can impact driving
55. Can depression impair driving? Yes
56. Can anticholinergics impair driving? What about antihypertensives? Yes, both drug classes affect
driving.
57. What are some metabolic conditions that you may have to assess and note progression as it
may negatively impact their ability to drive (for an elderly patient)? What are some
cerebrovascular conditions?
a. Diabetes
b. CVA, TIA, Cardiovascular, Carotid Stenosis
58. What are four aspects used to assess a patient’s physical function (to determine if patient is able
to keep driving)?
a. History
i. Is the patient able to perform ADL and IADL independently?
ii. What is the patient’s Driving history?
iii. What are the medications
iv. History of repeated falls
b. Regarding physical examination findings
i. Is there proprioception, focal neurologic deficits?
ii. Is the range of motion intact for: neck, upper extremity, lower extremity
iii. How is the patient’s grip strength? lower extremity strength ?
c. What is the time that patient takes to “get up and go” aka TUG? How fast can a patient
walk (Rapid Pace Walk)?
59. Name the following test: Physician lays out a measuring tape and says to his patient “I want you
to walk along side of this tape measure to the end, turn around and walk back as quickly as
possible” for a total of 20 ft.
a. Rapid Pace walk
60. Label as either Moderate, High, or Low risk driver:
a. Visual acuity of < or equal to 20/50, unable to be corrected? High risk
b. Has a visual field deficit? Moderate risk
c. Moderate dementia? High risk driver
d. Hearing Impairment? Moderate Risk
e. Uncontrolled Medical condition? High risk
f. Leg Strength less than 4/5 Moderate risk
g. Rapid Pace walk greater than 9 seconds? Moderate Risk
h. Rapid Pace walk less than than 9 seconds? Low risk
61. If a patient is “deemed” a moderate risk driver, what are the next steps? What about a high risk
driver?
a. Moderate risk:
i. refer to driving rehabilitation specialist
ii. have a formal eval by DMV
iii. Continue dialogue about driving retirement
b. High Risk:
i. Recommend Immediate driving retirement
ii. Provide alternative transportation solutions
62. T/F Advanced Driving Directives is an agreement with a patient and their family ( in writing),
naming the person they desire to tell them (the patient) can no longer drive (aka Do not Drive
prescription)
63.