2026/2027 THE ELITE
TEST BANK: HAM'S
PRIMARY CARE
GERIATRICS (v9.0)
PART 0: THE NAVIGATOR
● PART I: THE PRIMER
○ Welcome to the Big Leagues
○ The Critical Action Cheat Sheet (2026/2027 Standards)
● PART II: THE ELITE TEST BANK
○ Questions 1–28: Foundational Syntax & Application (Definitions, Physiologic
Changes, The 5Ms)
○ Questions 29–58: Professional Simulation (Acute Changes, Beers Criteria 2026,
Clinical Intercepts)
○ Questions 59–88: Grandmaster Synthesis (Complex Multimorbidity, Alzheimer's
DMTs, Deprescribing Cascades, Ethics)
PART I: THE PRIMER
Welcome to the Big Leagues. This test bank is not designed to help you pass a rudimentary
exam; it is designed to forge your clinical intuition so you do not kill a patient on your first day as
an advanced practitioner. By intercepting novice errors—such as misinterpreting polypharmacy
for dementia or treating delirium with chemical restraints—this document translates academic
theory into high-stakes, 2026/2027 professional competence for top-tier institutions like UT
Austin Dell Medical School and the School of Nursing.
The "Critical Action" Cheat Sheet:
● The Beers 2026 Imperative: Always prioritize the "Alternatives List." Default to
non-pharmacologic behavioral therapies for dementia, sleep hygiene over Z-drugs
(Zolpidem), and topical NSAIDs over systemic agents to prevent catastrophic GI bleeds
and falls.
● The Geriatric Vital Sign: Functional status (ADLs/IADLs) is the ultimate metric of
geriatric health. A sudden drop in function or mentation is an acute medical emergency
(infection, infarction, or iatrogenic), not "normal aging".
● The ADA 2026 Glycemic Mandate: Deprioritize strict HbA1c goals (<7.0%) in complex,
multimorbid elders. Target <8.0% or focus on Time-In-Range (TIR) via continuous glucose
monitoring to avoid fatal hypoglycemia.
, ● The Alzheimer's 2026 Paradigm: Disease-Modifying Therapies (Lecanemab,
Donanemab) require confirmed amyloid pathology via blood-based biomarkers or PET,
and are strictly indicated only for mild cognitive impairment or mild dementia.
PART II: THE ELITE TEST BANK
Q1: An 84-year-old male with a history of benign prostatic hyperplasia (BPH) and mild cognitive
impairment is brought to the clinic by his daughter. She reports he became acutely confused,
agitated, and unable to walk independently over the past 24 hours. Vital signs are stable, but he
is tachycardic. Which is the MOST APPROPRIATE INITIAL clinical action? A) Prescribe a
low-dose oral typical antipsychotic to manage the acute agitation. B) Perform a comprehensive
physical examination including a bladder scan and urinalysis. C) Immediately refer the patient to
a memory care facility for advanced dementia progression. D) Order a non-contrast CT of the
head to rule out a subacute subdural hematoma.
● The Answer: B (Perform a comprehensive physical examination including a bladder scan
and urinalysis.)
● Distractor Analysis:
○ A is incorrect: Prescribing antipsychotics for undifferentiated agitation without
seeking the underlying medical cause violates the 2026 AGS Beers Criteria.
○ C is incorrect: Dementia progresses over months to years; an acute change over 24
hours is delirium, not dementia progression.
○ D is incorrect: While a CT may eventually be warranted, looking for common,
reversible causes (urinary retention/UTI) is the immediate first step.
The Mentor's Analysis: Acute confusion in a geriatric patient is delirium until proven otherwise.
The most common triggers are infections, pain, and urinary retention. In a patient with BPH, a
silent urinary tract infection or acute retention is the primary suspect. Professional Intuition:
Always look for the simplest systemic insult before assuming structural brain pathology.
Q2: A 78-year-old female presents for a routine wellness visit. She has osteoarthritis,
hypertension, and insomnia. Her current medications include lisinopril, acetaminophen, and
zolpidem. According to the 2026 AGS Beers Criteria updates, which intervention is the FIRST
priority regarding her medication regimen? A) Increase the zolpidem dose as she reports
waking up frequently during the night. B) Switch zolpidem to diphenhydramine to achieve safer
sedative effects. C) Initiate a supervised taper of zolpidem and introduce Cognitive Behavioral
Therapy for Insomnia (CBT-I). D) Add a low-dose benzodiazepine to synergize with the
zolpidem for sleep maintenance.
● The Answer: C (Initiate a supervised taper of zolpidem and introduce Cognitive
Behavioral Therapy for Insomnia (CBT-I).)
● Distractor Analysis:
○ A is incorrect: Increasing a Z-drug exacerbates the risk of delirium, falls, and
fractures.
○ B is incorrect: Diphenhydramine is highly anticholinergic and strictly avoided in
older adults due to severe confusion and urinary retention risks.
○ D is incorrect: Combining Z-drugs with benzodiazepines is a catastrophic
prescribing cascade leading to fatal respiratory depression or falls.
The Mentor's Analysis: The 2026 Beers Criteria "Alternatives List" mandates an aggressive
shift away from pharmacologic sleep aids. Z-drugs (zolpidem) offer minimal sleep latency
benefit while drastically increasing fracture risk. Professional Intuition: Deprescribing is an
,active, vital clinical intervention. Replace pills with targeted behavioral protocols like CBT-I.
Q3: During a geriatric assessment, an 81-year-old patient demonstrates a slow, wide-based gait
and takes 22 seconds to complete the Timed Up and Go (TUG) test. The patient states they are
afraid of falling. What does this TUG score IMMEDIATELY indicate to the practitioner? A) The
patient requires immediate prescription of a walker and a wheelchair. B) The patient has a high
risk of falling and requires a comprehensive multifactorial fall risk assessment. C) The patient
has normal age-related slowing of motor function and requires reassurance. D) The patient is
suffering from Parkinson's disease and requires levodopa therapy.
● The Answer: B (The patient has a high risk of falling and requires a comprehensive
multifactorial fall risk assessment.)
● Distractor Analysis:
○ A is incorrect: Jumping straight to restrictive mobility aids without an assessment
promotes immobility and muscle deconditioning.
○ C is incorrect: A TUG score >12 seconds is highly abnormal and directly correlates
with severe fall risk, never "normal aging".
○ D is incorrect: While parkinsonism is on the differential, a slow TUG test is
non-specific and does not independently diagnose Parkinson's disease.
The Mentor's Analysis: The TUG test is the ultimate functional barometer. It tests strength,
balance, and executive function simultaneously. A prolonged TUG demands an immediate audit
of orthostatic vitals, vision, footwear, and polypharmacy. Professional Intuition: Never write off a
functional decline as "just getting old."
Q4: A 72-year-old male with a history of atrial fibrillation is currently managed on warfarin. His
time in therapeutic range (TTR) is 52%. He has no history of mechanical heart valves or
moderate-to-severe mitral stenosis. Under 2026 geriatric primary care guidelines, what is the
MOST APPROPRIATE pharmacological optimization? A) Increase the frequency of INR
monitoring to twice weekly to improve the TTR. B) Transition the patient to a Direct Oral
Anticoagulant (DOAC) such as apixaban. C) Add low-dose aspirin to the warfarin regimen to
ensure adequate clot prevention. D) Discontinue all anticoagulation due to the inherent fall risk
in the geriatric population.
● The Answer: B (Transition the patient to a Direct Oral Anticoagulant (DOAC) such as
apixaban.)
● Distractor Analysis:
○ A is incorrect: A TTR of 52% is subtherapeutic; switching to a DOAC is the 2026
standard of care over micromanaging a failing warfarin regimen.
○ C is incorrect: Adding aspirin to warfarin without a distinct indication increases fatal
bleeding risks.
○ D is incorrect: Fall risk rarely outweighs the stroke prevention benefit of
anticoagulation in AFib unless the patient falls daily with severe head trauma.
The Mentor's Analysis: The 2026 AGS guidelines prioritize DOACs (specifically apixaban)
over warfarin for non-valvular AFib due to a significantly lower risk of intracranial hemorrhage
and the elimination of dietary/INR monitoring barriers. Professional Intuition: Optimize safety
and compliance simultaneously by choosing drugs with predictable pharmacokinetics.
Q5: An 88-year-old female presents with a blood pressure of 165/85 mmHg. She is frail, has
severe osteoarthritis, and recently suffered a fall. She is on no antihypertensives. Based on the
2026 ADA and AGS standards for complex/frail older adults, what is the BEST initial approach
to her blood pressure? A) Initiate immediate combination therapy with an ACE inhibitor and a
diuretic to achieve a target <120/80 mmHg. B) Prescribe a peripheral alpha-blocker to quickly
reduce systolic pressure while managing potential urinary issues. C) Initiate monotherapy with a
, low-dose calcium channel blocker or ACE inhibitor, targeting a relaxed goal of <140/90 mmHg.
D) Withhold all antihypertensive therapy, as blood pressure intervention is futile in frail
octogenarians.
● The Answer: C (Initiate monotherapy with a low-dose calcium channel blocker or ACE
inhibitor, targeting a relaxed goal of <140/90 mmHg.)
● Distractor Analysis:
○ A is incorrect: Aggressive combination therapy targeting <120/80 in a frail elder will
likely cause orthostatic hypotension and another fall.
○ B is incorrect: Alpha-blockers cause profound orthostatic hypotension and are on
the Beers Criteria "avoid" list.
○ D is incorrect: Untreated severe hypertension still poses immediate stroke and
heart failure risks.
The Mentor's Analysis: In robust older adults, we aim for <130/80. In frail elders with a fall
history, the risk of orthostatic hypotension supersedes the long-term macrovascular benefits of
strict control. Professional Intuition: "Start low, go slow." Relax the target to <140/90 to maintain
cerebral perfusion and prevent syncopal falls.
Q6: A 68-year-old patient with type 2 diabetes has an HbA1c of 8.2%. The patient has multiple
chronic conditions, moderate cognitive impairment, and requires assistance with two ADLs.
Which statement represents the MOST APPROPRIATE 2026 clinical standard for this patient's
glycemic management? A) The HbA1c must be aggressively lowered to <7.0% using insulin
therapy to prevent microvascular complications. B) The current HbA1c is acceptable; goals
should focus on avoiding hypoglycemia and symptomatic hyperglycemia. C) The patient should
be placed on a sliding-scale insulin regimen to tightly control postprandial glucose spikes. D)
The patient must immediately begin a severe caloric restriction diet to reverse the diabetes
progression.
● The Answer: B (The current HbA1c is acceptable; goals should focus on avoiding
hypoglycemia and symptomatic hyperglycemia.)
● Distractor Analysis:
○ A is incorrect: Strict targets (<7.0%) in complex elders drastically increase the risk
of fatal hypoglycemic events.
○ C is incorrect: Sliding-scale insulin in the outpatient geriatric setting is a Beers
Criteria violation.
○ D is incorrect: Severe caloric restriction in a frail elder precipitates muscle wasting
(sarcopenia) and malnutrition.
The Mentor's Analysis: The 2026 ADA guidelines explicitly stratify older adults. For those with
complex health and functional limitations, the time frame of benefit for strict control outlasts their
life expectancy. Professional Intuition: In frail elders with diabetes, hypoglycemia kills today;
hyperglycemia kills in ten years. Protect them today.
Q7: A 75-year-old male complains of bilateral knee pain from osteoarthritis. He has a history of
a GI bleed two years ago and stage 3 chronic kidney disease (CKD). Which pharmacologic
intervention is the FIRST-LINE recommendation for his pain? A) Scheduled oral ibuprofen 600
mg every 6 hours. B) An oral COX-2 selective inhibitor (e.g., celecoxib) combined with a proton
pump inhibitor. C) Topical diclofenac gel applied to the knees, alongside physical therapy. D) A
low-dose oral opioid such as tramadol.
● The Answer: C (Topical diclofenac gel applied to the knees, alongside physical therapy.)
● Distractor Analysis:
○ A is incorrect: Systemic NSAIDs are strictly contraindicated in patients with a history
of GI bleeds and CKD due to the risk of perforation and renal failure.
TEST BANK: HAM'S
PRIMARY CARE
GERIATRICS (v9.0)
PART 0: THE NAVIGATOR
● PART I: THE PRIMER
○ Welcome to the Big Leagues
○ The Critical Action Cheat Sheet (2026/2027 Standards)
● PART II: THE ELITE TEST BANK
○ Questions 1–28: Foundational Syntax & Application (Definitions, Physiologic
Changes, The 5Ms)
○ Questions 29–58: Professional Simulation (Acute Changes, Beers Criteria 2026,
Clinical Intercepts)
○ Questions 59–88: Grandmaster Synthesis (Complex Multimorbidity, Alzheimer's
DMTs, Deprescribing Cascades, Ethics)
PART I: THE PRIMER
Welcome to the Big Leagues. This test bank is not designed to help you pass a rudimentary
exam; it is designed to forge your clinical intuition so you do not kill a patient on your first day as
an advanced practitioner. By intercepting novice errors—such as misinterpreting polypharmacy
for dementia or treating delirium with chemical restraints—this document translates academic
theory into high-stakes, 2026/2027 professional competence for top-tier institutions like UT
Austin Dell Medical School and the School of Nursing.
The "Critical Action" Cheat Sheet:
● The Beers 2026 Imperative: Always prioritize the "Alternatives List." Default to
non-pharmacologic behavioral therapies for dementia, sleep hygiene over Z-drugs
(Zolpidem), and topical NSAIDs over systemic agents to prevent catastrophic GI bleeds
and falls.
● The Geriatric Vital Sign: Functional status (ADLs/IADLs) is the ultimate metric of
geriatric health. A sudden drop in function or mentation is an acute medical emergency
(infection, infarction, or iatrogenic), not "normal aging".
● The ADA 2026 Glycemic Mandate: Deprioritize strict HbA1c goals (<7.0%) in complex,
multimorbid elders. Target <8.0% or focus on Time-In-Range (TIR) via continuous glucose
monitoring to avoid fatal hypoglycemia.
, ● The Alzheimer's 2026 Paradigm: Disease-Modifying Therapies (Lecanemab,
Donanemab) require confirmed amyloid pathology via blood-based biomarkers or PET,
and are strictly indicated only for mild cognitive impairment or mild dementia.
PART II: THE ELITE TEST BANK
Q1: An 84-year-old male with a history of benign prostatic hyperplasia (BPH) and mild cognitive
impairment is brought to the clinic by his daughter. She reports he became acutely confused,
agitated, and unable to walk independently over the past 24 hours. Vital signs are stable, but he
is tachycardic. Which is the MOST APPROPRIATE INITIAL clinical action? A) Prescribe a
low-dose oral typical antipsychotic to manage the acute agitation. B) Perform a comprehensive
physical examination including a bladder scan and urinalysis. C) Immediately refer the patient to
a memory care facility for advanced dementia progression. D) Order a non-contrast CT of the
head to rule out a subacute subdural hematoma.
● The Answer: B (Perform a comprehensive physical examination including a bladder scan
and urinalysis.)
● Distractor Analysis:
○ A is incorrect: Prescribing antipsychotics for undifferentiated agitation without
seeking the underlying medical cause violates the 2026 AGS Beers Criteria.
○ C is incorrect: Dementia progresses over months to years; an acute change over 24
hours is delirium, not dementia progression.
○ D is incorrect: While a CT may eventually be warranted, looking for common,
reversible causes (urinary retention/UTI) is the immediate first step.
The Mentor's Analysis: Acute confusion in a geriatric patient is delirium until proven otherwise.
The most common triggers are infections, pain, and urinary retention. In a patient with BPH, a
silent urinary tract infection or acute retention is the primary suspect. Professional Intuition:
Always look for the simplest systemic insult before assuming structural brain pathology.
Q2: A 78-year-old female presents for a routine wellness visit. She has osteoarthritis,
hypertension, and insomnia. Her current medications include lisinopril, acetaminophen, and
zolpidem. According to the 2026 AGS Beers Criteria updates, which intervention is the FIRST
priority regarding her medication regimen? A) Increase the zolpidem dose as she reports
waking up frequently during the night. B) Switch zolpidem to diphenhydramine to achieve safer
sedative effects. C) Initiate a supervised taper of zolpidem and introduce Cognitive Behavioral
Therapy for Insomnia (CBT-I). D) Add a low-dose benzodiazepine to synergize with the
zolpidem for sleep maintenance.
● The Answer: C (Initiate a supervised taper of zolpidem and introduce Cognitive
Behavioral Therapy for Insomnia (CBT-I).)
● Distractor Analysis:
○ A is incorrect: Increasing a Z-drug exacerbates the risk of delirium, falls, and
fractures.
○ B is incorrect: Diphenhydramine is highly anticholinergic and strictly avoided in
older adults due to severe confusion and urinary retention risks.
○ D is incorrect: Combining Z-drugs with benzodiazepines is a catastrophic
prescribing cascade leading to fatal respiratory depression or falls.
The Mentor's Analysis: The 2026 Beers Criteria "Alternatives List" mandates an aggressive
shift away from pharmacologic sleep aids. Z-drugs (zolpidem) offer minimal sleep latency
benefit while drastically increasing fracture risk. Professional Intuition: Deprescribing is an
,active, vital clinical intervention. Replace pills with targeted behavioral protocols like CBT-I.
Q3: During a geriatric assessment, an 81-year-old patient demonstrates a slow, wide-based gait
and takes 22 seconds to complete the Timed Up and Go (TUG) test. The patient states they are
afraid of falling. What does this TUG score IMMEDIATELY indicate to the practitioner? A) The
patient requires immediate prescription of a walker and a wheelchair. B) The patient has a high
risk of falling and requires a comprehensive multifactorial fall risk assessment. C) The patient
has normal age-related slowing of motor function and requires reassurance. D) The patient is
suffering from Parkinson's disease and requires levodopa therapy.
● The Answer: B (The patient has a high risk of falling and requires a comprehensive
multifactorial fall risk assessment.)
● Distractor Analysis:
○ A is incorrect: Jumping straight to restrictive mobility aids without an assessment
promotes immobility and muscle deconditioning.
○ C is incorrect: A TUG score >12 seconds is highly abnormal and directly correlates
with severe fall risk, never "normal aging".
○ D is incorrect: While parkinsonism is on the differential, a slow TUG test is
non-specific and does not independently diagnose Parkinson's disease.
The Mentor's Analysis: The TUG test is the ultimate functional barometer. It tests strength,
balance, and executive function simultaneously. A prolonged TUG demands an immediate audit
of orthostatic vitals, vision, footwear, and polypharmacy. Professional Intuition: Never write off a
functional decline as "just getting old."
Q4: A 72-year-old male with a history of atrial fibrillation is currently managed on warfarin. His
time in therapeutic range (TTR) is 52%. He has no history of mechanical heart valves or
moderate-to-severe mitral stenosis. Under 2026 geriatric primary care guidelines, what is the
MOST APPROPRIATE pharmacological optimization? A) Increase the frequency of INR
monitoring to twice weekly to improve the TTR. B) Transition the patient to a Direct Oral
Anticoagulant (DOAC) such as apixaban. C) Add low-dose aspirin to the warfarin regimen to
ensure adequate clot prevention. D) Discontinue all anticoagulation due to the inherent fall risk
in the geriatric population.
● The Answer: B (Transition the patient to a Direct Oral Anticoagulant (DOAC) such as
apixaban.)
● Distractor Analysis:
○ A is incorrect: A TTR of 52% is subtherapeutic; switching to a DOAC is the 2026
standard of care over micromanaging a failing warfarin regimen.
○ C is incorrect: Adding aspirin to warfarin without a distinct indication increases fatal
bleeding risks.
○ D is incorrect: Fall risk rarely outweighs the stroke prevention benefit of
anticoagulation in AFib unless the patient falls daily with severe head trauma.
The Mentor's Analysis: The 2026 AGS guidelines prioritize DOACs (specifically apixaban)
over warfarin for non-valvular AFib due to a significantly lower risk of intracranial hemorrhage
and the elimination of dietary/INR monitoring barriers. Professional Intuition: Optimize safety
and compliance simultaneously by choosing drugs with predictable pharmacokinetics.
Q5: An 88-year-old female presents with a blood pressure of 165/85 mmHg. She is frail, has
severe osteoarthritis, and recently suffered a fall. She is on no antihypertensives. Based on the
2026 ADA and AGS standards for complex/frail older adults, what is the BEST initial approach
to her blood pressure? A) Initiate immediate combination therapy with an ACE inhibitor and a
diuretic to achieve a target <120/80 mmHg. B) Prescribe a peripheral alpha-blocker to quickly
reduce systolic pressure while managing potential urinary issues. C) Initiate monotherapy with a
, low-dose calcium channel blocker or ACE inhibitor, targeting a relaxed goal of <140/90 mmHg.
D) Withhold all antihypertensive therapy, as blood pressure intervention is futile in frail
octogenarians.
● The Answer: C (Initiate monotherapy with a low-dose calcium channel blocker or ACE
inhibitor, targeting a relaxed goal of <140/90 mmHg.)
● Distractor Analysis:
○ A is incorrect: Aggressive combination therapy targeting <120/80 in a frail elder will
likely cause orthostatic hypotension and another fall.
○ B is incorrect: Alpha-blockers cause profound orthostatic hypotension and are on
the Beers Criteria "avoid" list.
○ D is incorrect: Untreated severe hypertension still poses immediate stroke and
heart failure risks.
The Mentor's Analysis: In robust older adults, we aim for <130/80. In frail elders with a fall
history, the risk of orthostatic hypotension supersedes the long-term macrovascular benefits of
strict control. Professional Intuition: "Start low, go slow." Relax the target to <140/90 to maintain
cerebral perfusion and prevent syncopal falls.
Q6: A 68-year-old patient with type 2 diabetes has an HbA1c of 8.2%. The patient has multiple
chronic conditions, moderate cognitive impairment, and requires assistance with two ADLs.
Which statement represents the MOST APPROPRIATE 2026 clinical standard for this patient's
glycemic management? A) The HbA1c must be aggressively lowered to <7.0% using insulin
therapy to prevent microvascular complications. B) The current HbA1c is acceptable; goals
should focus on avoiding hypoglycemia and symptomatic hyperglycemia. C) The patient should
be placed on a sliding-scale insulin regimen to tightly control postprandial glucose spikes. D)
The patient must immediately begin a severe caloric restriction diet to reverse the diabetes
progression.
● The Answer: B (The current HbA1c is acceptable; goals should focus on avoiding
hypoglycemia and symptomatic hyperglycemia.)
● Distractor Analysis:
○ A is incorrect: Strict targets (<7.0%) in complex elders drastically increase the risk
of fatal hypoglycemic events.
○ C is incorrect: Sliding-scale insulin in the outpatient geriatric setting is a Beers
Criteria violation.
○ D is incorrect: Severe caloric restriction in a frail elder precipitates muscle wasting
(sarcopenia) and malnutrition.
The Mentor's Analysis: The 2026 ADA guidelines explicitly stratify older adults. For those with
complex health and functional limitations, the time frame of benefit for strict control outlasts their
life expectancy. Professional Intuition: In frail elders with diabetes, hypoglycemia kills today;
hyperglycemia kills in ten years. Protect them today.
Q7: A 75-year-old male complains of bilateral knee pain from osteoarthritis. He has a history of
a GI bleed two years ago and stage 3 chronic kidney disease (CKD). Which pharmacologic
intervention is the FIRST-LINE recommendation for his pain? A) Scheduled oral ibuprofen 600
mg every 6 hours. B) An oral COX-2 selective inhibitor (e.g., celecoxib) combined with a proton
pump inhibitor. C) Topical diclofenac gel applied to the knees, alongside physical therapy. D) A
low-dose oral opioid such as tramadol.
● The Answer: C (Topical diclofenac gel applied to the knees, alongside physical therapy.)
● Distractor Analysis:
○ A is incorrect: Systemic NSAIDs are strictly contraindicated in patients with a history
of GI bleeds and CKD due to the risk of perforation and renal failure.
