APEA (Psych) 1
A 76 year-old depressed patient is started on an SSRI. When should another antidepressant be
tried if there is no response? - ANS-A 76 year-old depressed patient is started on an SSRI.
When should another antidepressant be tried if there is no response?
Parkinson's disease
Diseases associated with the central nervous system are associated with high rates of
depression. These include stroke, Parkinson's disease, multiple sclerosis, and dementia. Other
illnesses associated with high rates of depression are cancer and cardiovascular illnesses like
myocardial infarction. Depression worsens the outcome of any physical illness. - ANS-Which
patient is most likely to exhibit depression related to his illness? A patient with:
Anxiety disorders
Affective disorders, anxiety disorders, and substance abuse issues are common in patients who
have eating disorders. Obsessive-compulsive disorder is also commonly observed. Patients with
eating disorders are more likely to have a first or second degree relative with an eating disorder,
affective disorder, or alcohol abuse. There is no evidence that patients with eating disorders
exhibit a higher incidence of sleep disorders or liver disease. Thyroid disease should always be
assessed in patients with eating disorders, but this does not represent the reason for weight
loss when eating disorder is present. - ANS-A patient with an eating disorder may
concomitantly exhibit:
Impairment of executive function
The diagnostic criteria for Alzheimer's disease (AD) was established by DSM V and other
organizations. The criteria are similar. Criteria include a gradual onset of cognitive decline. A
rapid onset usually indicates another etiology, perhaps, delirium. Other criteria include
impairment of recent memory, difficulty with language or finding words, the inability to execute
skilled motor activities, disturbances of visual processing or disturbances in executive function
that includes abstract reasoning and concentration. Focal neurologic signs are consistent with a
vascular dementia. Radiologic evidence is not a criterion for diagnosis, though it may support
the diagnosis of AD. There is no laboratory evidence of AD. - ANS-Which criterion below is a
criterion for Alzheimer's Disease?
Next day sleepiness
Diphenhydramine should be avoided in older adults. Diphenhydramine exhibits potent
anti-cholinergic effects in patients who take this, but especially in older adults. Urinary retention
,is common (not incontinence) in older men with benign prostatic hyperplasia, but retention
occurs in women too. Diphenhydramine is contraindicated in patients with glaucoma. The most
serious side effect is cognitive impairment, like daytime sleepiness. Visual disturbances can
occur as well as annoying side effects like dry mouth and constipation. - ANS-An 80 year old
adult has begun to use over the counter diphenhydramine to help him fall asleep. What common
side effect can occur in older adults with use of this medication?
Depression
Anhedonia is the loss of pleasure or interest in things that have always brought pleasure or
interest. If this is the case, this patient should be screened for depression. Anhedonia is a red
flag for depression. - ANS-A 69 year-old female patient reports feelings of anhedonia for the
last month. What should be part of the nurse practitioner's assessment?
Alcohol abuse
This patient has an elevated mean corpuscular volume. This indicates a macrocytic anemia.
Common macrocytic anemias are B12 deficiency and folate deficiency. These are common in
older patients, especially if they consume large quantities of alcohol. This patient also has
elevated triglycerides. Triglycerides are commonly elevated when patients are exposed to
alcohol and carbohydrates. This patient's history indicates two elements that indicate alcohol
abuse. He should be questioned regarding alcohol abuse. - ANS-A 70 year-old male patient
has an elevated MCV with an anemia. His triglycerides are 420. What should be suspected?
Early morning wakening
Sleep difficulty is a common complaint among patients with depression. Patients with difficulty
falling asleep are often anxious. Frequent waking and early morning wakening are often
complaints by patients with depression. There is no agreed on physiologic explanation, but, this
is a common symptom. - ANS-Which symptom listed below is typical of depression?
often develops acutely
Delirium is a change in consciousness or cognition. It may be accompanied by a physical
diagnosis like urinary tract infection; or it may be due to consumption of a medication.
Regardless, a change in cognition or consciousness needs immediate evaluation. The
evaluation should include a medication review, physical exam and laboratory evaluation, and
mental status exam. - ANS-Delirium differs from dementia because delirium:
CAGE
CAGE is a screen for alcohol abuse that is validated in adults and older adults. The C stands for
"have you ever felt you should CUT down" your alcohol consumption. The A stands for " does
other's criticism of your drinking ANNOY you". G stands for "have you ever felt GUILTY about
, drinking". The E stands for "have you ever had an EYE opener to steady your nerves or get rid
of a hangover". A positive response on any question constitutes a positive screen. - ANS-Which
screen for alcohol abuse has been validated in the elderly?
dementia
The mini mental status exam (MMSE) is a very common and easily administered cognitive
evaluation for dementia. It tests orientation, recall, attention, calculation, language manipulation,
and constructional praxis. It is not sensitive for mild dementia and may be influenced by
educational level and age. Even with these limitations, the MMSE is the most widely used
cognitive test for dementia in the US. - ANS-MMSE helps to identify patients with symptoms of:
Weight below 90% of ideal body weight
Weight below 85% of ideal body weight is the correct criterion. This involves refusal to gain or
maintain weight within normal range. Occasionally weight below ideal body range does not
involve losing weight, but instead involves refusal to gain weight during a growth spurt. This is
commonly observed during pubertal growth spurts and is more common in adolescent females
than males. The other three criteria are correct as listed. - ANS-An adolescent female patient
with anorexia nervosa must exhibit 4 criteria for diagnosis. Which criterion listed below is NOT
part of the diagnostic criteria?
High dose SSRIs are used to treat this
The medications of choice to treat bulimia nervosa are the SSRIs. Generally, high doses are
required. Wellbutrin is not an SSRI and should not be given to patients with eating disorders
because of great fluctuations in drug levels related to purging. Generally, this is more common
in women than men. Loss of control IS a characteristic of this illness. - ANS-Which statement
about bulimia nervosa is accurate?
anxiety
Anxiety is very common in older adults. Depression is very common too, and may accompany
anxiety in older adults. The prevalence of anxiety may be due in part to other physical illnesses
or serious diseases or disorders, like cancer, Parkinson's disease. New onset anxiety should
prompt the examiner to consider withdrawal of medication or side effects of medication being
taken at therapeutic levels. - ANS-The most common mental disorder in older adults is:
Amenorrhea
This patient has anorexia nervosa. She is far below ideal body weight and exhibits evidence of
poor nutrition and health. More than 90% of patients with anorexia are amenorrheic. These
patients have low levels of leuteinizing hormone and follicle stimulating hormone. Because of
prolonged hypoestrogenic states, they are highly susceptible to osteopenia and osteoporosis. It
A 76 year-old depressed patient is started on an SSRI. When should another antidepressant be
tried if there is no response? - ANS-A 76 year-old depressed patient is started on an SSRI.
When should another antidepressant be tried if there is no response?
Parkinson's disease
Diseases associated with the central nervous system are associated with high rates of
depression. These include stroke, Parkinson's disease, multiple sclerosis, and dementia. Other
illnesses associated with high rates of depression are cancer and cardiovascular illnesses like
myocardial infarction. Depression worsens the outcome of any physical illness. - ANS-Which
patient is most likely to exhibit depression related to his illness? A patient with:
Anxiety disorders
Affective disorders, anxiety disorders, and substance abuse issues are common in patients who
have eating disorders. Obsessive-compulsive disorder is also commonly observed. Patients with
eating disorders are more likely to have a first or second degree relative with an eating disorder,
affective disorder, or alcohol abuse. There is no evidence that patients with eating disorders
exhibit a higher incidence of sleep disorders or liver disease. Thyroid disease should always be
assessed in patients with eating disorders, but this does not represent the reason for weight
loss when eating disorder is present. - ANS-A patient with an eating disorder may
concomitantly exhibit:
Impairment of executive function
The diagnostic criteria for Alzheimer's disease (AD) was established by DSM V and other
organizations. The criteria are similar. Criteria include a gradual onset of cognitive decline. A
rapid onset usually indicates another etiology, perhaps, delirium. Other criteria include
impairment of recent memory, difficulty with language or finding words, the inability to execute
skilled motor activities, disturbances of visual processing or disturbances in executive function
that includes abstract reasoning and concentration. Focal neurologic signs are consistent with a
vascular dementia. Radiologic evidence is not a criterion for diagnosis, though it may support
the diagnosis of AD. There is no laboratory evidence of AD. - ANS-Which criterion below is a
criterion for Alzheimer's Disease?
Next day sleepiness
Diphenhydramine should be avoided in older adults. Diphenhydramine exhibits potent
anti-cholinergic effects in patients who take this, but especially in older adults. Urinary retention
,is common (not incontinence) in older men with benign prostatic hyperplasia, but retention
occurs in women too. Diphenhydramine is contraindicated in patients with glaucoma. The most
serious side effect is cognitive impairment, like daytime sleepiness. Visual disturbances can
occur as well as annoying side effects like dry mouth and constipation. - ANS-An 80 year old
adult has begun to use over the counter diphenhydramine to help him fall asleep. What common
side effect can occur in older adults with use of this medication?
Depression
Anhedonia is the loss of pleasure or interest in things that have always brought pleasure or
interest. If this is the case, this patient should be screened for depression. Anhedonia is a red
flag for depression. - ANS-A 69 year-old female patient reports feelings of anhedonia for the
last month. What should be part of the nurse practitioner's assessment?
Alcohol abuse
This patient has an elevated mean corpuscular volume. This indicates a macrocytic anemia.
Common macrocytic anemias are B12 deficiency and folate deficiency. These are common in
older patients, especially if they consume large quantities of alcohol. This patient also has
elevated triglycerides. Triglycerides are commonly elevated when patients are exposed to
alcohol and carbohydrates. This patient's history indicates two elements that indicate alcohol
abuse. He should be questioned regarding alcohol abuse. - ANS-A 70 year-old male patient
has an elevated MCV with an anemia. His triglycerides are 420. What should be suspected?
Early morning wakening
Sleep difficulty is a common complaint among patients with depression. Patients with difficulty
falling asleep are often anxious. Frequent waking and early morning wakening are often
complaints by patients with depression. There is no agreed on physiologic explanation, but, this
is a common symptom. - ANS-Which symptom listed below is typical of depression?
often develops acutely
Delirium is a change in consciousness or cognition. It may be accompanied by a physical
diagnosis like urinary tract infection; or it may be due to consumption of a medication.
Regardless, a change in cognition or consciousness needs immediate evaluation. The
evaluation should include a medication review, physical exam and laboratory evaluation, and
mental status exam. - ANS-Delirium differs from dementia because delirium:
CAGE
CAGE is a screen for alcohol abuse that is validated in adults and older adults. The C stands for
"have you ever felt you should CUT down" your alcohol consumption. The A stands for " does
other's criticism of your drinking ANNOY you". G stands for "have you ever felt GUILTY about
, drinking". The E stands for "have you ever had an EYE opener to steady your nerves or get rid
of a hangover". A positive response on any question constitutes a positive screen. - ANS-Which
screen for alcohol abuse has been validated in the elderly?
dementia
The mini mental status exam (MMSE) is a very common and easily administered cognitive
evaluation for dementia. It tests orientation, recall, attention, calculation, language manipulation,
and constructional praxis. It is not sensitive for mild dementia and may be influenced by
educational level and age. Even with these limitations, the MMSE is the most widely used
cognitive test for dementia in the US. - ANS-MMSE helps to identify patients with symptoms of:
Weight below 90% of ideal body weight
Weight below 85% of ideal body weight is the correct criterion. This involves refusal to gain or
maintain weight within normal range. Occasionally weight below ideal body range does not
involve losing weight, but instead involves refusal to gain weight during a growth spurt. This is
commonly observed during pubertal growth spurts and is more common in adolescent females
than males. The other three criteria are correct as listed. - ANS-An adolescent female patient
with anorexia nervosa must exhibit 4 criteria for diagnosis. Which criterion listed below is NOT
part of the diagnostic criteria?
High dose SSRIs are used to treat this
The medications of choice to treat bulimia nervosa are the SSRIs. Generally, high doses are
required. Wellbutrin is not an SSRI and should not be given to patients with eating disorders
because of great fluctuations in drug levels related to purging. Generally, this is more common
in women than men. Loss of control IS a characteristic of this illness. - ANS-Which statement
about bulimia nervosa is accurate?
anxiety
Anxiety is very common in older adults. Depression is very common too, and may accompany
anxiety in older adults. The prevalence of anxiety may be due in part to other physical illnesses
or serious diseases or disorders, like cancer, Parkinson's disease. New onset anxiety should
prompt the examiner to consider withdrawal of medication or side effects of medication being
taken at therapeutic levels. - ANS-The most common mental disorder in older adults is:
Amenorrhea
This patient has anorexia nervosa. She is far below ideal body weight and exhibits evidence of
poor nutrition and health. More than 90% of patients with anorexia are amenorrheic. These
patients have low levels of leuteinizing hormone and follicle stimulating hormone. Because of
prolonged hypoestrogenic states, they are highly susceptible to osteopenia and osteoporosis. It
