NRNP 6540 Midterm Exam
1. Cardiovascular - Cardiovascular disease (CVD) remains the leading cause of morbidity and mor-
Disorders in tality in older adults.
Older Adults - Aging leads to structural and functional changes in the cardiovascular system
Overview & (e.g. increased arterial stiffness, left ventricular hypertrophy, endothelial dysfunc-
Epidemiology tion) that predispose to disease states.
- Comorbid conditions (hypertension, diabetes, chronic kidney disease, dyslipi-
demia) are common and influence presentation and management.
2. Age-Related Car- - Arterial stiffening: Loss of vascular elasticity; increased systolic blood pressure
diac and Vascular and pulse pressure.
Changes - Left ventricular changes: Increased left ventricular wall thickness, diastolic dys-
function due to stiff ventricles.
- Conduction system: More fibrosis, conduction delays, increased prevalence of
arrhythmias (e.g. atrial fibrillation, heart block).
- Baroreceptor and autonomic changes: Decreased baroreceptor sensitivity, al-
tered autonomic regulation, blunted heart rate response.
These changes mean older adults may manifest cardiovascular diseases different-
ly than younger patients, often with atypical or subtle symptoms.
3. Hypertension - Hypertension is widespread in older adults and a major modifiable risk factor
and for CVD, stroke, HF.
Management in - Treatment goals must balance benefit with risks (e.g. orthostatic hypotension,
Older Adults renal function).
- First-line therapies often include thiazide diuretics, ACE inhibitors/ARBs, calcium
channel blockers, or combination therapy.
- Monitor for side effects (electrolyte disturbances, renal impairment).
4. Ischemic Heart - Presentation in older adults may be atypical: fatigue, dyspnea, confusion, syn-
Disease, Coro- cope, or functional decline instead of classic chest pain.
nary Artery Dis- - Diagnostic challenges: baseline ECG changes, comorbidities, polypharmacy.
ease (CAD) - Management aligns with guideline-based therapy (antiplatelet therapy, statins,
, NRNP 6540 Midterm Exam
beta blockers, revascularization) but must be individualized considering frailty,
bleeding risk, life expectancy.
5. Heart Failure (HF) - HF with preserved ejection fraction (HFpEF) is more common in older adults;
in Older Adults reduced EF still occurs.
- Symptoms: fatigue, exertional dyspnea, fluid retention (edema, pulmonary
congestion).
- Diagnosis relies on history, physical exam, biomarkers (BNP/NT-proBNP),
echocardiography.
- Treatment: diuretics for volume control; guideline-directed medical therapy
(GDMT) including ACEi/ARB/ARNI, beta blockers, mineralocorticoid receptor an-
tagonists, and newer agents (e.g. SGLT2 inhibitors) as tolerated and indicated.
6. Valvular Heart - Prevalent in older adults due to degenerative changes (e.g. calcific aortic steno-
Disease sis, degenerative mitral regurgitation).
- Aortic stenosis is a common and serious valve disease in elders — progressive,
may require surgical or transcatheter intervention (TAVR) when severe and symp-
tomatic.
- Mitral and tricuspid lesions likewise require evaluation; decisions on repair vs
replacement depend on symptoms, risk, and comorbidities.
7. Peripheral Vascu- - Peripheral arterial disease (PAD) is common and underdiagnosed in older
lar Disease & Ath- adults.
erosclerosis - Clinical features: intermittent claudication, rest pain, nonhealing ulcers, de-
creased peripheral pulses.
- Diagnosis primarily via ankle-brachial index (ABI) and imaging.
- Management: risk factor control, antiplatelet therapy, supervised exercise, revas-
cularization if needed.
8. Arrhythmias and - Atrial fibrillation (AFib) is highly prevalent and increases stroke risk.
Conduction Dis- - In older adults, rate vs rhythm control decisions must consider comorbidities,
orders stroke and bleeding risk (use CHA₂DS₂-VASc, HAS-BLED).
, NRNP 6540 Midterm Exam
- Other conduction issues: heart block, sick sinus syndrome. May require pace-
maker implantation after evaluation.
9. Acute Coronary - Presentation often subtle. High index of suspicion is needed.
Syndromes and - Management must weigh benefits of invasive strategies vs risks (bleeding, renal
MI in Older injury).
Adults - Use of dual antiplatelet therapy, statins, ACEi/ARB, and cardiac rehabilitation is
still standard but must be tailored.
10. Cardiovascular - Prevention is key: control of hypertension, dyslipidemia, diabetes, smoking
Preventive cessation, diet, exercise, weight management.
Strategies & Risk - Use of risk calculators (e.g. ASCVD risk) must be adapted given life expectancy
Reduction and competing risks.
- Shared decision-making is essential: consider functional status, frailty, patient
goals, and risks vs benefits of interventions in older adults.
11. Cardiovascular - Frailty & Comorbidity: Frail patients may not tolerate aggressive interventions;
Special functional status, cognitive status, social support must inform decisions.
Considerations - Polypharmacy & drug interactions: Be cautious with cardiovascular medica-
in Older Adults tions (especially anticoagulants, antiarrhythmics) in the context of renal/hepatic
changes.
- Renal function & contrast use: Many cardiovascular procedures use contrast; old-
er adults often have reduced renal reserve — need assessment and mitigation.
- Shared decision making & goals of care: Always weigh life expectancy, quality of
life, patient preferences; palliative options may be appropriate.
12. Peripheral Vas- - Peripheral vascular disorders (PVD) encompass peripheral arterial disease
cular Disorders: (PAD), venous insufficiency, arterial ulcers, venous ulcers, and lymphedema/ve-
Scope & Impor- nous edema.
tance in Older - These conditions are common in older adults and contribute to morbidity (pain,
Adults mobility limitation, risk of ulceration/infection, impaired quality of life).
- Aging changes (arterial stiffness, endothelial dysfunction, reduced collateral
circulation) predispose to PVD.
, NRNP 6540 Midterm Exam
13. PVD Risk Factors Risk factors: age, smoking, diabetes mellitus, hypertension, hyperlipidemia,
& Pathophysiolo- chronic kidney disease, obesity, sedentary lifestyle.
gy Pathophysiology (arterial side): atherosclerosis narrowing arterial lumens ’is-
chemia in distal tissues; reduced perfusion under stress (walking) leads to clau-
dication, resting pain, ulceration.
Venous side: incompetent valves, venous hypertension, stasis ’chronic venous
insufficiency, edema, skin changes, ulceration.
14. PVD Clinical Pre- Arterial disease (PAD)- Symptoms: intermittent claudication (pain with exertion re-
sentation & As- lieved by rest), rest pain (especially forefoot/night), nonhealing ulcers, coldness,
sessment pallor, decreased hair/nail growth.- Signs: diminished or absent pulses, delayed
capillary refill, bruit, skin changes (shiny, hairless, thinned skin).
Venous insufficiency- Symptoms: leg heaviness, aching, edema (often worse by
day's end), skin pigmentation, stasis dermatitis, ulceration (medial malleolus
common).
Ulcers- Arterial ulcers: painful, punched out, at distal sites (toes, feet).- Venous
ulcers: less painful, irregular borders, located at gaiter area (ankle).
Edema / lymphedema- Distinguish pitting vs nonpitting, chronicity, bilateral vs
unilateral.
15. PVD Diagnostic Ankle-Brachial Index (ABI): ratio of ankle to brachial systolic pressures. ABI d0.90
Evaluation suggests PAD; d0.40 indicates severe disease.
Segmental pressures / Doppler studies: to localize level of obstruction.
Duplex ultrasonography, CT/MR angiography, contrast angiography: for more
precise mapping and planning of interventions.
For venous disease: venous duplex ultrasound, venography if needed.
Evaluate wound culture, infection, and comorbidities (diabetes, renal disease) in
ulcer assessments.
16. PVD Manage- Risk factor modification: smoking cessation, glycemic control, blood pressure
ment Principles control, lipid-lowering therapy.
& Treatment Pharmacotherapy (PAD): antiplatelet therapy, statins, cilostazol (for claudication in
1. Cardiovascular - Cardiovascular disease (CVD) remains the leading cause of morbidity and mor-
Disorders in tality in older adults.
Older Adults - Aging leads to structural and functional changes in the cardiovascular system
Overview & (e.g. increased arterial stiffness, left ventricular hypertrophy, endothelial dysfunc-
Epidemiology tion) that predispose to disease states.
- Comorbid conditions (hypertension, diabetes, chronic kidney disease, dyslipi-
demia) are common and influence presentation and management.
2. Age-Related Car- - Arterial stiffening: Loss of vascular elasticity; increased systolic blood pressure
diac and Vascular and pulse pressure.
Changes - Left ventricular changes: Increased left ventricular wall thickness, diastolic dys-
function due to stiff ventricles.
- Conduction system: More fibrosis, conduction delays, increased prevalence of
arrhythmias (e.g. atrial fibrillation, heart block).
- Baroreceptor and autonomic changes: Decreased baroreceptor sensitivity, al-
tered autonomic regulation, blunted heart rate response.
These changes mean older adults may manifest cardiovascular diseases different-
ly than younger patients, often with atypical or subtle symptoms.
3. Hypertension - Hypertension is widespread in older adults and a major modifiable risk factor
and for CVD, stroke, HF.
Management in - Treatment goals must balance benefit with risks (e.g. orthostatic hypotension,
Older Adults renal function).
- First-line therapies often include thiazide diuretics, ACE inhibitors/ARBs, calcium
channel blockers, or combination therapy.
- Monitor for side effects (electrolyte disturbances, renal impairment).
4. Ischemic Heart - Presentation in older adults may be atypical: fatigue, dyspnea, confusion, syn-
Disease, Coro- cope, or functional decline instead of classic chest pain.
nary Artery Dis- - Diagnostic challenges: baseline ECG changes, comorbidities, polypharmacy.
ease (CAD) - Management aligns with guideline-based therapy (antiplatelet therapy, statins,
, NRNP 6540 Midterm Exam
beta blockers, revascularization) but must be individualized considering frailty,
bleeding risk, life expectancy.
5. Heart Failure (HF) - HF with preserved ejection fraction (HFpEF) is more common in older adults;
in Older Adults reduced EF still occurs.
- Symptoms: fatigue, exertional dyspnea, fluid retention (edema, pulmonary
congestion).
- Diagnosis relies on history, physical exam, biomarkers (BNP/NT-proBNP),
echocardiography.
- Treatment: diuretics for volume control; guideline-directed medical therapy
(GDMT) including ACEi/ARB/ARNI, beta blockers, mineralocorticoid receptor an-
tagonists, and newer agents (e.g. SGLT2 inhibitors) as tolerated and indicated.
6. Valvular Heart - Prevalent in older adults due to degenerative changes (e.g. calcific aortic steno-
Disease sis, degenerative mitral regurgitation).
- Aortic stenosis is a common and serious valve disease in elders — progressive,
may require surgical or transcatheter intervention (TAVR) when severe and symp-
tomatic.
- Mitral and tricuspid lesions likewise require evaluation; decisions on repair vs
replacement depend on symptoms, risk, and comorbidities.
7. Peripheral Vascu- - Peripheral arterial disease (PAD) is common and underdiagnosed in older
lar Disease & Ath- adults.
erosclerosis - Clinical features: intermittent claudication, rest pain, nonhealing ulcers, de-
creased peripheral pulses.
- Diagnosis primarily via ankle-brachial index (ABI) and imaging.
- Management: risk factor control, antiplatelet therapy, supervised exercise, revas-
cularization if needed.
8. Arrhythmias and - Atrial fibrillation (AFib) is highly prevalent and increases stroke risk.
Conduction Dis- - In older adults, rate vs rhythm control decisions must consider comorbidities,
orders stroke and bleeding risk (use CHA₂DS₂-VASc, HAS-BLED).
, NRNP 6540 Midterm Exam
- Other conduction issues: heart block, sick sinus syndrome. May require pace-
maker implantation after evaluation.
9. Acute Coronary - Presentation often subtle. High index of suspicion is needed.
Syndromes and - Management must weigh benefits of invasive strategies vs risks (bleeding, renal
MI in Older injury).
Adults - Use of dual antiplatelet therapy, statins, ACEi/ARB, and cardiac rehabilitation is
still standard but must be tailored.
10. Cardiovascular - Prevention is key: control of hypertension, dyslipidemia, diabetes, smoking
Preventive cessation, diet, exercise, weight management.
Strategies & Risk - Use of risk calculators (e.g. ASCVD risk) must be adapted given life expectancy
Reduction and competing risks.
- Shared decision-making is essential: consider functional status, frailty, patient
goals, and risks vs benefits of interventions in older adults.
11. Cardiovascular - Frailty & Comorbidity: Frail patients may not tolerate aggressive interventions;
Special functional status, cognitive status, social support must inform decisions.
Considerations - Polypharmacy & drug interactions: Be cautious with cardiovascular medica-
in Older Adults tions (especially anticoagulants, antiarrhythmics) in the context of renal/hepatic
changes.
- Renal function & contrast use: Many cardiovascular procedures use contrast; old-
er adults often have reduced renal reserve — need assessment and mitigation.
- Shared decision making & goals of care: Always weigh life expectancy, quality of
life, patient preferences; palliative options may be appropriate.
12. Peripheral Vas- - Peripheral vascular disorders (PVD) encompass peripheral arterial disease
cular Disorders: (PAD), venous insufficiency, arterial ulcers, venous ulcers, and lymphedema/ve-
Scope & Impor- nous edema.
tance in Older - These conditions are common in older adults and contribute to morbidity (pain,
Adults mobility limitation, risk of ulceration/infection, impaired quality of life).
- Aging changes (arterial stiffness, endothelial dysfunction, reduced collateral
circulation) predispose to PVD.
, NRNP 6540 Midterm Exam
13. PVD Risk Factors Risk factors: age, smoking, diabetes mellitus, hypertension, hyperlipidemia,
& Pathophysiolo- chronic kidney disease, obesity, sedentary lifestyle.
gy Pathophysiology (arterial side): atherosclerosis narrowing arterial lumens ’is-
chemia in distal tissues; reduced perfusion under stress (walking) leads to clau-
dication, resting pain, ulceration.
Venous side: incompetent valves, venous hypertension, stasis ’chronic venous
insufficiency, edema, skin changes, ulceration.
14. PVD Clinical Pre- Arterial disease (PAD)- Symptoms: intermittent claudication (pain with exertion re-
sentation & As- lieved by rest), rest pain (especially forefoot/night), nonhealing ulcers, coldness,
sessment pallor, decreased hair/nail growth.- Signs: diminished or absent pulses, delayed
capillary refill, bruit, skin changes (shiny, hairless, thinned skin).
Venous insufficiency- Symptoms: leg heaviness, aching, edema (often worse by
day's end), skin pigmentation, stasis dermatitis, ulceration (medial malleolus
common).
Ulcers- Arterial ulcers: painful, punched out, at distal sites (toes, feet).- Venous
ulcers: less painful, irregular borders, located at gaiter area (ankle).
Edema / lymphedema- Distinguish pitting vs nonpitting, chronicity, bilateral vs
unilateral.
15. PVD Diagnostic Ankle-Brachial Index (ABI): ratio of ankle to brachial systolic pressures. ABI d0.90
Evaluation suggests PAD; d0.40 indicates severe disease.
Segmental pressures / Doppler studies: to localize level of obstruction.
Duplex ultrasonography, CT/MR angiography, contrast angiography: for more
precise mapping and planning of interventions.
For venous disease: venous duplex ultrasound, venography if needed.
Evaluate wound culture, infection, and comorbidities (diabetes, renal disease) in
ulcer assessments.
16. PVD Manage- Risk factor modification: smoking cessation, glycemic control, blood pressure
ment Principles control, lipid-lowering therapy.
& Treatment Pharmacotherapy (PAD): antiplatelet therapy, statins, cilostazol (for claudication in
