Facts read from aanpcert.org and 2 more · last checked Nov 7, 2026
Older adults account for 30% (40 of 135 scored items), more than any other age band on the blueprint. The questions test medication safety, cognition, function and falls, and the way familiar diseases look different after 65.
Practice questions
60 questions written to the FNP-C outline; each choice is explained once you pick.
Pain in dementia: when self-report fails, scheduled analgesia.
Rights and safety: decision-making capacity, elder mistreatment and reporting.
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15 questions on older adults
0 / 15 answered15 questions
Tap an option: why each one is right or wrong appears under it.
Older adults
An 82-year-old woman with moderate dementia is brought in by her son, who manages her money. She has bruises on both inner upper arms, a stage 3 sacral pressure injury, and has lost 8% of her weight. The son says she 'bruises easily' and refuses a home health referral. Which is the most appropriate action?
Reporting suspected elder abuse does not require the patient's consent, and she may lack capacity because of moderate dementia.
Bruising on the inner upper arms, a neglected stage 3 pressure injury, weight loss, a financially controlling caregiver, and refusal of help are reasonable suspicion of abuse and neglect, and NPs are mandated reporters to Adult Protective Services.
Waiting a month after discussing it with the suspected abuser leaves her at risk and may lead to more harm or concealment.
The pressure injury does need wound care, but arranging it and waiting 2 weeks without a report leaves her in the setting that caused the injuries; reasonable suspicion calls for a report now.
A 78-year-old community-dwelling woman is seen for a wellness visit. She has mild osteoarthritis and takes several medications. Which approach is most appropriate to screen her for fall risk?
Imaging is not a fall-risk screening tool; it is ordered for focal neurologic findings.
Asking about falls is the first step, but stopping there misses gait and balance problems in people who have not fallen yet.
CDC STEADI pairs questions about falls, unsteadiness, and fear of falling with an observed gait and balance test such as the Timed Up and Go to identify who needs intervention.
A home-safety checklist addresses environmental hazards but does not measure her gait, strength, or balance.
An 86-year-old nursing-home resident with advanced Alzheimer disease grimaces and moans when repositioned after a fall 2 days ago. She speaks only a few words and cannot follow commands. Which method is most appropriate to assess her pain?
PAINAD scores breathing, vocalization, facial expression, body language, and consolability, so it measures pain in advanced dementia when self-report is not possible.
The FACES scale still needs the patient to understand the task and choose a face, which advanced dementia prevents.
Heart rate and blood pressure change for many reasons and are unreliable as pain indicators in chronic or dementia-related pain.
A 0–10 numeric scale needs understanding and verbal reporting, which she has lost.
A 78-year-old woman's daughter reports that her mother has repeated questions and missed bills for 6 months. On the Mini-Cog, she recalls 1 of 3 words and her clock drawing is abnormal. What is the most appropriate next step?
Starting donepezil before the diagnosis is established skips the workup for reversible causes and the dementia type.
A positive Mini-Cog calls for a fuller cognitive test such as MoCA plus labs for reversible contributors such as B12 deficiency and hypothyroidism.
Amyloid PET is a specialist test used when the diagnosis is uncertain or anti-amyloid therapy is being considered, not as the next step after a screen.
Repeated questions and missed bills for months, with a positive Mini-Cog, are not normal aging and need evaluation.
A 74-year-old man was fitted with bilateral hearing aids 1 month ago for presbycusis. He reports that both devices now whistle constantly and that his hearing seems worse than at the fitting. Otoscopy shows both ear canals occluded by hard cerumen. What is the most appropriate next step?
Reprogramming does not fix feedback caused by wax, and it adds a visit before the simple cause is treated.
MRI of the internal auditory canals is for asymmetric or sudden sensorineural loss; occluding cerumen explains both symptoms.
Cerumen blocking the canals reflects sound back into the microphone (feedback whistle) and muffles hearing; removing it and rechecking the aids comes first.
Audiometry for presumed progression is premature when the canals are blocked; the result would be falsely worse.
An 82-year-old man with moderate Alzheimer dementia paces and becomes verbally agitated each evening. Pain, infection, constipation, urinary retention, and delirium have been excluded, and he is not a danger to himself or others. Which is the most appropriate initial management?
Antipsychotics carry a boxed warning for increased mortality in dementia and are reserved for severe, dangerous symptoms after nondrug measures fail.
Zolpidem increases falls, fractures, and confusion in older adults and does not address evening agitation.
Benzodiazepines increase falls, confusion, and paradoxical agitation in older adults with dementia (Beers criteria).
Once medical causes are excluded, evening agitation in dementia is first managed with nondrug measures: a structured routine, daytime activity, light exposure, and caregiver training.
A 74-year-old woman has 18 months of steadily worsening memory for recent events, repeated questions, and trouble managing her bills. Gait, continence, and the neurologic exam are normal, and B12 and TSH are normal. MoCA is 19/30. Which brain MRI finding is most consistent with the likely diagnosis?
Frontal and anterior temporal atrophy fits frontotemporal dementia, which starts with behavior or language change rather than memory loss.
Multiple lacunar infarcts point to small-vessel cerebrovascular disease, which brings a stepwise course or focal signs rather than steady memory loss.
Ventricles enlarged out of proportion to sulci suggest normal pressure hydrocephalus, which presents with gait disturbance and incontinence early.
Gradual loss of recent memory with normal gait and continence is typical of Alzheimer disease, which shows bilateral hippocampal (medial temporal) atrophy.
A 76-year-old man with diabetes, hypertension, and atrial fibrillation has declining cognition over 2 years. His wife describes sudden worsening after each of two hospital stays for 'small strokes', with stable periods between. He is slow and apathetic, with a shuffling gait and brisk reflexes on the right. MRI shows extensive white matter lesions and multiple lacunes. What is the most likely diagnosis?
Stepwise decline after strokes, slowing, a shuffling gait, focal signs, and extensive white matter disease with lacunes are characteristic of vascular dementia.
Alzheimer disease causes a gradual, steady decline that begins with memory, not stepwise worsening after strokes.
NPH causes a magnetic gait, urinary incontinence, and ventriculomegaly, not stepwise decline with lacunes.
Lewy body dementia features fluctuating attention, visual hallucinations, and parkinsonism, with no link to strokes.
An 82-year-old woman with mild cognitive impairment takes 12 medications including several with anticholinergic properties. Her daughter reports the patient is increasingly confused and has had two recent falls. The patient states she wants to reduce her pill burden but is afraid of her symptoms getting worse. Which approach best incorporates shared decision-making in deprescribing?
Mild cognitive impairment does not remove her right to take part in decisions; she has stated her own goals.
Keeping all 12 drugs despite confusion and falls ignores harm from anticholinergic burden; her fear is addressed by a gradual plan, not by inaction.
Shared deprescribing sets priorities with the patient and family, addresses her fear, and tapers one drug at a time so effects can be monitored.
Stopping several drugs at once risks withdrawal and makes it impossible to tell which change caused a new symptom.
An 84-year-old man with BPH and chronic constipation has had small-volume urine leakage day and night for 2 weeks and feels that his bladder never empties. Urinalysis is normal. Which is the most appropriate next step?
An antimuscarinic for presumed urge incontinence can worsen retention and cause acute urinary retention when the real problem is overflow.
Pads manage leakage but leave possible retention, which can damage the kidneys, unevaluated for months.
Dribbling day and night with a sense of incomplete emptying in a man with BPH and constipation suggests overflow incontinence from retention; a bladder scan for post-void residual confirms it before any drug is chosen.
Urodynamics is a specialist test for unclear or refractory cases; a simple post-void residual answers the first question.
A 72-year-old woman has had burning, lancinating pain over a left thoracic dermatome for 4 months since a shingles rash healed. Light touch from clothing is painful. She has mild chronic kidney disease (eGFR 55 mL/min/1.73 m²) and a history of falls. Which is the most appropriate oral medication?
Gabapentin is first-line oral therapy for postherpetic neuralgia; with reduced kidney function it is dosed for eGFR and titrated slowly to limit dizziness and falls.
Antivirals shorten acute zoster but do nothing for established postherpetic neuralgia 4 months later.
Amitriptyline works for neuropathic pain, but its anticholinergic and sedating effects make it a drug to avoid in an older adult with falls (Beers criteria).
Opioids are not first-line for postherpetic neuralgia and add sedation and fall risk.
An 84-year-old woman with advanced dementia and hip osteoarthritis lives in a nursing home. For 1 week she has been moaning, grimacing, and resisting staff during bathing and transfers. She cannot describe pain. There is no fever, and urinalysis is normal. Which is the most appropriate initial management?
Haloperidol treats the behavior rather than the pain and carries the antipsychotic mortality warning in dementia.
Diphenhydramine is strongly anticholinergic and worsens confusion in dementia (Beers criteria).
Lorazepam sedates without treating pain and increases falls and confusion.
Moaning, grimacing, and resisting care during movement in someone with hip osteoarthritis suggests untreated pain; a scheduled acetaminophen trial treats the likely cause and tests that explanation.
An 86-year-old nursing-home resident who takes oxycodone for hip pain has had small amounts of liquid stool leaking several times a day for 4 days. She has no fever, and her abdomen is mildly distended. Rectal examination finds a large mass of hard stool. What is the most likely cause of her diarrhea?
Ischemic colitis causes sudden crampy pain and bloody diarrhea, not small-volume leakage around retained stool.
Liquid stool seeping around a mass of hard stool in an older adult on an opioid is overflow from fecal impaction; disimpaction and a bowel regimen treat it, and antidiarrheals would make it worse.
C. difficile causes frequent watery diarrhea, often with fever or leukocytosis after antibiotics; a rectum packed with hard stool points to impaction instead.
IBS is a chronic disorder that starts in younger adults; a new change at 86 with a hard stool mass is not IBS.
An 80-year-old man reports lightheadedness when he gets out of bed and has fallen once this month. He takes tamsulosin and hydrochlorothiazide. Which technique best assesses him for orthostatic hypotension?
Without a baseline after lying down, the drop on standing cannot be measured.
Orthostatic hypotension is a fall of 20 mm Hg systolic or 10 mm Hg diastolic within 3 minutes of standing after lying down for about 5 minutes; checking the pulse also shows whether the heart rate rises to compensate.
A seated reading does not test the change on standing, and comparing with old readings ignores the posture change that causes his symptoms.
Comparing arms looks for subclavian stenosis or aortic disease, not a posture-related drop.
A running total sits here; it fills in after your last pick.
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Delirium, dementia and depression side by side
Delirium: acute onset with a fluctuating course and inattention, plus either disorganized thinking or an altered level of consciousness. That is the Confusion Assessment Method's algorithm, and delirium is a medical emergency until its cause is found.
Dementia: gradual, progressive decline; attention is usually preserved early.
Depression: can look like cognitive decline in an older adult. Treatment beyond first-line primary care is on PMHNP-BC diagnosis and treatment.
A patient with dementia can also develop delirium, so a sudden change in someone with known dementia is not “the dementia getting worse” until other causes are excluded.
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Prescribing traps in the Beers era
First-generation antihistamines. Diphenhydramine and hydroxyzine are strongly anticholinergic, and Beers 2023 lists them to avoid, sleep aids included.
Benzodiazepines and Z-drugs. Avoided for insomnia and agitation because of falls, fractures and cognitive impairment.
Sulfonylureas. Beers 2023 now flags every sulfonylurea, not only the long-acting ones, as a poor first or second choice; when one cannot be avoided, prefer short action to long.
PPIs beyond 8 weeks without a clear indication.
Sliding-scale insulin alone, without basal insulin.
Treating bacteriuria because of confusion. IDSA 2019 advises looking for other causes of delirium, not treating asymptomatic bacteriuria, in an older adult without urinary symptoms or systemic signs.
Beers is a list of medicines to use with caution, not a ban, and it does not apply to hospice and palliative care.
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Older-adult topics on other pages
Aspirin for primary prevention and screening stop ages:adult screening.
Parkinson disease, normal pressure hydrocephalus, stroke:adult neurology.
Among other changes, the warning on sulfonylureas now covers the whole class, warfarin is avoided as a first choice for atrial fibrillation or venous thromboembolism unless direct oral anticoagulants are unsuitable, and aspirin for primary prevention is to be avoided.
Which delirium tool is worth knowing by name?
The Confusion Assessment Method. Its four features, and the rule for combining them, are in the delirium section above.