CCP Clinical Care in Long-Term Care 2 — Questions and Answers
Question 1: A 78-year-old LTC resident with stage 3 chronic kidney disease has an eGFR of 28 mL/min. Which antibiotic requires the most significant dose reduction for a urinary tract infection?
- Nitrofurantoin (Correct answer)
- Azithromycin
- Ciprofloxacin
- Doxycycline
Correct answer: Nitrofurantoin
Nitrofurantoin is contraindicated when eGFR <45 mL/min because it fails to achieve adequate urinary concentrations and can cause peripheral neuropathy due to drug accumulation.
Question 2: Which of the following is the MOST appropriate first-line pharmacological treatment for pain management in a non-verbal LTC resident with moderate osteoarthritis pain?
- Scheduled low-dose acetaminophen (Correct answer)
- Ibuprofen 400 mg TID
- Tramadol 50 mg PRN
- Morphine IR 5 mg PRN
Correct answer: Scheduled low-dose acetaminophen
Scheduled acetaminophen up to 3 g/day is the preferred first-line analgesic in older adults due to its favorable safety profile compared to NSAIDs and opioids.
Question 3: A consultant pharmacist reviews a resident's medication list and notes she is receiving both warfarin and fluconazole. What is the primary pharmacokinetic concern?
- Fluconazole induces CYP2C9, decreasing warfarin levels
- Fluconazole inhibits CYP2C9, increasing warfarin levels (Correct answer)
- Fluconazole displaces warfarin from albumin, lowering efficacy
- Fluconazole increases renal clearance of warfarin
Correct answer: Fluconazole inhibits CYP2C9, increasing warfarin levels
Fluconazole is a potent CYP2C9 inhibitor that dramatically reduces warfarin metabolism, leading to significantly elevated INR and bleeding risk.
Question 4: Under the CMS F-tag F758 regulations, which of the following constitutes an unnecessary antipsychotic use in a LTC setting?
- Antipsychotic for diagnosed schizophrenia with documented benefit
- Antipsychotic for behavioral symptoms of dementia without safety risk (Correct answer)
- Antipsychotic for Huntington's disease with documented benefit
- Antipsychotic for Tourette's syndrome with physician documentation
Correct answer: Antipsychotic for behavioral symptoms of dementia without safety risk
F758 prohibits antipsychotics for behavioral symptoms of dementia (wandering, repetitive behaviors) unless a specific diagnosis justifies use and non-pharmacological interventions have failed.
Question 5: A LTC resident with heart failure is started on carvedilol. The consultant pharmacist should monitor for which electrolyte disturbance that is especially common in heart failure patients on diuretics?
- Hypernatremia
- Hyperkalemia from carvedilol
- Hypokalemia from loop diuretics (Correct answer)
- Hypercalcemia from thiazides
Correct answer: Hypokalemia from loop diuretics
Loop diuretics commonly used in heart failure cause urinary potassium wasting, leading to hypokalemia, which can increase the risk of cardiac arrhythmias.
Question 6: Which clinical tool is MOST appropriate for systematic fall risk stratification in a newly admitted LTC resident?
- Mini-Mental State Examination (MMSE)
- Morse Fall Scale (Correct answer)
- CAGE questionnaire
- Braden Scale
Correct answer: Morse Fall Scale
The Morse Fall Scale is a validated, widely used instrument specifically designed to assess fall risk using six predictive factors in institutional settings.
Question 7: A consultant pharmacist identifies that a resident's bisphosphonate is being administered with the resident in a supine position due to limited mobility. What is the primary concern?
- Reduced absorption leading to treatment failure
- Esophageal irritation and risk of erosive esophagitis (Correct answer)
- Increased renal toxicity from prolonged contact
- CNS toxicity from systemic absorption
Correct answer: Esophageal irritation and risk of erosive esophagitis
Oral bisphosphonates require upright positioning for at least 30 minutes after administration to prevent esophageal irritation, erosion, and potentially esophageal ulcers.
CCP Clinical Care in Long-Term Care 2
A 78-year-old LTC resident with stage 3 chronic kidney disease has an eGFR of 28 mL/min.
Which antibiotic requires the most significant dose reduction for a urinary tract infection?