SPEX Exam Geriatrics — Questions and Answers
Question 1: An 80-year-old man with baseline mild cognitive impairment is hospitalized for pneumonia. On hospital day 2, his family notes acute confusion, agitation alternating with somnolence, and disorganized speech that fluctuates over the day. His baseline cognition was intact 48 hours ago. The most likely diagnosis is:
- Rapidly progressing Alzheimer disease
- Delirium (Correct answer)
- New-onset psychosis
- Lewy body dementia
Correct answer: Delirium
Delirium is defined by acute onset, fluctuating course, inattention, and disorganized thinking or altered consciousness—all present here. Pre-existing cognitive impairment is the strongest risk factor. Dementia (including Alzheimer and Lewy body) progresses over months to years, not hours. New-onset psychosis in an 80-year-old is far less likely than delirium in a medically ill patient. The key distinguishing features of delirium are acute onset and fluctuation.
Question 2: A 75-year-old woman is taking 12 medications. Her physician wants to identify potentially inappropriate medications using evidence-based criteria. The MOST widely used tool for this purpose in older adults is:
- The Beers Criteria (Correct answer)
- The Braden Scale
- The CURB-65 score
- The Framingham Risk Score
Correct answer: The Beers Criteria
The American Geriatrics Society Beers Criteria is the standard evidence-based tool identifying medications that are potentially inappropriate in older adults due to increased risk of adverse effects, including anticholinergics, benzodiazepines, NSAIDs, and first-generation antihistamines. The Braden Scale assesses pressure injury risk. CURB-65 stratifies pneumonia severity. The Framingham Risk Score estimates cardiovascular event risk.
Question 3: A 72-year-old woman presents after her third fall in 6 months. She takes amlodipine, temazepam, and mirtazapine. On exam, she has orthostatic hypotension and a Timed Up and Go (TUG) test of 18 seconds. The MOST impactful single intervention to reduce fall risk is:
- Prescribe a walker
- Discontinue temazepam (Correct answer)
- Refer for physical therapy gait training
- Start vitamin D 800 IU daily
Correct answer: Discontinue temazepam
Benzodiazepines (temazepam) are among the highest-risk medications for falls in older adults and are explicitly listed on the Beers Criteria. Sedation, impaired balance, and altered cognition from benzodiazepine use are strongly associated with falls and fractures. While PT, vitamin D, and assistive devices are all components of fall prevention, medication deprescribing—particularly benzodiazepines—has the strongest evidence for reducing falls. TUG ≥ 12 seconds confirms mobility impairment.
Question 4: An 85-year-old man with moderate Alzheimer dementia becomes increasingly agitated at night, wandering and shouting. Non-pharmacologic interventions (scheduled activities, light therapy, caregiver training) have been tried without sufficient relief. Which pharmacologic approach is most appropriate?
- Haloperidol 5 mg nightly
- Diphenhydramine 50 mg at bedtime
- Low-dose antipsychotic (e.g., quetiapine 12.5–25 mg) with close monitoring (Correct answer)
- Lorazepam 1 mg as needed for agitation
Correct answer: Low-dose antipsychotic (e.g., quetiapine 12.5–25 mg) with close monitoring
If pharmacotherapy is required for dementia-related behavioral disturbance after non-pharmacologic measures fail, low-dose atypical antipsychotics (quetiapine, risperidone) are used with informed consent about the black box warning (increased mortality in elderly with dementia). They are preferred over typical antipsychotics (higher EPS risk), diphenhydramine (anticholinergic, worsens cognition), and benzodiazepines (paradoxical agitation, fall risk, delirium). Non-pharmacologic approaches are always first-line.
Question 5: A 90-year-old woman at a skilled nursing facility develops a sacral wound that is 3 cm Ă— 2 cm with a shallow crater exposing the dermis. There is no slough or necrotic tissue. This is classified as a:
- Stage 1 pressure injury
- Stage 2 pressure injury (Correct answer)
- Stage 3 pressure injury
- Unstageable pressure injury
Correct answer: Stage 2 pressure injury
Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis; the wound bed is viable (pink/red, moist) and may present as a shallow open ulcer or an intact or ruptured serum-filled blister. Stage 1 is intact skin with non-blanchable erythema. Stage 3 involves full-thickness skin loss (subcutaneous fat may be visible). Unstageable injuries are covered by slough or eschar preventing staging. No slough/eschar and shallow dermis exposure confirm Stage 2.
Question 6: A frail 82-year-old woman with heart failure, CKD stage 3, and COPD is admitted for hip fracture repair. Preoperatively, the most validated tool to predict her risk of postoperative complications and functional decline is:
- ASA Physical Status Classification
- Comprehensive Geriatric Assessment (CGA) (Correct answer)
- APACHE II score
- Glasgow Coma Scale
Correct answer: Comprehensive Geriatric Assessment (CGA)
Comprehensive Geriatric Assessment (CGA) evaluates functional status, cognition, mood, nutrition, polypharmacy, social support, and comorbidities in older adults. It is the most validated approach for predicting postoperative outcomes, identifying reversible risk factors, and guiding perioperative optimization in elderly patients. The ASA classification is a global anesthesia risk tool but does not capture geriatric-specific vulnerabilities. APACHE II is used in ICU mortality prediction. GCS measures neurological status.
SPEX Exam Geriatrics
An 80-year-old man with baseline mild cognitive impairment is hospitalized for pneumonia.
On hospital day 2, his family notes acute confusion, agitation alternating with somnolence, and disorganized speech that fluctuates over the day.
His baseline cognition was intact 48 hours ago.
The most likely diagnosis is: