CPC Geriatric Care and Fall Prevention 2 — Questions and Answers

Question 1: Sarcopenia in elderly patients is BEST defined as:

Age-related bone loss leading to osteoporosis
Progressive and generalized loss of skeletal muscle mass and strength associated with adverse outcomes (Correct answer)
Degeneration of joint cartilage causing osteoarthritis
Pathological weight loss from malignancy

Correct answer: Progressive and generalized loss of skeletal muscle mass and strength associated with adverse outcomes

Sarcopenia (from Greek: 'sarco' = muscle, 'penia' = loss) is the age-related progressive loss of skeletal muscle mass, strength, and function — a major driver of frailty, falls, and functional dependence in the elderly.

The EWGSOP2 (European Working Group on Sarcopenia in Older People) defines sarcopenia as probable when low muscle strength is identified, confirmed by low muscle quantity/quality, and severe when combined with low physical performance. Community paramedicine implications: sarcopenic patients have 3× higher fall risk, prolonged hospitalization, and higher mortality. Assessment: grip strength (dominant hand dynamometry; men <27 kg, women <16 kg = low), gait speed (<0.8 m/s = poor performance), calf circumference (<31 cm). Interventions: progressive resistance exercise, protein supplementation (1.2–1.5 g/kg/day), vitamin D optimization. Community paramedics identify sarcopenia signs and refer to physical therapy and nutrition support.

Question 2: The FRAIL scale is a validated tool for assessing frailty in older adults. Which of the following correctly lists all 5 domains assessed?

Falls, Resistance, Ambulation, Illness, and Loss of weight
Fatigue, Resistance, Ambulation, Illness, and Loss of weight (Correct answer)
Falls, Rigidity, Anxiety, Incontinence, and Loss of appetite
Frailty, Resistance, Ability, Independence, and Loneliness

Correct answer: Fatigue, Resistance, Ambulation, Illness, and Loss of weight

The FRAIL scale assesses: Fatigue, Resistance (difficulty climbing stairs), Ambulation (difficulty walking one block), Illness (>5 diseases), and Loss of weight (>5% in 1 year). 0 = robust, 1–2 = pre-frail, 3–5 = frail.

The FRAIL scale (Morley et al., 2012) is a 5-item validated frailty screening tool: (F) Fatigue — are you fatigued? (R) Resistance — difficulty climbing one flight of stairs alone without aids? (A) Ambulation — difficulty walking one block? (I) Illness — do you have >5 illnesses? (L) Loss of weight — have you lost >5% body weight in the past year? Scoring: 0 = robust, 1–2 = pre-frail (risk reduction opportunity), 3–5 = frail (comprehensive geriatric assessment needed). Frail patients have 3–5× higher risk of ADL dependence, hospitalization, and death. Community paramedics administer FRAIL during initial geriatric assessments and use results to guide care intensity and referral decisions.

Question 3: A community paramedic visits an 82-year-old patient who takes 12 prescription medications. The Beers Criteria specifically warn against the use of which medication class in older adults due to its high risk of cognitive impairment, sedation, and falls?

Metformin
First-generation antihistamines (e.g., diphenhydramine) (Correct answer)
Metoprolol
Calcium supplements

Correct answer: First-generation antihistamines (e.g., diphenhydramine)

First-generation antihistamines like diphenhydramine (Benadryl) are strongly anticholinergic and are explicitly listed on the Beers Criteria as potentially inappropriate in older adults due to high risk of cognitive impairment, confusion, sedation, urinary retention, and falls.

The American Geriatrics Society Beers Criteria 2023 explicitly lists diphenhydramine and other first-generation antihistamines as 'avoid in older adults' due to: CNS anticholinergic effects (confusion, hallucinations, delirium), sedation and oversedation (fall and injury risk), urinary retention (in men with BPH), constipation, and dry mouth. Patients commonly use diphenhydramine OTC as a sleep aid or for allergies without knowing the risks. Community paramedics performing medication reconciliation identify OTC antihistamine use, educate patients on safer alternatives (loratadine, cetirizine for allergies; melatonin or CBT-I for insomnia), and communicate findings to the PCP for deprescribing consideration.

Question 4: Delirium in hospitalized or recently discharged elderly patients is BEST described as:

A chronic progressive neurodegenerative disease causing memory loss
An acute disturbance in attention and cognition that fluctuates over the course of the day and has an identifiable medical cause (Correct answer)
A psychiatric condition requiring long-term antipsychotic treatment
A normal response to hospitalization in patients over age 80

Correct answer: An acute disturbance in attention and cognition that fluctuates over the course of the day and has an identifiable medical cause

Delirium is an acute, fluctuating neuropsychiatric syndrome characterized by impaired attention and cognition, with an identifiable underlying cause (infection, medications, metabolic derangement) — distinct from the chronic, stable cognitive decline of dementia.

DSM-5 delirium criteria: (1) Disturbance in attention and awareness; (2) Acute onset over hours to days, fluctuating course; (3) Additional cognitive disturbance (disorientation, memory impairment, language disturbance); (4) Not better explained by pre-existing neurocognitive disorder; (5) Evidence of a direct medical cause. Community paramedics recognize delirium in post-discharge patients using the 4AT tool or brief Confusion Assessment Method (b-CAM): acute onset/fluctuating mental status, inattention, disorganized thinking, altered level of consciousness. Common causes: UTI, pneumonia, medication toxicity, electrolyte disorders, urinary retention, pain, sleep deprivation. Delirium is a medical emergency requiring identification and treatment of the underlying cause.

Question 5: Which of the following community paramedicine interventions MOST directly addresses the risk of social isolation in elderly patients?

Increasing the frequency of blood pressure monitoring visits
Connecting the patient to befriending programs, senior centers, and community social activities, and screening using the UCLA Loneliness Scale (Correct answer)
Prescribing antidepressants for loneliness
Relocating the patient to a skilled nursing facility

Correct answer: Connecting the patient to befriending programs, senior centers, and community social activities, and screening using the UCLA Loneliness Scale

Social isolation is a major determinant of physical and mental health in the elderly. Community paramedics screen using validated tools (UCLA Loneliness Scale) and actively connect patients to befriending programs, senior centers, faith community outreach, and telephone/video companionship programs.

Social isolation and loneliness in older adults are associated with increased risk of dementia (50%), heart disease (29%), stroke (32%), depression, and premature death equivalent to smoking 15 cigarettes per day (Holt-Lunstad meta-analysis). Community paramedics assess social isolation using: UCLA Loneliness Scale (validated 3-item version), clinical observation (no visitors during home visits, report of no social contact), and caregiver burden screening. Interventions: befriending volunteer programs (e.g., Senior Companions), telephone reassurance programs, technology-based social connection (video calls training), referral to senior centers, faith community outreach, and Meals on Wheels social contact. Community paramedics are uniquely positioned to identify social isolation through in-home observation.

Question 6: A community paramedic reviews a geriatric patient's medication list and finds that metformin is prescribed for type 2 diabetes. The patient's latest eGFR is 28 mL/min/1.73m². The community paramedic should:

Continue metformin as it is the safest diabetes medication in all patients
Flag this as a potential safety concern — metformin is generally contraindicated when eGFR <30 mL/min/1.73m² (Correct answer)
Advise the patient to double the metformin dose to control blood sugar
Stop all diabetes medications immediately pending physician review

Correct answer: Flag this as a potential safety concern — metformin is generally contraindicated when eGFR <30 mL/min/1.73m²

Metformin is contraindicated (or requires discontinuation) when eGFR falls below 30 mL/min/1.73m² due to impaired renal clearance, leading to metformin accumulation and risk of potentially fatal lactic acidosis.

FDA labeling states: metformin is contraindicated in patients with eGFR <30 mL/min/1.73m² due to the risk of lactic acidosis from drug accumulation. Action thresholds: eGFR ≥60 — metformin is safe; eGFR 45–59 — continue with monitoring; eGFR 30–44 — use with caution, reassess benefits/risks; eGFR <30 — contraindicated, discontinue. Lactic acidosis associated with metformin has a case fatality rate of ~50%. Community paramedics performing medication reconciliation check current renal function against renally-dosed medications — not just metformin but also NSAIDs, certain antibiotics (nitrofurantoin contraindicated at eGFR <30), and digoxin. This finding requires immediate provider notification, not independent medication discontinuation or dose adjustment.

CPC Geriatric Care and Fall Prevention 2

Sarcopenia in elderly patients is BEST defined as: