For Student

An 84-year-old man was found by his daughter on the floor of his apartment after failing to
answer the telephone for a day. He complained of pain in his left knee, but was otherwise
confused and unable to explain what had occurred. He was brought to the hospital by ambulance
and admitted.
Past Medical/Surgical History – provided by the daughter
Myocardial infarction 10 years ago
Hypertension
Peptic ulcer disease with bleeding 20 years ago
Benign prostatic hypertrophy
Venous insufficiency
Bilateral cataract surgery 5 years ago
Left inguinal hernia repair 25 years ago
Medications:
aspirin 325 mg daily atenolol 50 mg daily one Multivitamin daily
Vitamin E 800 U daily terazosin 5 mg daily lisinopril 10 mg daily
Vitamin C 1000 mg daily Ginkgo biloba one capsule daily
Physical Examination:
In the emergency room, his physical examination revealed a thin male who appeared alert but
agitated and in moderate pain, lying on the stretcher.
His vital signs were:
Pulse 48 Weight 140 lbs
Blood pressure lying down 190/70 Height 5 ft. 9 in.
Respiratory rate 20 Temperature 99 F

Tasks:
1. Which of the following contributes to falls in the elderly?
They are often due to a combination of intrinsic factors (chronic illnesses, gait, strength,
vision, medication effects, etc.) and extrinsic factors (environmental and activity-related
factors)
2. Why is the systolic blood pressure elevated?
 vascular occlusion

3. Why may his heart rate be slow?

“sick sinus syndrome,” which includes persistent, severe and inappropriate sinus bradycardia,
episodes of sinoatrial block, sinus arrest, or both, cessation of sinus rhythm or long pauses
with failure of subsidiary pacemakers, etc. Atenolol, a beta1-selective blocker, reduces the
sinus rate at rest and with exercise.

Student’s name
For examiner
An 84-year-old man was found by his daughter on the floor of his apartment after failing to
answer the telephone for a day. He complained of pain in his left knee, but was otherwise
confused and unable to explain what had occurred. He was brought to the hospital by ambulance
and admitted.
Past Medical/Surgical History – provided by the daughter
Myocardial infarction 10 years ago
Hypertension
Peptic ulcer disease with bleeding 20 years ago
Benign prostatic hypertrophy
Venous insufficiency
Bilateral cataract surgery 5 years ago
Left inguinal hernia repair 25 years ago
Medications:
aspirin 325 mg daily atenolol 50 mg daily one Multivitamin daily
Vitamin E 800 U daily terazosin 5 mg daily lisinopril 10 mg daily
Vitamin C 1000 mg daily Ginkgo biloba one capsule daily
Physical Examination:
In the emergency room, his physical examination revealed a thin male who appeared alert but
agitated and in moderate pain, lying on the stretcher.
His vital signs were:
Pulse 48 Weight 140 lbs
Blood pressure lying down 190/70 Height 5 ft. 9 in.
Respiratory rate 20 Temperature 99 F

Task 1 (3.5) Falls occur in 30-40% of community-dwelling elderly over the age of 65, 50% of
those over age 80, and 30-60% of nursing home residents. They are often due to a combination
of intrinsic factors (chronic illnesses, gait, strength, vision, medication effects, etc.) and extrinsic
factors (environmental and activity-related factors). Older adults should be asked at least once
yearly about falls. When evaluating falls, it is critical to obtain a careful history regarding the
events surrounding a fall in order to direct the evaluation. Multiple risk factors have been
identified and include a past history of a fall, age, cognitive impairment, female, lower extremity
weakness, balance problems, psychotropic drug use, arthritis, history of stroke, orthostatic
hypotension, dizziness, and anemia. Atenolol, a beta-blocker, can contribute to falls by causing
hypotension and/or bradyarrythmias. Terazosin, an alpha-1 adrenergic receptor antagonist
(peripherally acting alpha blocker), can cause orthostasis. Lisinopril, an ACE-inhibitor, can
cause hypotension and contribute to falls. It generally does not cause orthostasis.
Task 2 (3.0) Although cross-sectional studies have shown that blood pressure, particularly
systolic blood pressure, increases with age, however, the threshold values that define high blood
pressure are not altered for age. Blood Pressure may be elevated in response to a disease process
(secondary hypertension) or be due to essential hypertension. High blood pressure in the aged is
viewed as a disease process, rather than normal aging (as it does not occur in everyone), with an
associated increase in risk for adverse outcomes (coronary heart disease, congestive heart failure,
stroke, peripheral vascular disease, and renal disease). Although the etiology of essential
hypertension is not known, changes in peripheral vascular resistance are central to the
development of hypertension in the elderly. Resistance may be due to vascular occlusion, and/or
changes in vascular -adrenergic-mediated smooth muscle dilatation during normal aging. In
addition, there may be an expanded extracellular volume, especially in black and elderly
hypertensives, which may correspond to a low plasma renin and a high sensitivity to dietary
sodium.
Task 3 (3.5)Basic sinus-node function (i.e. heart rate, sinus node recovery time, and sinoatrial
conduction time) does not change with age. Maximal heart rate declines with aging. The
sinoatrial node becomes more fibrotic with advancing age and sinus node dysfunction is
common in the elderly, but often does not cause any symptoms. When symptomatic, it is often
referred to as the “sick sinus syndrome,” which includes persistent, severe and inappropriate
sinus bradycardia, episodes of sinoatrial block, sinus arrest, or both, cessation of sinus rhythm or
long pauses with failure of subsidiary pacemakers, etc. Atenolol, a beta1-selective blocker,
reduces the sinus rate at rest and with exercise.