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CME Post-Test and Evaluation Form
CME POST-TEST AND EVALUATION FORM In order to receive credit, this CME Post-Test and Evaluation Form must be received in the AMDA education office by June 30, 2006. Read the articles of interest to you and complete Parts I through IV for each article read. Please complete Part V to help us learn your educational needs. Complete Part VI in order to receive your CME certificate. One credit hour may be earned for each article read and each corresponding test completed, up to 12 credits of category 1 toward the AMA PRA. You may fax or mail this form as indicated at the bottom of the page. A certificate will be mailed or faxed to you as you indicate below. Please allow 4 weeks for your certificate to arrive. Please maintain your own record of credits received.
a) with usual nursing home care. b) only with optimal feeding assistance. c) under both conditions. (5) After 9 weeks on megestrol acetate, participants experienced, on average, ________ in body weight. a) a substantial increase b) a slight increase c) a slight decrease d) a substantial decrease
Article 2: Barriers to Managing Pain in the Nursing Home: Findings from a Statewide Survey, A. J. Tarzian and D. E. Hoffmann
Part I. Post-Test: Content Questions Article 1: The Effect of Megestrol Acetate on Oral Food and Fluid Intake in Nursing Home Residents: A Pilot Study, S. F. Simmons et al. (1) All the following statements about nursing home residents are correct EXCEPT: a) Numerous studies show that at least two-thirds of nursing home residents take inadequate amounts of food and fluids. b) The federal definition of low intake is eating less than three-fourths of the food offered during most meals. c) Special diet orders tend to increase appetite and oral intake. d) Low food intake augments the risk of adverse clinical outcomes. e) Social isolation may contribute to poor oral intake. (2) Optimal feeding assistance: a) is one-on-one and continuous. b) is not enhanced by a graduated prompting protocol. c) need not include social stimulation. d) allows access to the food tray for up to 30 minutes. (3) According to a recent controlled study, about ______ of nursing home residents with low oral intake increase their intake when given high-quality feeding assistance. a) 10% b) 25% c) 50% d) 75% e) 90% (4) In nursing home residents with inadequate oral intake, treatment with 400 mg daily of megestrol acetate (Megace) as an orally administered liquid suspension was associated with increased food consumption: SUPPLEMENT
(1) The directors of nursing (DONs) in this survey stated that ________ was by far the commonest type of pain that was suboptimally treated at their facilities. a) pain in terminally ill residents b) acute short-term pain c) chronic pain d) postoperative pain (2) Which of the following was NOT perceived by DONs to be among the commonest barriers to effective pain management? a) Limited availability of pharmacy medications. b) Nurses’ lack of specific knowledge of pain management. c) Physicians’ lack of specific knowledge of pain management. d) Lack of a standardized approach to treating pain. e) Difficulty in selecting effective analgesic medication. (3) ________ of the nursing homes surveyed had a designated palliative care unit or hospice unit. a) Fewer than 10% b) About one fourth c) About half d) About three fourths (4) The LEAST common way for staff to be educated in pain management was through: a) hospice personnel. b) pharmacists. c) drug representatives. d) outside seminars and conferences. (5) A majority of nursing homes rarely if ever attempted to relieve pain by: a) trigger point injections. b) transcutaneous electrical nerve stimulation. c) complementary therapies such as massage, biofeedback and medication. d) use of a narcotic pump. e) any of these methods. S105
Article 3: End-of-Life Care in US Nursing Homes: A Review of the Evidence, D. P. Oliver et al. (1) A review of 43 journal articles dealing with end-of-life care in the nursing home suggests that: a) acute illness does not signify a shortened survival time. b) accurate predictions of death are aided by an active total quality management program. c) declining cognitive function and communicative ability are not related to short-term mortality. d) social withdrawal does not help to predict impending death. (2) Which statement about hospice care in the nursing home is NOT correct? a) It improves pain management. b) It is viewed by family members as duplicating conventional nursing home care. c) Hospice residents are likelier than others to have an advanced care plan. d) Nursing home staff tend to believe that hospice care is beneficial to residents. (3) Several studies have found that nursing home residents in a hospice program are _______ other residents to be hospitalized. a) more likely than b) less likely than c) about as likely as (4) Compared to standard nursing home care, families have, in general, reported being _______ hospice services. a) very satisfied with b) satisfied with c) accepting of d) dissatisfied with (5) In a survey of bereavement services, approximately ______ of nursing homes provided educational materials to families. a) 5% b) 25% c) 50% d) 75% Article 4: Management of Constipation in Residents with Dementia: Sorbitol Effectiveness and Cost, L. Volicer et al. (1) This study comparing sorbitol with lactulose in chronically constipated, demented male nursing home residents shows that: a) lactulose is ineffective as an osmotic laxative. b) there is a lower risk of side effects when using sorbitol. c) sorbitol is significantly less costly. d) lactulose leaves a bitter taste in the mouth. (2) Compared to non-demented nursing home residents, those who are demented are ________ of rectally administered laxatives such as bisacodyl suppositories. S106
a) more tolerant b) less tolerant c) about as tolerant (3) After replacing lactulose with sorbitol, there was a statistically significant reduction in the use of: a) Milk of Magnesia. b) bisacodyl suppositories. c) Fleet enemas. d) all of these. e) none of these. (4) When using sorbitol in place of lactulose, the overall cost of managing constipation in this study: a) increased substantially. b) increased slightly. c) did not change. d) decreased slightly. e) decreased substantially. (5) Sorbitol-based management in this study was much less expensive than estimated costs of managing chronic constipation in previous reports. The difference chiefly reflects: a) less staff time. b) lower medication costs. Article 5: Quality Indicators for the Management of Medical Conditions in Nursing Home Residents, D. Saliba et al. (1) Case processes in nursing homes differ in many respects from community-based care of the elderly. An exception is: a) a greater burden of disease in nursing home residents. b) more ongoing integrative care in the nursing home. c) fewer opportunities for monitoring patients in community care. d) a higher quality of care in the nursing home. e) more certainty in the nursing home when implementing planned treatment. (2) Of 114 process-based quality indicators (QIs) developed for 11 medical disorders, approximately _____ were the same as those considered to be valid for elderly community-dwelling persons. a) 5% b) 25% c) 50% d) 80% (3) Nursing home care processes associated with improved outcomes were identified, and subsequently reviewed, by: a) the same panel of experts. b) separate panels of experts. (4) The domains considered for each proposed QI included all of the following EXCEPT: a) validity. b) feasibility of assessment. c) feasibility of implementation. d) proved efficacy. e) importance. JAMDA – May/June 2005
(5) Approximately _______ of the QIs would be inapplicable to severely demented residents and those not expected to live for at least 6 months. a) one third b) half c) two thirds Article 6: Feasibility of Quality Indicators for the Management of Geriatric Syndromes in Nursing Home Residents, D. Saliba et al. (1) Which statement is NOT correct? a) More than two thirds of nursing home residents reportedly are demented, as diagnosed by the Minimum Data Set Cognitive Performance Scale. b) Pressure ulcers are rare in residents of modern nursing homes. c) Nursing home residents fall nearly three times more often than do elderly people living in the community. d) In the 1995 National Nursing Home Survey, more than half of nursing home residents had urinary incontinence. (2) More than 80% of nursing home residents are dependent in at least three basic self-care tasks or activities of daily living. a) True b) False (3) In determining the feasibility of measurement of quality indicators (QIs), implementation of care is assessed using: a) a resident or proxy interview. b) nursing home records. c) either of these. (4) QIs related to ________ are significantly likelier to be rated as having questionable feasibility of implementation. a) geriatric syndromes b) medical conditions (5) Of 68 QIs identified as valid and important in nursing home residents in this study, __________ 25% would be excluded because of advanced dementia or a poor prognosis. a) fewer than b) more than Article 7: Barriers to Providing Osteoporosis Care in Skilled Nursing Facilities: Perceptions of Medical Directors and Directors of Nursing, C. S. Colon-Emeric et al. (1) Both medical directors and directors of nursing (DONs) in this survey strongly agreed that current guidelines for managing osteoporosis in the institutional setting are likely to be: a) effective. b) somewhat effective in some instances. c) ineffective. d) incomplete. SUPPLEMENT
(2) The respondents generally agreed that: a) patients will utilize hip protectors. b) staff lack the time needed to properly implement guidelines. c) bisphonates are safe. d) malpractice liability is a major concern. (3) DONs and other staff were more likely than the medical director to believe that: a) staff turnover is a barrier to osteoporosis care. b) level of staff knowledge is a barrier to osteoporosis care. c) both patients and their relatives are concerned about preventing fractures. (4) Those in practice for longer periods were more concerned than other respondents about: a) staff knowledge. b) malpractice liability. c) both. d) neither. (5) Formal training in geriatrics __________ responses to the survey questions. a) strongly influenced b) modestly influenced c) had no effect on
Article 8: Corticosteroids and Chronic Obstructive Pulmonary Disease in the Nursing Home, A. Rich
(1) Which of the following statements about steroid treatment for nursing home residents with chronic obstructive pulmonary disease (COPD) is NOT accurate? a) Nursing home residents admitted to hospital with an exacerbation of COPD who received inhaled steroids after discharge and were followed up for 12 months had approximately 25% fewer readmissions. b) The same patients had a lower mortality rate than others not on inhaled steroids. c) Ongoing treatment with oral steroids has a demonstrable disease-modifying effect. d) Systemic steroids are reliably effective in patients having acute exacerbations of COPD. (2) Elderly patients with COPD usually require ________ steroid treatment. a) a single b) intermittent c) continuous (3) In the Lung Health Study, patients with COPD who were followed up after 3 years on inhaled steroids had a significantly increased incidence of: a) diabetes. b) myopathy. c) cataracts. d) all of these. e) none of these. S107
(4) Oral steroids should be a routine part of the long-term treatment of nursing home residents with chronic, stable COPD. a) True b) False (5) If spirometric monitoring is not feasible for a nursing home resident with COPD, inhaled steroids: a) should be avoided. b) may be tried and the effects monitored clinically. c) should be given continuously for at least 6 months even if there is no clear response. Article 9: Can We Prevent Aspiration Pneumonia in the Nursing Home?, E. Oh et al. (1) The risk of aspiration pneumonia in older persons is increased by: a) impaired host defenses. b) an increased concentration of bacteria in the oropharynx. c) inability to feed one’s self. d) all of these. (2) Which statement about elderly patients with aspiration pneumonia is NOT accurate? a) Neither an increased respiratory rate nor pleuritic chest pain is consistently noted. b) High fever is invariably present. c) Some patients may not have a productive cough. d) Sudden incontinence may be a presenting feature. (3) Aspiration pneumonia: a) virtually always develops in elderly persons who aspirate solids or liquid. b) is not a risk when swallowing is normal. c) is likelier to occur when the flow of saliva is reduced for any reason. d) is not directly related to the number of decayed teeth. (4) Treatment with an angiotensin-converting enzyme inhibitor could increase levels of substance P in the respiratory tract and thereby _______ the risk of aspiration. a) increase b) decrease (5) Several feeding cues given by nursing staff to dysphagic patients can help to prevent aspiration. An exception is: a) providing finger foods. b) slower feeding. c) small bites. d) coughing forcefully before bites. e) reminding patients to swallow. Article 10: Falls in the Nursing Home: Are They Preventable?, M. Q. Vu et al. (1) The authors of this literature review characterize the results of several randomized, controlled clinical trials S108
(2)
(3)
(4)
(5)
evaluating multifaceted fall prevention programs as being: a) uniformly excellent. b) encouraging. c) uncertain. d) disappointing. Removal of physical bed and chair restraints from nursing home residents: a) lowers the risk of falling. b) reduces the risk of serious injury from a fall. c) has both of these effects. d) has neither of these effects. When nursing home residents exercise regularly, their chance of falling: a) decreases. b) remains the same. c) increases. The use of hip protectors by nursing home residents: a) is convenient and never uncomfortable. b) makes falls less frequent. c) lowers the risk of hip fracture when a resident falls. All of the following drugs or drug classes have been associated with an increased risk of falling EXCEPT: a) angiotensin-converting enzyme inhibitors. b) psychotropic drugs. c) Digoxin. d) antiarrhythmic drugs.
Article 11: Ten Myths About Decision-Making Capacity, L. Ganzini et al. (1) Which ONE of the following statements about who assesses decision-making capacity and who is subject to this evaluation is correct. a) Only experts in mental health are qualified to assess a patient’s decision-making capacity. b) It may be advantageous for primary-care clinicians to make the assessment. c) When a patient makes a decision that conflicts with medical advice, a lack of decision-making capacity may be assumed. d) a patient who complies with all medical advice may be presumed to possess decision-making capacity. (2) How do judgments of DMC relate to competency and to cognitive impairment? a) It is not possible for a legally incompetent person to remain able to make sound health care decisions. b) DMC and adequate cognitive function amount to the same thing. c) Tests of cognitive ability should not be used to evaluate a patient’s DMC. (3) It may be taken for granted that patients who _________ necessarily lack DMC. a) have dementia or schizophrenia b) have been involuntarily committed c) are in either of these categories JAMDA – May/June 2005
(4) Which statement is NOT accurate? a) A lack of DMC is always permanent, so that patients need not be reassessed. b) Important decisions should be delayed if possible when loss of DMC is expected to be temporary. c) A loss of DMC does not mean that the patient cannot make choices about such things as handling money or living independently. (5) A person given inappropriate or inconsistent information can still be expected to make informed decisions. a) True b) False
(2)
(3)
(4) Article 12: Quality Palliative Care in Long-Term Care Settings, P. A. S. Winn and A. N. Dentino (1) Which of these statements is NOT accurate? a) Air hunger in the form of breathlessness or dyspnea usually is distinct from tachypnea etiologically and pathophysiologically. b) Progressive weight loss is very unusual in the last 6 to 12 months of life.
(5)
c) Delirium at the end of life may be a result of fecal impaction. d) Clinical depression may account for progressive weakness in patients with advanced disease. When a dyspneic patient is placed on opioid therapy, respiratory distress is least frequent: a) when starting treatment. b) when opioid tolerance has developed. c) in the last days or weeks of life. Anticholinergic drugs may: a) relieve nausea and vomiting. b) worsen nausea and vomiting. c) have either of these effects. Terminal delirium can be adequately treated by: a) a benzodiazepine such as lorazepam. b) a neuroleptic agent such as haloperidol. c) both these drugs in combination. d) any of these options. Criteria for admission to hospice care do NOT include: a) end-stage disease. b) significant functional decline. c) critically compromised nutritional status. d) having a do-not-resuscitate request, living will, or advance directive for health care.
Part II. Impact of CME Activity Please answer questions 1–5 below by circling one number on the scale provided (5 ⴝ strongly agree; 0 ⴝ strongly disagree). 1.
2.
3.
SUPPLEMENT
This article reinforced my experience and my practice approach on this subject. Article 1: Effect of Megestrol Acetate on Food and Fluid Intake 5 4 Article 2: Barriers to Managing Pain 5 4 Article 3: End-of-Life Care in US Nursing Homes 5 4 Article 4: Management of Constipation 5 4 Article 5: QIs for Management of Medical Conditions 5 4 Article 6: Feasibility of QIs - Management of Geriatric Syndromes 5 4 Article 7: Barriers to Providing Osteoporosis Care 5 4 Article 8: Corticosteroids and COPD 5 4 Article 9: Can We Prevent Aspiration Pneumonia in the NH 5 4 Article 10: Falls in the Nursing Home 5 4 Article 11: Ten Myths about Decision-Making Capacity 5 4 Article 12: Quality Palliative Care in LTC Settings 5 4
1 1 1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0 0 0
This article provided a different perspective from which to approach management of this subject. Article 1: Effect of Megestrol Acetate on Food and Fluid Intake 5 4 3 2 Article 2: Barriers to Managing Pain 5 4 3 2 Article 3: End-of-Life Care in US Nursing Homes 5 4 3 2 Article 4: Management of Constipation 5 4 3 2 Article 5: QIs for Management of Medical Conditions 5 4 3 2 Article 6: Feasibility of QIs – Management of Geriatric Syndromes 5 4 3 2 Article 7: Barriers to Providing Osteoporosis Care 5 4 3 2 Article 8: Corticosteroids and COPD 5 4 3 2 Article 9: Can We Prevent Aspiration Pneumonia in the NH 5 4 3 2 Article 10: Falls in the Nursing Home 5 4 3 2 Article 11: Ten Myths about Decision-Making Capacity 5 4 3 2 Article 12: Qualtiy Palliative Care in LTC Settings 5 4 3 2
1 1 1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0 0
I plan to seek more information about this subject. Article 1: Effect of Megestrol Acetate on Food and Fluid Intake Article 2: Barriers to Managing Pain Article 3: End-of-Life Care in US Nursing Homes Article 4: Management of Constipation Article 5: QIs for Management of Medical Conditions Article 6: Feasibility of QIs – Management of Geriatric Syndromes
1 1 1 1 1 1
0 0 0 0 0 0
5 5 5 5 5 5
4 4 4 4 4 4
3 3 3 3 3 3 3 3 3 3 3 3
3 3 3 3 3 3
2 2 2 2 2 2 2 2 2 2 2 2
2 2 2 2 2 2
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Article Article Article Article Article Article 4.
7: Barriers to Providing Osteoporosis Care 8: Corticosteroids and COPD 9: Can We Prevent Aspiration Pneumonia in the NH 10: Falls in the Nursing Home 11: Ten Myths about Decision-Making Capacity 12: Quality Palliative Care in LTC Settings
5 5 5 5 5 5
4 4 4 4 4 4
3 3 3 3 3 3
2 2 2 2 2 2
1 1 1 1 1 1
0 0 0 0 0 0
I plan to discuss this information with colleagues to learn more about to this subject. Article 1: Effect of Megestrol Acetate on Food and Fluid Intake Article 2: Barriers to Managing Pain Article 3: End-of-Life Care in US Nursing Homes Article 4: Management of Constipation Article 5: QIs for Management of Medical Conditions Article 6: Feasibility of QIs – Management of Geriatric Syndromes Article 7: Barriers to Providing Osteoporosis Care Article 8: Corticosteroids and COPD Article 9: Can We Prevent Aspiration Pneumonia in the NH Article 10: Falls in the Nursing Home Article 11: Ten Myths about Decision-Making Capacity Article 12: Quality Palliative Care in LTC Settings
my peers’ perceptions and approaches 5 5 5 5 5 5 5 5 5 5 5 5
4 4 4 4 4 4 4 4 4 4 4 4
3 3 3 3 3 3 3 3 3 3 3 3
2 2 2 2 2 2 2 2 2 2 2 2
1 1 1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0 0 0
5.
Having read the article(s), I plan to make changes in my practice.
5
4
3
2
1
0
6.
What change(s), if any, do you plan to make in your practice as a result of reading the articles?
Part III. Quality of CME Activity 1.
2.
3.
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To what extent did the content of each article meet the stated learning objective(s)? number on the scale below: 5 ⴝ entirely met; 0 ⴝ not met at all.) Article 1: Effect of Megestrol Acetate on Food and Fluid Intake 5 4 Article 2: Barriers to Managing Pain 5 4 Article 3: End-of-Life Care in US Nursing Homes 5 4 Article 4: Management of Constipation 5 4 Article 5: QIs for Management of Medical Conditions 5 4 Article 6: Feasibility of QIs – Management of Geriatric Syndromes 5 4 Article 7: Barriers to Providing Osteoporosis Care 5 4 Article 8: Corticosteroids and COPD 5 4 Article 9: Can We Prevent Aspiration Pneumonia in the NH 5 4 Article 10: Falls in the Nursing Home 5 4 Article 11: Ten Myths about Decision-Making Capacity 5 4 Article 12: Quality Palliative Care in LTC Settings 5 4
(Please circle one 3 3 3 3 3 3 3 3 3 3 3 3
2 2 2 2 2 2 2 2 2 2 2 2
How clearly was the information presented in each article? (Please circle one number on the scale ⴝ extremely clear; 0 ⴝ extremely unclear.) Article 1: Effect of Megestrol Acetate on Food and Fluid Intake 5 4 3 2 Article 2: Barriers to Managing Pain 5 4 3 2 Article 3: End-of-Life Care in US Nursing Homes 5 4 3 2 Article 4: Management of Constipation 5 4 3 2 Article 5: QIs for Mangement of Medical Conditions 5 4 3 2 Article 6: Feasibility of QIs – Management of Geriatric Syndromes 5 4 3 2 Article 7: Barriers to Providing Osteoporosis Care 5 4 3 2 Article 8: Corticosteroids and COPD 5 4 3 2 Article 9: Can We Prevent Aspiration Pneumonia in the NH 5 4 3 2 Article 10: Falls in the Nursing Home 5 4 3 2 Article 11: Ten Myths about Decision-Making Capacity 5 4 3 2 Article 12: Quality Palliative Care in LTC Settings 5 4 3 2
1 1 1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0 0 0
below: 5 1 1 1 1 1 1 1 1 1 1 1 1
On the scale below, please rate the overall quality of this CME activity. (Please circle one number: 5 ⴝ excellent quality; 0 ⴝ poorest quality.) 5 4 3 2 1
0 0 0 0 0 0 0 0 0 0 0 0 0
JAMDA – May/June 2005
4.
Did you perceive any evidence of bias for or against any commercial products? If yes, please note in which article(s) and explain. __ Yes __ No ____________________________________________________________________________________________ ____________________________________________________________________________________________
Part IV. Statement of Completion I attest to having read and completed the articles listed below and request credit hours in category 1 toward the AMA PRA. I understand that credit hours are awarded based on a passing score of 70% or higher on the test(s) that I have completed. __ Article 1; __ Article 2; __ Article 3; __ Article 4; __ Article 5; __ Article 6; __ Article 7; __ Article 8 __ Article 9; __ Article 10; __ Article 11; __ Article 12. Signature Date Part V. Please list topics for articles that you would like to see provided in future journals:
Part VI. In order to receive your certificate of credit: Identify your preference for receipt of certificate by e-mail or fax with an *. Please PRINT legibly or type: Name Address Telephone number FAX number E-mail address Return this CME Post-Test and Evaluation Form to Suzanne Harris via fax to (410) 740-4572; or by e-mail to [email protected].
SUPPLEMENT
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a) with usual nursing home care. b) only with optimal feeding assistance. c) under both conditions. (5) After 9 weeks on megestrol acetate, participants experienced, on average, ________ in body weight. a) a substantial increase b) a slight increase c) a slight decrease d) a substantial decrease
Article 2: Barriers to Managing Pain in the Nursing Home: Findings from a Statewide Survey, A. J. Tarzian and D. E. Hoffmann
Part I. Post-Test: Content Questions Article 1: The Effect of Megestrol Acetate on Oral Food and Fluid Intake in Nursing Home Residents: A Pilot Study, S. F. Simmons et al. (1) All the following statements about nursing home residents are correct EXCEPT: a) Numerous studies show that at least two-thirds of nursing home residents take inadequate amounts of food and fluids. b) The federal definition of low intake is eating less than three-fourths of the food offered during most meals. c) Special diet orders tend to increase appetite and oral intake. d) Low food intake augments the risk of adverse clinical outcomes. e) Social isolation may contribute to poor oral intake. (2) Optimal feeding assistance: a) is one-on-one and continuous. b) is not enhanced by a graduated prompting protocol. c) need not include social stimulation. d) allows access to the food tray for up to 30 minutes. (3) According to a recent controlled study, about ______ of nursing home residents with low oral intake increase their intake when given high-quality feeding assistance. a) 10% b) 25% c) 50% d) 75% e) 90% (4) In nursing home residents with inadequate oral intake, treatment with 400 mg daily of megestrol acetate (Megace) as an orally administered liquid suspension was associated with increased food consumption: SUPPLEMENT
(1) The directors of nursing (DONs) in this survey stated that ________ was by far the commonest type of pain that was suboptimally treated at their facilities. a) pain in terminally ill residents b) acute short-term pain c) chronic pain d) postoperative pain (2) Which of the following was NOT perceived by DONs to be among the commonest barriers to effective pain management? a) Limited availability of pharmacy medications. b) Nurses’ lack of specific knowledge of pain management. c) Physicians’ lack of specific knowledge of pain management. d) Lack of a standardized approach to treating pain. e) Difficulty in selecting effective analgesic medication. (3) ________ of the nursing homes surveyed had a designated palliative care unit or hospice unit. a) Fewer than 10% b) About one fourth c) About half d) About three fourths (4) The LEAST common way for staff to be educated in pain management was through: a) hospice personnel. b) pharmacists. c) drug representatives. d) outside seminars and conferences. (5) A majority of nursing homes rarely if ever attempted to relieve pain by: a) trigger point injections. b) transcutaneous electrical nerve stimulation. c) complementary therapies such as massage, biofeedback and medication. d) use of a narcotic pump. e) any of these methods. S105
Article 3: End-of-Life Care in US Nursing Homes: A Review of the Evidence, D. P. Oliver et al. (1) A review of 43 journal articles dealing with end-of-life care in the nursing home suggests that: a) acute illness does not signify a shortened survival time. b) accurate predictions of death are aided by an active total quality management program. c) declining cognitive function and communicative ability are not related to short-term mortality. d) social withdrawal does not help to predict impending death. (2) Which statement about hospice care in the nursing home is NOT correct? a) It improves pain management. b) It is viewed by family members as duplicating conventional nursing home care. c) Hospice residents are likelier than others to have an advanced care plan. d) Nursing home staff tend to believe that hospice care is beneficial to residents. (3) Several studies have found that nursing home residents in a hospice program are _______ other residents to be hospitalized. a) more likely than b) less likely than c) about as likely as (4) Compared to standard nursing home care, families have, in general, reported being _______ hospice services. a) very satisfied with b) satisfied with c) accepting of d) dissatisfied with (5) In a survey of bereavement services, approximately ______ of nursing homes provided educational materials to families. a) 5% b) 25% c) 50% d) 75% Article 4: Management of Constipation in Residents with Dementia: Sorbitol Effectiveness and Cost, L. Volicer et al. (1) This study comparing sorbitol with lactulose in chronically constipated, demented male nursing home residents shows that: a) lactulose is ineffective as an osmotic laxative. b) there is a lower risk of side effects when using sorbitol. c) sorbitol is significantly less costly. d) lactulose leaves a bitter taste in the mouth. (2) Compared to non-demented nursing home residents, those who are demented are ________ of rectally administered laxatives such as bisacodyl suppositories. S106
a) more tolerant b) less tolerant c) about as tolerant (3) After replacing lactulose with sorbitol, there was a statistically significant reduction in the use of: a) Milk of Magnesia. b) bisacodyl suppositories. c) Fleet enemas. d) all of these. e) none of these. (4) When using sorbitol in place of lactulose, the overall cost of managing constipation in this study: a) increased substantially. b) increased slightly. c) did not change. d) decreased slightly. e) decreased substantially. (5) Sorbitol-based management in this study was much less expensive than estimated costs of managing chronic constipation in previous reports. The difference chiefly reflects: a) less staff time. b) lower medication costs. Article 5: Quality Indicators for the Management of Medical Conditions in Nursing Home Residents, D. Saliba et al. (1) Case processes in nursing homes differ in many respects from community-based care of the elderly. An exception is: a) a greater burden of disease in nursing home residents. b) more ongoing integrative care in the nursing home. c) fewer opportunities for monitoring patients in community care. d) a higher quality of care in the nursing home. e) more certainty in the nursing home when implementing planned treatment. (2) Of 114 process-based quality indicators (QIs) developed for 11 medical disorders, approximately _____ were the same as those considered to be valid for elderly community-dwelling persons. a) 5% b) 25% c) 50% d) 80% (3) Nursing home care processes associated with improved outcomes were identified, and subsequently reviewed, by: a) the same panel of experts. b) separate panels of experts. (4) The domains considered for each proposed QI included all of the following EXCEPT: a) validity. b) feasibility of assessment. c) feasibility of implementation. d) proved efficacy. e) importance. JAMDA – May/June 2005
(5) Approximately _______ of the QIs would be inapplicable to severely demented residents and those not expected to live for at least 6 months. a) one third b) half c) two thirds Article 6: Feasibility of Quality Indicators for the Management of Geriatric Syndromes in Nursing Home Residents, D. Saliba et al. (1) Which statement is NOT correct? a) More than two thirds of nursing home residents reportedly are demented, as diagnosed by the Minimum Data Set Cognitive Performance Scale. b) Pressure ulcers are rare in residents of modern nursing homes. c) Nursing home residents fall nearly three times more often than do elderly people living in the community. d) In the 1995 National Nursing Home Survey, more than half of nursing home residents had urinary incontinence. (2) More than 80% of nursing home residents are dependent in at least three basic self-care tasks or activities of daily living. a) True b) False (3) In determining the feasibility of measurement of quality indicators (QIs), implementation of care is assessed using: a) a resident or proxy interview. b) nursing home records. c) either of these. (4) QIs related to ________ are significantly likelier to be rated as having questionable feasibility of implementation. a) geriatric syndromes b) medical conditions (5) Of 68 QIs identified as valid and important in nursing home residents in this study, __________ 25% would be excluded because of advanced dementia or a poor prognosis. a) fewer than b) more than Article 7: Barriers to Providing Osteoporosis Care in Skilled Nursing Facilities: Perceptions of Medical Directors and Directors of Nursing, C. S. Colon-Emeric et al. (1) Both medical directors and directors of nursing (DONs) in this survey strongly agreed that current guidelines for managing osteoporosis in the institutional setting are likely to be: a) effective. b) somewhat effective in some instances. c) ineffective. d) incomplete. SUPPLEMENT
(2) The respondents generally agreed that: a) patients will utilize hip protectors. b) staff lack the time needed to properly implement guidelines. c) bisphonates are safe. d) malpractice liability is a major concern. (3) DONs and other staff were more likely than the medical director to believe that: a) staff turnover is a barrier to osteoporosis care. b) level of staff knowledge is a barrier to osteoporosis care. c) both patients and their relatives are concerned about preventing fractures. (4) Those in practice for longer periods were more concerned than other respondents about: a) staff knowledge. b) malpractice liability. c) both. d) neither. (5) Formal training in geriatrics __________ responses to the survey questions. a) strongly influenced b) modestly influenced c) had no effect on
Article 8: Corticosteroids and Chronic Obstructive Pulmonary Disease in the Nursing Home, A. Rich
(1) Which of the following statements about steroid treatment for nursing home residents with chronic obstructive pulmonary disease (COPD) is NOT accurate? a) Nursing home residents admitted to hospital with an exacerbation of COPD who received inhaled steroids after discharge and were followed up for 12 months had approximately 25% fewer readmissions. b) The same patients had a lower mortality rate than others not on inhaled steroids. c) Ongoing treatment with oral steroids has a demonstrable disease-modifying effect. d) Systemic steroids are reliably effective in patients having acute exacerbations of COPD. (2) Elderly patients with COPD usually require ________ steroid treatment. a) a single b) intermittent c) continuous (3) In the Lung Health Study, patients with COPD who were followed up after 3 years on inhaled steroids had a significantly increased incidence of: a) diabetes. b) myopathy. c) cataracts. d) all of these. e) none of these. S107
(4) Oral steroids should be a routine part of the long-term treatment of nursing home residents with chronic, stable COPD. a) True b) False (5) If spirometric monitoring is not feasible for a nursing home resident with COPD, inhaled steroids: a) should be avoided. b) may be tried and the effects monitored clinically. c) should be given continuously for at least 6 months even if there is no clear response. Article 9: Can We Prevent Aspiration Pneumonia in the Nursing Home?, E. Oh et al. (1) The risk of aspiration pneumonia in older persons is increased by: a) impaired host defenses. b) an increased concentration of bacteria in the oropharynx. c) inability to feed one’s self. d) all of these. (2) Which statement about elderly patients with aspiration pneumonia is NOT accurate? a) Neither an increased respiratory rate nor pleuritic chest pain is consistently noted. b) High fever is invariably present. c) Some patients may not have a productive cough. d) Sudden incontinence may be a presenting feature. (3) Aspiration pneumonia: a) virtually always develops in elderly persons who aspirate solids or liquid. b) is not a risk when swallowing is normal. c) is likelier to occur when the flow of saliva is reduced for any reason. d) is not directly related to the number of decayed teeth. (4) Treatment with an angiotensin-converting enzyme inhibitor could increase levels of substance P in the respiratory tract and thereby _______ the risk of aspiration. a) increase b) decrease (5) Several feeding cues given by nursing staff to dysphagic patients can help to prevent aspiration. An exception is: a) providing finger foods. b) slower feeding. c) small bites. d) coughing forcefully before bites. e) reminding patients to swallow. Article 10: Falls in the Nursing Home: Are They Preventable?, M. Q. Vu et al. (1) The authors of this literature review characterize the results of several randomized, controlled clinical trials S108
(2)
(3)
(4)
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evaluating multifaceted fall prevention programs as being: a) uniformly excellent. b) encouraging. c) uncertain. d) disappointing. Removal of physical bed and chair restraints from nursing home residents: a) lowers the risk of falling. b) reduces the risk of serious injury from a fall. c) has both of these effects. d) has neither of these effects. When nursing home residents exercise regularly, their chance of falling: a) decreases. b) remains the same. c) increases. The use of hip protectors by nursing home residents: a) is convenient and never uncomfortable. b) makes falls less frequent. c) lowers the risk of hip fracture when a resident falls. All of the following drugs or drug classes have been associated with an increased risk of falling EXCEPT: a) angiotensin-converting enzyme inhibitors. b) psychotropic drugs. c) Digoxin. d) antiarrhythmic drugs.
Article 11: Ten Myths About Decision-Making Capacity, L. Ganzini et al. (1) Which ONE of the following statements about who assesses decision-making capacity and who is subject to this evaluation is correct. a) Only experts in mental health are qualified to assess a patient’s decision-making capacity. b) It may be advantageous for primary-care clinicians to make the assessment. c) When a patient makes a decision that conflicts with medical advice, a lack of decision-making capacity may be assumed. d) a patient who complies with all medical advice may be presumed to possess decision-making capacity. (2) How do judgments of DMC relate to competency and to cognitive impairment? a) It is not possible for a legally incompetent person to remain able to make sound health care decisions. b) DMC and adequate cognitive function amount to the same thing. c) Tests of cognitive ability should not be used to evaluate a patient’s DMC. (3) It may be taken for granted that patients who _________ necessarily lack DMC. a) have dementia or schizophrenia b) have been involuntarily committed c) are in either of these categories JAMDA – May/June 2005
(4) Which statement is NOT accurate? a) A lack of DMC is always permanent, so that patients need not be reassessed. b) Important decisions should be delayed if possible when loss of DMC is expected to be temporary. c) A loss of DMC does not mean that the patient cannot make choices about such things as handling money or living independently. (5) A person given inappropriate or inconsistent information can still be expected to make informed decisions. a) True b) False
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(4) Article 12: Quality Palliative Care in Long-Term Care Settings, P. A. S. Winn and A. N. Dentino (1) Which of these statements is NOT accurate? a) Air hunger in the form of breathlessness or dyspnea usually is distinct from tachypnea etiologically and pathophysiologically. b) Progressive weight loss is very unusual in the last 6 to 12 months of life.
(5)
c) Delirium at the end of life may be a result of fecal impaction. d) Clinical depression may account for progressive weakness in patients with advanced disease. When a dyspneic patient is placed on opioid therapy, respiratory distress is least frequent: a) when starting treatment. b) when opioid tolerance has developed. c) in the last days or weeks of life. Anticholinergic drugs may: a) relieve nausea and vomiting. b) worsen nausea and vomiting. c) have either of these effects. Terminal delirium can be adequately treated by: a) a benzodiazepine such as lorazepam. b) a neuroleptic agent such as haloperidol. c) both these drugs in combination. d) any of these options. Criteria for admission to hospice care do NOT include: a) end-stage disease. b) significant functional decline. c) critically compromised nutritional status. d) having a do-not-resuscitate request, living will, or advance directive for health care.
Part II. Impact of CME Activity Please answer questions 1–5 below by circling one number on the scale provided (5 ⴝ strongly agree; 0 ⴝ strongly disagree). 1.
2.
3.
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This article reinforced my experience and my practice approach on this subject. Article 1: Effect of Megestrol Acetate on Food and Fluid Intake 5 4 Article 2: Barriers to Managing Pain 5 4 Article 3: End-of-Life Care in US Nursing Homes 5 4 Article 4: Management of Constipation 5 4 Article 5: QIs for Management of Medical Conditions 5 4 Article 6: Feasibility of QIs - Management of Geriatric Syndromes 5 4 Article 7: Barriers to Providing Osteoporosis Care 5 4 Article 8: Corticosteroids and COPD 5 4 Article 9: Can We Prevent Aspiration Pneumonia in the NH 5 4 Article 10: Falls in the Nursing Home 5 4 Article 11: Ten Myths about Decision-Making Capacity 5 4 Article 12: Quality Palliative Care in LTC Settings 5 4
1 1 1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0 0 0
This article provided a different perspective from which to approach management of this subject. Article 1: Effect of Megestrol Acetate on Food and Fluid Intake 5 4 3 2 Article 2: Barriers to Managing Pain 5 4 3 2 Article 3: End-of-Life Care in US Nursing Homes 5 4 3 2 Article 4: Management of Constipation 5 4 3 2 Article 5: QIs for Management of Medical Conditions 5 4 3 2 Article 6: Feasibility of QIs – Management of Geriatric Syndromes 5 4 3 2 Article 7: Barriers to Providing Osteoporosis Care 5 4 3 2 Article 8: Corticosteroids and COPD 5 4 3 2 Article 9: Can We Prevent Aspiration Pneumonia in the NH 5 4 3 2 Article 10: Falls in the Nursing Home 5 4 3 2 Article 11: Ten Myths about Decision-Making Capacity 5 4 3 2 Article 12: Qualtiy Palliative Care in LTC Settings 5 4 3 2
1 1 1 1 1 1 1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0 0
I plan to seek more information about this subject. Article 1: Effect of Megestrol Acetate on Food and Fluid Intake Article 2: Barriers to Managing Pain Article 3: End-of-Life Care in US Nursing Homes Article 4: Management of Constipation Article 5: QIs for Management of Medical Conditions Article 6: Feasibility of QIs – Management of Geriatric Syndromes
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Article Article Article Article Article Article 4.
7: Barriers to Providing Osteoporosis Care 8: Corticosteroids and COPD 9: Can We Prevent Aspiration Pneumonia in the NH 10: Falls in the Nursing Home 11: Ten Myths about Decision-Making Capacity 12: Quality Palliative Care in LTC Settings
5 5 5 5 5 5
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I plan to discuss this information with colleagues to learn more about to this subject. Article 1: Effect of Megestrol Acetate on Food and Fluid Intake Article 2: Barriers to Managing Pain Article 3: End-of-Life Care in US Nursing Homes Article 4: Management of Constipation Article 5: QIs for Management of Medical Conditions Article 6: Feasibility of QIs – Management of Geriatric Syndromes Article 7: Barriers to Providing Osteoporosis Care Article 8: Corticosteroids and COPD Article 9: Can We Prevent Aspiration Pneumonia in the NH Article 10: Falls in the Nursing Home Article 11: Ten Myths about Decision-Making Capacity Article 12: Quality Palliative Care in LTC Settings
my peers’ perceptions and approaches 5 5 5 5 5 5 5 5 5 5 5 5
4 4 4 4 4 4 4 4 4 4 4 4
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5.
Having read the article(s), I plan to make changes in my practice.
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What change(s), if any, do you plan to make in your practice as a result of reading the articles?
Part III. Quality of CME Activity 1.
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To what extent did the content of each article meet the stated learning objective(s)? number on the scale below: 5 ⴝ entirely met; 0 ⴝ not met at all.) Article 1: Effect of Megestrol Acetate on Food and Fluid Intake 5 4 Article 2: Barriers to Managing Pain 5 4 Article 3: End-of-Life Care in US Nursing Homes 5 4 Article 4: Management of Constipation 5 4 Article 5: QIs for Management of Medical Conditions 5 4 Article 6: Feasibility of QIs – Management of Geriatric Syndromes 5 4 Article 7: Barriers to Providing Osteoporosis Care 5 4 Article 8: Corticosteroids and COPD 5 4 Article 9: Can We Prevent Aspiration Pneumonia in the NH 5 4 Article 10: Falls in the Nursing Home 5 4 Article 11: Ten Myths about Decision-Making Capacity 5 4 Article 12: Quality Palliative Care in LTC Settings 5 4
(Please circle one 3 3 3 3 3 3 3 3 3 3 3 3
2 2 2 2 2 2 2 2 2 2 2 2
How clearly was the information presented in each article? (Please circle one number on the scale ⴝ extremely clear; 0 ⴝ extremely unclear.) Article 1: Effect of Megestrol Acetate on Food and Fluid Intake 5 4 3 2 Article 2: Barriers to Managing Pain 5 4 3 2 Article 3: End-of-Life Care in US Nursing Homes 5 4 3 2 Article 4: Management of Constipation 5 4 3 2 Article 5: QIs for Mangement of Medical Conditions 5 4 3 2 Article 6: Feasibility of QIs – Management of Geriatric Syndromes 5 4 3 2 Article 7: Barriers to Providing Osteoporosis Care 5 4 3 2 Article 8: Corticosteroids and COPD 5 4 3 2 Article 9: Can We Prevent Aspiration Pneumonia in the NH 5 4 3 2 Article 10: Falls in the Nursing Home 5 4 3 2 Article 11: Ten Myths about Decision-Making Capacity 5 4 3 2 Article 12: Quality Palliative Care in LTC Settings 5 4 3 2
1 1 1 1 1 1 1 1 1 1 1 1
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below: 5 1 1 1 1 1 1 1 1 1 1 1 1
On the scale below, please rate the overall quality of this CME activity. (Please circle one number: 5 ⴝ excellent quality; 0 ⴝ poorest quality.) 5 4 3 2 1
0 0 0 0 0 0 0 0 0 0 0 0 0
JAMDA – May/June 2005
4.
Did you perceive any evidence of bias for or against any commercial products? If yes, please note in which article(s) and explain. __ Yes __ No ____________________________________________________________________________________________ ____________________________________________________________________________________________
Part IV. Statement of Completion I attest to having read and completed the articles listed below and request credit hours in category 1 toward the AMA PRA. I understand that credit hours are awarded based on a passing score of 70% or higher on the test(s) that I have completed. __ Article 1; __ Article 2; __ Article 3; __ Article 4; __ Article 5; __ Article 6; __ Article 7; __ Article 8 __ Article 9; __ Article 10; __ Article 11; __ Article 12. Signature Date Part V. Please list topics for articles that you would like to see provided in future journals:
Part VI. In order to receive your certificate of credit: Identify your preference for receipt of certificate by e-mail or fax with an *. Please PRINT legibly or type: Name Address Telephone number FAX number E-mail address Return this CME Post-Test and Evaluation Form to Suzanne Harris via fax to (410) 740-4572; or by e-mail to [email protected].
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