Assessment of the Older Adult: Communication, Atypical Presentations, and the GEMS Diamond Practice Questions

25 multiple-choice questions on Assessment of the older adult: communication, atypical presentations, and the GEMS diamond for paramedic and EMT students, from Chapter 45 (Geriatric Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. The four elements of the GEMS diamond are:

   1. A. Geriatric, environmental, medical, and social
   2. B. General, emotional, mental, and safety
   3. C. Geriatric, emergency, medication, and support
   4. D. Gait, eyesight, memory, and skin
   Show answer

   Answer: A. Geriatric, environmental, medical, and social

   GEMS stands for Geriatric, Environmental, Medical, and Social assessment, a reminder to look beyond the chief complaint. Medication review and support networks fall within the medical and social parts rather than being separate letters.

2. Under the 'E' of the GEMS diamond, you should evaluate:

   1. A. The patient's list of chronic medical conditions
   2. B. Whether the patient has family or friends nearby
   3. C. How the patient's skin and mucosa look
   4. D. Home hazards such as loose rugs and poor lighting
   Show answer

   Answer: D. Home hazards such as loose rugs and poor lighting

   The environmental assessment looks at the home itself: fall hazards, temperature, cleanliness, food, and working utilities. Family and friends belong to the social ('S') component.

3. Under the 'S' of the GEMS diamond, the most relevant question is whether the patient:

   1. A. Has stairs or loose rugs in the home
   2. B. Has people who help and check on them
   3. C. Takes more than five medications a day
   4. D. Has age-normal vital signs on arrival
   Show answer

   Answer: B. Has people who help and check on them

   The social assessment covers support networks, isolation, and the ability to get food, medicines, and help. Home hazards are environmental, and medication count belongs to the medical assessment.

4. An 86-year-old man with hearing loss is having trouble understanding you. The best technique is to:

   1. A. Face him and speak slowly in a lower pitch
   2. B. Raise your voice to a near shout
   3. C. Speak from behind so he can concentrate
   4. D. Direct your questions to his caregiver instead
   Show answer

   Answer: A. Face him and speak slowly in a lower pitch

   Facing the patient allows lip reading, and a slower, lower-pitched voice suits age-related high-frequency loss. Shouting distorts speech and raises its pitch, making it harder to understand.

5. Before questioning an 80-year-old woman who wears hearing aids and glasses, you should first:

   1. A. Ask her daughter to answer for her
   2. B. Speak louder than normal to compensate
   3. C. Remove them to examine her head
   4. D. Make sure she has them on and working
   Show answer

   Answer: D. Make sure she has them on and working

   Sensory aids let the patient take part in her own history, so confirm they are in place and switched on. Routing questions to family disregards a patient who may be fully able to answer.

6. Which approach best reflects sensitive, patient-focused care for an older adult?

   1. A. Using closed questions to keep the history brief
   2. B. Speaking mainly to the family rather than to the patient
   3. C. Explaining each step and allowing time to answer
   4. D. Speaking loudly in case her hearing is reduced
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   Answer: C. Explaining each step and allowing time to answer

   Older adults may process questions more slowly and benefit from clear explanations, privacy, and patience, which also yields a more accurate history. Quick closed questions asked to keep the history brief can miss vague or atypical complaints. Speaking loudly assumes a hearing loss that may not exist and can come across as disrespectful; check hearing and adjust instead. Talking past the patient to the family erodes trust and dignity.

7. An 82-year-old woman with diabetes reports new weakness and fatigue for 2 days but no chest pain. Which condition must you consider first?

   1. A. Normal age-related fatigue
   2. B. Acute coronary syndrome
   3. C. Seasonal depression
   4. D. Simple dehydration
   Show answer

   Answer: B. Acute coronary syndrome

   Older adults, women, and people with diabetes often have MI without chest pain, presenting with weakness, dyspnea, fatigue, or confusion, so obtain a 12-lead ECG. Attributing new weakness to age risks missing a time-sensitive event.

8. Which statement about the chief complaint of older adults is most accurate?

   1. A. It is usually precise and easy to localize
   2. B. It is rarely related to a medication change
   3. C. It reliably reflects the most serious problem
   4. D. It may be vague and miss the real problem
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   Answer: D. It may be vague and miss the real problem

   Complaints such as 'weakness' or 'not feeling right' may mask MI, sepsis, or a drug reaction, and older adults often have several complaints at once. Do not assume the stated complaint is the most serious problem.

9. Basic activities of daily living (ADLs) include:

   1. A. Driving, shopping, and paying bills
   2. B. Bathing, dressing, eating, and toileting
   3. C. Using a telephone and managing finances
   4. D. Cooking meals and doing housework
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   Answer: B. Bathing, dressing, eating, and toileting

   Basic ADLs are self-care tasks: bathing, dressing, eating, toileting, transferring, and continence. Phone use, finances, shopping, and housework are instrumental ADLs, which are usually lost earlier.

10. A daughter reports that her 80-year-old father can no longer manage his pill box or pay his bills but still bathes and dresses himself. This describes a decline in his:

    1. A. Basic self-care activities of daily living
    2. B. Short-term memory recall
    3. C. Instrumental activities of daily living
    4. D. Decision-making capacity
    Show answer

    Answer: C. Instrumental activities of daily living

    Managing medications and finances are instrumental ADLs, which need planning and often decline first in early dementia. His basic self-care ADLs such as bathing and dressing are still intact.

11. A 79-year-old fainted at home and is now alert with a BP of 128/74 mm Hg supine. To look for volume loss or a drug effect, you should:

    1. A. Check orthostatic vital signs if safe to do so
    2. B. Give a 1-liter bolus before further assessment
    3. C. Assume a vasovagal faint and release the patient
    4. D. Recheck the supine BP in 15 minutes
    Show answer

    Answer: A. Check orthostatic vital signs if safe to do so

    A drop in BP or rise in pulse on sitting or standing suggests hypovolemia, bleeding, or an antihypertensive effect, common causes of syncope in older adults. Releasing the patient as 'vasovagal' is unsafe until cardiac and volume causes are considered.

12. Bedside hydration signs are unreliable in older adults, and no single sign rules dehydration in or out. Of these, the most useful supporting sign is:

    1. A. Skin turgor on the forearm
    2. B. Capillary refill in the toes
    3. C. The color of the nail beds
    4. D. Dry tongue and oral mucosa
    Show answer

    Answer: D. Dry tongue and oral mucosa

    No single bedside sign reliably detects dehydration in older adults, so findings are combined with the history, intake, orthostatic changes, and mental status. A dry tongue and oral mucosa (and a dry axilla) give some support, though mouth breathing and medications can also dry the mouth. Loss of skin elasticity with age makes skin turgor on the forearm unreliable. Capillary refill in the toes is slowed by age, cold, and vascular disease. The color of the nail beds reflects oxygenation, perfusion, and anemia rather than hydration.

13. A 90-year-old bedbound resident has fine crackles at both lung bases but no dyspnea and a normal SpO2. You should interpret this by:

    1. A. Comparing with her baseline and other findings
    2. B. Treating as acute pulmonary edema with nitroglycerin
    3. C. Ignoring the finding because crackles are normal
    4. D. Assuming pneumonia and withholding oxygen
    Show answer

    Answer: A. Comparing with her baseline and other findings

    Basilar crackles can be chronic in bedbound older adults from atelectasis, so interpret them alongside the baseline, vital signs, and work of breathing. Treating an isolated finding as pulmonary edema in a stable patient risks hypotension.

14. While assessing an alert 75-year-old, you note an irregular, unequal left pupil. The best next step is to:

    1. A. Assume a herniation syndrome and hyperventilate
    2. B. Give naloxone for possible opioid toxicity
    3. C. Ask about prior eye surgery or eye disease
    4. D. Document it as normal aging without asking
    Show answer

    Answer: C. Ask about prior eye surgery or eye disease

    Cataract surgery, glaucoma drops, and other eye conditions commonly cause irregular or unequal pupils, so ask before blaming a neurologic injury. An alert patient with a stable exam is not herniating.

15. On a bedbound resident's sacrum you find an open wound with full-thickness skin loss. Yellow fat is visible, but no bone, tendon, or muscle. This pressure injury is stage:

    1. A. 1
    2. B. 3
    3. C. 2
    4. D. 4
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    Answer: B. 3

    Stage 3 is full-thickness skin loss in which subcutaneous fat may be visible but bone, tendon, and muscle are not; describe it objectively (size, depth, odor, drainage) in the chart and handoff, because advanced pressure injuries are a sepsis source and can signal neglect. Stage 1 is intact skin with redness that does not blanch. Stage 2 is partial-thickness loss with exposed dermis, such as a shallow open sore or an intact blister, with no fat visible. Stage 4 exposes bone, tendon, muscle, or cartilage. (NPIAP staging.)

16. An 84-year-old with a possible wrist fracture rates her pain 2 of 10 but grimaces whenever you move her arm. You should:

    1. A. Accept the low score and withhold analgesia
    2. B. Assume dementia and stop asking about pain
    3. C. Weigh her behavior along with her rating
    4. D. Rate her pain yourself as 10 of 10
    Show answer

    Answer: C. Weigh her behavior along with her rating

    Older adults often underreport pain from stoicism or fear of being a burden, so nonverbal signs such as grimacing and guarding matter. Withholding analgesia because of a low number leaves pain undertreated.

17. An 83-year-old with mild dementia refuses transport after a fall. Before accepting the refusal, you must determine whether she:

    1. A. Has a family member who agrees with her
    2. B. Can understand risks and explain her choice
    3. C. Has been diagnosed with any form of dementia
    4. D. Is able to walk to the door without help
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    Answer: B. Can understand risks and explain her choice

    Decision-making capacity is specific to the decision: the patient must understand the situation, risks, and alternatives and communicate a consistent choice. A dementia diagnosis alone does not remove capacity.

18. An 88-year-old has been 'not herself' for a day. Her HR is 84, BP 132/78, temperature 37.0 °C, and respiratory rate 28. Which finding is the most important clue to serious illness?

    1. A. Heart rate of 84
    2. B. BP of 132/78 mm Hg
    3. C. Temperature of 37.0 °C
    4. D. Respiratory rate of 28
    Show answer

    Answer: D. Respiratory rate of 28

    In older adults, tachypnea is often the earliest and most sensitive sign of pneumonia, sepsis, heart failure, or pulmonary embolism, appearing before fever, tachycardia, or hypotension; a rate of 28 should be counted carefully and taken seriously. A heart rate of 84 can hide shock in a patient on beta blockers but is not itself the clue here. A BP of 132/78 may even be low for a chronically hypertensive patient, but by itself it is not alarming. A normal temperature does not exclude infection because the febrile response is blunted.

19. In the kitchen of a 79-year-old man with weakness, you find spoiled food and an empty refrigerator. This finding most suggests:

    1. A. Malnutrition or self-care decline
    2. B. A power outage that spoiled his food
    3. C. Normal loss of appetite with aging
    4. D. Adequate support from his family
    Show answer

    Answer: A. Malnutrition or self-care decline

    An empty or spoiled refrigerator suggests he cannot shop or cook, pointing to malnutrition, cognitive decline, or self-neglect; document it and include it in the handoff. A power outage could spoil food but would not leave the refrigerator empty, and the modest appetite changes of aging do not explain a home with nothing to eat. The finding argues against, not for, adequate family support.

20. When an older patient arrives with a caregiver, how should you take the history?

    1. A. Ask the patient first, then the caregiver
    2. B. Direct your questions to the caregiver
    3. C. Ask the caregiver to leave the room each time
    4. D. Rely on the facility's written records instead
    Show answer

    Answer: A. Ask the patient first, then the caregiver

    Speaking to the patient first respects autonomy and often yields accurate information, while the caregiver can fill gaps and describe the patient's usual baseline. Directing the questions to the caregiver treats a capable patient as absent. Sending the caregiver out on every call loses a valuable source of baseline information. Facility records help but may be outdated and do not replace the patient's own account.

21. During a community paramedicine visit, an 81-year-old takes 18 seconds to stand from a chair, walk 3 m (10 ft), turn, walk back, and sit. This result suggests:

    1. A. Normal for someone over 80
    2. B. A gait problem but no added fall risk
    3. C. Weak legs with a normal sense of balance
    4. D. A high risk of a future fall
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    Answer: D. A high risk of a future fall

    The Timed Up and Go test is part of CDC's STEADI fall-risk assessment; taking 12 seconds or longer to complete it indicates increased fall risk, so 18 seconds calls for referral for strength, balance, medication, vision, and home-safety review. The 12-second cutoff is used for older adults generally, so 18 seconds is not a normal result for someone over 80, and a low-risk result would be under 12 seconds. A slow time is itself the fall-risk finding, so it cannot be read as a gait problem without added risk. The test combines strength, gait, and balance and cannot show that her balance is normal.

22. Which pair of findings is part of the frailty phenotype in older adults?

    1. A. Elevated BP and high cholesterol levels
    2. B. Unintentional weight loss and slow gait
    3. C. Hearing loss and cataracts in both eyes
    4. D. Gray hair and thinning skin with age
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    Answer: B. Unintentional weight loss and slow gait

    The frailty phenotype includes unintentional weight loss, exhaustion, weakness (low grip strength), slow walking speed, and low activity, and frail patients decompensate with minor stressors. Hypertension and sensory loss are common in older adults but are not frailty criteria.

23. An 81-year-old grimaces and holds his belly, but when asked he says he has 'no pain.' When you ask whether he has any ache or discomfort, he says yes. This shows that older adults:

    1. A. Feel less pain as nerves age
    2. B. Rarely have serious belly problems
    3. C. May describe pain using other words
    4. D. Exaggerate symptoms to get attention
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    Answer: C. May describe pain using other words

    Many older adults deny 'pain' but admit to aching, soreness, or discomfort, and some see pain as a normal part of aging. Asking with several words, and watching behavior, finds pain that a single question misses. Serious abdominal disease is more common, not less, in older adults and often presents with mild complaints.

24. When performing a physical exam on an older adult, you should:

    1. A. Assess through clothing to preserve modesty
    2. B. Skip the back unless she reports pain
    3. C. Protect privacy and keep the patient warm
    4. D. Limit the exam to the area of complaint
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    Answer: C. Protect privacy and keep the patient warm

    Older adults lose heat quickly and value modesty, so expose one area at a time and then cover it. Assessing through clothing misses bruises, skin tears, and pressure injuries, and the back and sacrum should be inspected even without a pain complaint because older adults often underreport pain. Limiting the exam to the complaint misses injuries, pressure ulcers, and signs of abuse that a full survey can reveal.

25. Medical information programs such as File of Life and Vial of Life usually place the patient's form:

    1. A. Inside a bedroom closet
    2. B. In the car's glove box
    3. C. In a bathroom medicine cabinet
    4. D. On or in the refrigerator
    Show answer

    Answer: D. On or in the refrigerator

    These programs keep medical history, medications, and contacts on or in the refrigerator, where EMS is taught to look. Checking there early saves time when the patient cannot give a history.