Mr. Roberts, a 72-year-old patient who has sought medical care on an intermittent basis in the past, complains of aching discomfort in his perineal area, urinary urgency, and frequency for the past few years. He also complains of insomnia and intermittent anxiety that he attributes to loneliness after his wife’s death about a year ago. Digital rectal examination (DRE) reveals a slightly enlarged, nontender prostate with no palpable nodules. Perineal examination is normal. Bladder scan is unremarkable and postvoid residual urine volume is 50 mL. Urinalysis shows no WBCs or RBCs. Urine culture is negative. Previous treatment has included dietary modifications and alpha-blocker medication. What is the most appropriate next step?

Correct Answer: D

Rationale: The correct answer is D: Screen for depression. The patient's symptoms of insomnia, anxiety, and loneliness after his wife's death suggest he may be experiencing depression, which can manifest as physical symptoms like urinary urgency and frequency. Since the patient has already received appropriate treatment for his urinary symptoms, addressing his mental health is the next crucial step. This can help improve his overall well-being and quality of life. Starting an antibiotic course (choice A) is not indicated as there are no signs of infection. Initiating a 5-alpha-reductase inhibitor (choice B) is not necessary given the absence of specific indications such as obstructive voiding symptoms. Urodynamic testing (choice C) is not warranted at this stage as the patient's history and findings do not suggest underlying bladder dysfunction.

Correct Answer: B

Rationale: The correct answer is B: Haloperidol. Haloperidol is a first-line antipsychotic commonly used to manage agitation in delirium due to its rapid onset and minimal sedative effects. It acts by blocking dopamine receptors in the brain, which helps to reduce agitation and combativeness. Melatonin (A) is not effective for acute agitation. Diazepam (C) can worsen confusion in elderly patients and is not recommended for delirium. Gabapentin (D) is not indicated for managing agitation in delirium and may not be effective in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Extrapyramidal symptoms. Selective serotonin reuptake inhibitors (SSRIs) are not known to cause extrapyramidal symptoms, which are more commonly associated with antipsychotic medications. SSRIs can cause gastrointestinal bleeding, irritation, and hyponatremia in older adults due to their effects on serotonin levels and platelet function. Extrapyramidal symptoms involve movement disorders like tremors and muscle rigidity, which are not typically seen with SSRIs. Therefore, A is the correct answer.

Correct Answer: C

Rationale: The correct answer is C because clinical diagnosis of anxiety or depression can indeed have an effect on frailty rates. Anxiety and depression can contribute to the development and progression of frailty through various mechanisms such as decreased physical activity, poor nutrition, and social isolation. This can lead to a higher risk of frailty in individuals with mental health issues. Choices A, B, and D are incorrect because both prominent frailty models (e.g., Fried's phenotype model and Rockwood's accumulation of deficits model) do consider age as a component for defining frailty, individuals who are prefrail are at a higher risk of progressing to frailty rather than becoming robust, and frailty diagnosis has been shown to be valuable in preoperative assessment as it helps identify patients who may not do well with surgical interventions.

Correct Answer: C

Rationale: The correct answer is C: Stop aspirin and begin apixaban 5 mg twice a day. The rationale is that for stroke risk reduction in nonvalvular atrial fibrillation, anticoagulation therapy with direct oral anticoagulants (DOACs) like apixaban is preferred over antiplatelet therapy like aspirin. DOACs have been shown to be more effective in reducing stroke risk with a lower bleeding risk compared to warfarin. Choice A is incorrect as aspirin alone is not sufficient for stroke prevention in atrial fibrillation. Choice B is incorrect as warfarin has more monitoring requirements and potential drug interactions compared to DOACs like apixaban. Choice D is incorrect as aspirin and apixaban together are not recommended due to increased bleeding risk.