Caregiver support and education US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Caregiver support and education. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Caregiver support and education US Medical PG Question 1: A 71-year-old man is brought in by his daughter for forgetfulness. The daughter finds herself repeating things she has already told him. She also reports that the patient recently missed a lunch date they had scheduled. She is worried that he may have Alzheimer's disease because her mother had it, and this is how it started. The patient states that he sometimes forgets where he puts his glasses, but this is not new. He also admits to missing appointments if he doesn't write them in his planner, but he states “I always remember birthdays.” Since his wife passed, the patient has been responsible for all the finances, and the daughter confirms that he pays the bills on time. He cooks for himself, though sometimes he is “lazy” and will order fast food. The patient’s medical history is significant for hypertension, atherosclerosis, and rheumatoid arthritis. His medications include aspirin, lisinopril, atorvastatin, and methotrexate. He was also treated for depression for the first year following his wife's death, which was 3 years ago. He currently denies feelings of depression or suicidal ideation, but admits that he has been thinking more about death since some of his weekly golfing buddies have passed away. He drinks a beer every night with dinner and smokes cigars socially. A physical examination reveals ulnar deviation of the fingers, decreased grip strength, and a slow, steady gait. The patient is able to spell a 5-letter word backwards and remembers 3/3 items after 5 minutes. Which of the following diagnoses most likely explains the patient’s symptoms?
- A. Vascular dementia
- B. Alzheimer disease
- C. Frontotemporal dementia
- D. Normal aging (Correct Answer)
- E. Major depressive disorder
Caregiver support and education Explanation: ***Normal aging***
- The patient exhibits age-associated memory impairment, such as occasional forgetfulness (e.g., misplacing glasses, missing an appointment if not written down), but his **activities of daily living** (ADLs) and instrumental ADLs (IADLs) like managing finances and cooking are **intact**.
- His cognitive function, evidenced by recalling 3/3 items after 5 minutes and spelling a 5-letter word backward, is **normal for his age**, and there's no significant decline affecting his overall function.
*Vascular dementia*
- This dementia type typically presents with a **step-wise decline** in cognitive function and often has **focal neurological deficits** corresponding to ischemic events.
- The patient's history of **hypertension and atherosclerosis** are risk factors, but his current symptoms do not suggest a significant, progressive decline or focal neurological signs indicative of vascular dementia.
*Alzheimer disease*
- Characterized by **progressive memory decline** that significantly impacts ADLs and IADLs, often starting with difficulty learning and recalling new information, which is not evident here.
- While familial history is a risk factor, the patient's ability to manage finances, cook, and perform well on short cognitive tests makes Alzheimer's less likely at this stage.
*Frontotemporal dementia*
- Primarily affects **personality, behavior, and language** earlier than memory, often leading to disinhibition, apathy, or language difficulties.
- The patient's presentation does not describe significant changes in personality or behavior, distinguishing it from frontotemporal dementia.
*Major depressive disorder*
- Although the patient had a history of depression and mentions thinking about death (contextually appropriate given friends' recent deaths), he **denies current feelings of depression or suicidal ideation**.
- His forgetfulness is mild and does not show features of **pseudodementia** (depression-related cognitive impairment), which typically presents with more prominent subjective complaints, poor effort on testing, and greater functional impairment than objective findings suggest.
- His **normal performance** on cognitive testing (3/3 recall) further argues against depression-related cognitive dysfunction.
Caregiver support and education US Medical PG Question 2: A 61-year-old woman presents to her primary care doctor with her son who reports that his mother is not acting like herself. She has gotten lost while driving several times in the past 2 months and appears to be talking to herself frequently. Of note, the patient’s husband died from a stroke 4 months ago. The patient reports feeling sad and guilty for causing so much trouble for her son. Her appetite has decreased since her husband died. On examination, she is oriented to person, place, and time. She is inattentive, and her speech is disorganized. She shakes her hand throughout the exam without realizing it. Her gait is slow and appears unstable. This patient’s condition would most likely benefit from which of the following medications?
- A. Bromocriptine
- B. Rivastigmine (Correct Answer)
- C. Reserpine
- D. Selegiline
- E. Levodopa
Caregiver support and education Explanation: ***Rivastigmine***
- The patient's symptoms of progressive cognitive decline (getting lost while driving, talking to herself), inattention, disorganized speech, and motor symptoms (hand tremor, unstable gait) suggest **Dementia with Lewy Bodies (DLB)**.
- Key features supporting DLB over depression with pseudodementia: **involuntary hand tremor**, **unstable gait**, **visual hallucinations** (talking to herself), and **disorganized speech** occurring with cognitive decline.
- **Rivastigmine**, a cholinesterase inhibitor, is a first-line treatment for the cognitive and behavioral symptoms in DLB and is FDA-approved for this indication.
- While bereavement-related depression is present, the prominent motor and cognitive features indicate an underlying neurodegenerative process.
*Bromocriptine*
- This is a **dopamine agonist** typically used for Parkinson's disease, hyperprolactinemia, and acromegaly.
- While Parkinsonian features are present in DLB, dopamine agonists can worsen **psychotic symptoms** (hallucinations) common in DLB, making them unsuitable as first-line treatment.
*Reserpine*
- **Reserpine** depletes catecholamines and serotonin and is primarily used as an antihypertensive.
- Its use in dementia is not indicated and could exacerbate mood, cognitive issues, and Parkinsonian symptoms due to its dopamine-depleting effects.
- This medication is rarely used in modern practice.
*Selegiline*
- **Selegiline** is a **monoamine oxidase-B (MAO-B) inhibitor** used in Parkinson's disease to reduce dopamine breakdown.
- While it may help with motor symptoms, its benefit in DLB is less established compared to cholinesterase inhibitors.
- The prominent **cognitive and behavioral symptoms** in this patient make cholinesterase inhibition the priority.
*Levodopa*
- **Levodopa** is a dopamine precursor and the most effective medication for motor symptoms of Parkinson's disease.
- In DLB, while it can improve motor symptoms, it can significantly worsen **psychotic symptoms** (hallucinations, delusions) and cognitive fluctuations.
- Given the prominent non-motor symptoms and existing hallucinations, levodopa is not first-line therapy for this patient.
Caregiver support and education US Medical PG Question 3: A 72-year-old man is brought in by his daughter who is concerned about his recent memory impairment. The patient’s daughter says she has noticed impairment in memory and functioning for the past month. She says that he has forgotten to pay bills and go shopping, and, as a result, the electricity was cut off due to non-payment. She also says that last week, he turned the stove on and forgot about it, resulting in a kitchen fire. The patient has lived by himself since his wife died last year. He fondly recalls living with his wife and how much he misses her. He admits that he feels ‘down’ most days of the week living on his own and doesn’t have much energy. When asked about the kitchen fire and problems with the electricity, he gets defensive and angry. At the patient’s last routine check-up 3 months ago, he was healthy with no medical problems. His vital signs are within normal limits. On physical examination, the patient appears to have a flat affect. Which of the following is the most likely diagnosis in this patient?
- A. Pseudodementia (Correct Answer)
- B. Pick’s disease
- C. Delirium
- D. Dementia
- E. Both dementia and delirium
Caregiver support and education Explanation: ***Pseudodementia***
- The rapid onset of symptoms (within the last month), coupled with the patient's **depressed mood** (feeling 'down', low energy, flat affect, recent loss of spouse), strongly suggests **pseudodementia**, which is cognitive impairment mimicking dementia but caused by depression.
- Patients with pseudodementia often highlight their **memory problems**, get defensive about cognitive failures, and show a more global cognitive decline rather than specific deficits, all of which are present in this case.
*Pick’s disease*
- This is a form of **frontotemporal dementia** characterized by prominent behavioral changes and language difficulties, which are not the primary features here.
- Cognitive decline in Pick's disease is typically **insidious and progressive**, not acute and linked to a depressive episode.
*Delirium*
- Delirium is characterized by an **acute onset of fluctuating attention** and **altered consciousness**, often with disorientation and disorganized thinking.
- There is no mention of fluctuating mental status or altered consciousness, and the patient's presentation points more towards a mood disorder impacting cognition over a few weeks, rather than hours to days.
*Dementia*
- Dementia typically has an **insidious onset** and a **gradual, progressive decline** in cognitive function over months to years.
- While the symptoms include memory impairment and functional decline, the rapid onset, association with a depressive episode, and patient's awareness/defensiveness about cognitive issues are more characteristic of pseudodementia.
*Both dementia and delirium*
- While both conditions cause cognitive impairment, the patient's symptoms do not align with the fluctuating course and acute altered consciousness of delirium, nor the typical insidious progression of true dementia.
- The presentation is more consistent with a **depressive pseudo-dementia**, and there's no evidence to suggest co-occurrence of both dementia and delirium.
Caregiver support and education US Medical PG Question 4: A 5-year-old non-verbal child with a history of autism is brought into the emergency department by his grandmother. The patient’s grandmother is concerned her grandchild is being abused at home. The patient lives in an apartment with his mother, step-father, and two older brothers in low-income housing. The department of social services has an open case regarding this patient and his family. The patient is afebrile. His vital signs include: blood pressure 97/62 mm Hg, pulse 175/min, respiratory rate 62/min. Physical examination reveals a malnourished and dehydrated child in dirty and foul-smelling clothes. Which one of the following people is most likely abusing this patient?
- A. Mother (Correct Answer)
- B. Neighbor
- C. Brother
- D. Stranger
- E. Step-father
Caregiver support and education Explanation: ***Mother***
- **Child abuse** is complex, but the **mother (or primary caregiver)** is often the abuser, especially in cases where the child is non-verbal and has a disability.
- The child's **malnutrition and poor hygiene** point to neglect, which is a form of abuse, and the primary caregiver is responsible for the child's basic needs.
*Neighbor*
- While abuse can occur outside the home, a **neighbor is highly unlikely** to be responsible for the child's chronic neglect, malnutrition, and dehydration, given the living circumstances described.
- **Neighbors typically do not have consistent, unsupervised access** to a child in a manner that would lead to such severe and ongoing neglect.
*Brother*
- Although **siblings can be perpetrators of abuse**, particularly physical or sexual abuse, it is **uncommon for siblings to be responsible for severe neglect** leading to malnutrition and chronic poor hygiene in a younger child.
- This kind of chronic neglect usually points to a **primary caregiver's failure** to provide basic needs.
*Stranger*
- Abuse by a **stranger is relatively rare** compared to abuse by a family member or acquaintance.
- The consistent pattern of **neglect, malnutrition, and poor hygiene** suggests ongoing failure of care within the home environment, not a single or intermittent encounter with a stranger.
*Step-father*
- A **step-father is a recognized risk factor for child abuse**, and he could certainly be involved, especially given the child's vulnerability.
- However, in cases of **chronic neglect and failure to provide basic care**, the primary responsibility often lies with the **biological parent** who is also a co-resident caregiver.
Caregiver support and education US Medical PG Question 5: One week after admission to the hospital for an extensive left middle cerebral artery stroke, a 91-year-old woman is unable to communicate, walk, or safely swallow food. She has been without nutrition for the duration of her hospitalization. The patient's sister requests placement of a percutaneous endoscopic gastrostomy tube for nutrition. The patient's husband declines the intervention. There is no living will. Which of the following is the most appropriate course of action by the physician?
- A. Encourage a family meeting (Correct Answer)
- B. Initiate total parenteral nutrition
- C. Consult the hospital ethics committee
- D. Proceed with PEG placement
- E. Transfer to a physician specialized in hospice care
Caregiver support and education Explanation: ***Encourage a family meeting***
- In situations of **disagreement among family members** regarding a patient's care, especially when there's no pre-existing expressed wish like a living will, a **family meeting is crucial** to facilitate open communication and achieve consensus.
- This step allows all relevant family members to discuss the patient's best interests, values, and potential wishes, guided by the medical team's input, to determine the most appropriate course of action.
*Initiate total parenteral nutrition*
- Initiating total parenteral nutrition (TPN) is a medical intervention that brings its own risks and benefits and should only be considered after a **clear decision has been made about the patient's long-term nutritional support**.
- TPN is not a solution for family disagreement, and can be more invasive than a PEG for long-term nutrition, and does not directly address the ethical dilemma of conflicting family wishes.
*Consult the hospital ethics committee*
- While an ethics committee consultation may be necessary if a resolution cannot be reached through a family meeting, it is generally considered a **later step** in managing such conflicts.
- The initial priority is to foster communication and consensus among the family members themselves before escalating to an external review body.
*Proceed with PEG placement*
- Proceeding with PEG placement when there is a **direct conflict between immediate family members** (sister versus husband) and no clear advance directive would be inappropriate and could lead to significant ethical and legal challenges.
- Patient autonomy, even through a surrogate, must be respected, and acting unilaterally without resolving the family dispute would be a breach of this principle.
*Transfer to a physician specialized in hospice care*
- Transferring the patient to hospice care implies a decision has been made to focus on comfort care and forego aggressive interventions, which is precisely the point of contention among the family.
- This action would be **premature and inappropriate** as long as there is an unresolved disagreement about the goals of care and whether a PEG should be placed or not.
Caregiver support and education US Medical PG Question 6: A 77-year-old Caucasian woman presents to her primary care provider for a general checkup. The patient is with her daughter who brought her to this appointment. The patient states that she is doing well and has some minor joint pain in both hips. She states that sometimes she is sad because her husband recently died. She lives alone and follows a vegan diet. The patient's daughter states that she has noticed her mother struggling with day to day life. It started 2 years ago with her forgetting simple instructions or having difficulty running errands. Now the patient has gotten to the point where she can no longer pay her bills. Sometimes the patient forgets how to get home. The patient has a past medical history of obesity, hypertension, gastroesophageal reflux disease (GERD) controlled with pantoprazole, and diabetes mellitus. Her temperature is 99.5°F (37.5°C), blood pressure is 158/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Which of the following will most likely help with this patient's presentation?
- A. Vitamin B12 and discontinue pantoprazole
- B. No intervention needed
- C. Donepezil (Correct Answer)
- D. Fluoxetine and cognitive behavioral therapy
- E. Lisinopril and metoprolol
Caregiver support and education Explanation: ***Correct: Donepezil***
- This patient presents with **progressive dementia**, most consistent with **Alzheimer's disease**: gradual cognitive decline over 2 years, short-term memory loss (forgetting instructions), executive dysfunction (unable to pay bills), impaired navigation (getting lost), and functional decline in activities of daily living (ADLs).
- **Donepezil**, an **acetylcholinesterase inhibitor**, is first-line pharmacotherapy for mild-to-moderate Alzheimer's disease, improving cognitive function by increasing acetylcholine availability in the brain.
- Key differentiator: The **progressive, global cognitive impairment** with functional decline over years distinguishes this from reversible causes or mood disorders.
*Incorrect: Vitamin B12 and discontinue pantoprazole*
- While **vitamin B12 deficiency** can cause cognitive impairment and this patient has risk factors (vegan diet, chronic PPI use with pantoprazole), the **severity, duration, and progressive nature** of her symptoms indicate a **neurodegenerative process** rather than a reversible nutritional deficiency.
- B12 deficiency typically presents with more prominent neurological signs (peripheral neuropathy, subacute combined degeneration) and would be expected to show improvement with supplementation.
- Though checking B12 levels would be part of the dementia workup, it would not be the **primary treatment** for this presentation.
*Incorrect: No intervention needed*
- This patient has **significant functional impairment** with safety concerns (getting lost, inability to manage finances), requiring immediate intervention.
- Progressive cognitive decline causing loss of independence in ADLs is never "normal aging" and always warrants medical evaluation and treatment.
- Failure to intervene risks patient safety and further deterioration.
*Incorrect: Fluoxetine and cognitive behavioral therapy*
- While the patient reports sadness related to her husband's death (suggesting **grief** or possible **depression**), her **predominant symptoms are cognitive and functional**, not primarily mood-related.
- **Key differentiation**: Depression can cause "pseudodementia" with cognitive complaints, but true dementia shows objective functional decline (inability to pay bills, getting lost) that progresses regardless of mood, whereas depression-related cognitive symptoms typically improve with mood treatment.
- The **2-year progressive course** with worsening executive function points to **organic dementia**, not a primary mood disorder.
- Fluoxetine and CBT target depression but would not address the underlying neurodegenerative process.
*Incorrect: Lisinopril and metoprolol*
- The patient's blood pressure is elevated (158/108 mmHg), indicating uncontrolled **hypertension** that should be managed.
- While controlling vascular risk factors is important in dementia management (to prevent vascular dementia progression), treating hypertension would not address her **current cognitive symptoms** or provide symptomatic relief.
- The **primary issue** is dementia requiring acetylcholinesterase inhibitor therapy; blood pressure management is secondary.
Caregiver support and education US Medical PG Question 7: A 67-year-old woman presents to her primary care physician for memory difficulty. She states that for the past couple months she has had trouble with her memory including forgetting simple things like bills she needs to pay or locking doors. She was previously fully functional and did not make these types of mistakes. The patient has not been ill lately but came in because her daughter was concerned about her memory. She makes her own food and eats a varied diet. Review of systems is notable for a decrease in the patient’s mood for the past 2 months since her husband died and a sensation that her limbs are heavy making it difficult for her to do anything. Her temperature is 99.3°F (37.4°C), blood pressure is 112/68 mmHg, pulse is 71/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam is notable for an elderly woman. Her neurological exam is unremarkable; however, the patient struggles to recall 3 objects after a short period of time and can only recall 2 of them. The patient’s weight is unchanged from her previous visit and cardiac, pulmonary, and dermatologic exams are within normal limits. Which of the following is the most likely diagnosis?
- A. Depression (Correct Answer)
- B. Vascular dementia
- C. Alzheimer dementia
- D. Hypothyroidism
- E. Normal aging
Caregiver support and education Explanation: ***Depression***
- The patient exhibits classic signs of depression, including a **recent decline in mood** following her husband's death, anhedonia (sensation of heavy limbs making it difficult to do anything), and **memory difficulties** that appear to be a recent change from her previous baseline.
- **Pseudodementia**, or cognitive impairment due to depression, often presents with memory complaints that resolve with treatment of the underlying mood disorder.
*Vascular dementia*
- This typically presents with a **step-wise decline** in cognitive function, often associated with a history of stroke or cardiovascular risk factors, which are not mentioned here.
- Memory impairment in vascular dementia is often characterized by **executive dysfunction** and difficulty with information processing rather than primary memory recall alone.
*Alzheimer dementia*
- Characteristically involves a more **gradual and progressive decline** in memory, especially with new learning and recall, over a longer period.
- While memory loss is a feature, the constellation of recent onset, mood disturbance, and lack of other neurological deficits points away from Alzheimer's as the initial diagnosis.
*Hypothyroidism*
- Can cause cognitive slowing and memory problems, but it typically presents with other systemic symptoms like **fatigue, weight gain, constipation, and cold intolerance**, which are not present in this patient.
- The patient's vital signs are normal, and there's no mention of thyroid-related physical exam findings.
*Normal aging*
- While some mild memory lapses are normal with aging, the patient's complaints go beyond minor issues; she is having trouble with bills and locking doors, which indicates a **significant functional impact**.
- The rapid onset of symptoms and current functional impairment suggest something beyond typical age-related cognitive changes.
Caregiver support and education US Medical PG Question 8: A 76-year-old man is brought to his geriatrician by his daughter, who reports that he has been "losing his memory." While the patient previously performed all household duties by himself, he has recently had several bills that were unpaid. He also called his daughter on several occasions after getting lost while driving and having "accidents" before getting to the toilet. On exam, the patient is conversant and alert to person, place, and time, though his gait is wide-based and slow. Which of the following diagnostic procedures would be most appropriate to confirm the suspected diagnosis in this patient?
- A. Warfarin
- B. Donepezil
- C. Carbidopa/Levodopa
- D. Memantine
- E. Lumbar puncture (Correct Answer)
Caregiver support and education Explanation: ***Lumbar puncture***
- The patient's symptoms of **cognitive decline**, **gait disturbance**, and **urinary incontinence** (losing control before reaching the toilet) represent the classic triad of **Normal Pressure Hydrocephalus (NPH)**.
- **Lumbar puncture** with removal of CSF (30-50 mL) serves as both a **diagnostic and therapeutic test** (tap test); transient improvement in symptoms, especially gait, strongly supports the diagnosis of NPH.
- This is the only **diagnostic procedure** among the options; the others are medications/treatments.
*Warfarin*
- This is an **anticoagulant medication** (not a diagnostic procedure) used to prevent blood clots in atrial fibrillation or venous thromboembolism.
- Has no role in diagnosing or treating NPH, which involves CSF dynamics, not coagulation.
*Donepezil*
- **Donepezil** is an **acetylcholinesterase inhibitor medication** (not a diagnostic procedure) used to treat Alzheimer's disease symptoms.
- While the patient has cognitive decline, the classic NPH triad (cognitive, gait, incontinence) distinguishes this from typical Alzheimer's dementia.
- This is a treatment option, not a diagnostic test.
*Carbidopa/Levodopa*
- This **medication combination** (not a diagnostic procedure) is the primary treatment for **Parkinson's disease**, replacing dopamine.
- While Parkinson's causes gait issues, it doesn't typically present with this specific triad, and parkinsonian gait differs from NPH's magnetic/apraxic gait.
- This is a treatment, not a diagnostic procedure.
*Memantine*
- **Memantine** is an **NMDA receptor antagonist medication** (not a diagnostic procedure) used in moderate to severe Alzheimer's disease.
- Like donepezil, this treats dementia symptoms but is not a diagnostic test for NPH.
Caregiver support and education US Medical PG Question 9: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Caregiver support and education Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
Caregiver support and education US Medical PG Question 10: An 83-year-old man is being seen in the hospital for confusion. The patient was admitted 4 days ago for pneumonia. He has been improving on ceftriaxone and azithromycin. Then 2 nights ago he had an episode of confusion. He was unsure where he was and attempted to leave. He was calmed down by nurses with redirection. He had a chest radiograph that was stable from admission, a normal EKG, and a normal urinalysis. This morning he was alert and oriented. Then this evening he became confused and agitated again. The patient has a history of benign prostatic hyperplasia, severe dementia, and osteoarthritis. He takes tamsulosin in addition to the newly started antibiotics. Upon physical examination, the patient is alert but orientated only to name. He tries to get up, falls back onto the bed, and grabs his right knee. He states, “I need to get to work. My boss is waiting, but my knee hurts.” He tries to walk again, threatens the nurse who stops him, and throws a plate at the wall. In addition to reorientation, which of the following is the next best step in management?
- A. Morphine
- B. Lorazepam
- C. Haloperidol (Correct Answer)
- D. Rivastigmine
- E. Physical restraints
Caregiver support and education Explanation: ***Haloperidol***
- The patient exhibits **delirium** with acute agitation, threatening behavior, and violent actions (throwing objects), representing an **imminent safety risk** to himself and staff.
- After **non-pharmacological interventions** (reorientation) have failed, **low-dose haloperidol** is appropriate for managing **severe agitation** in delirium when there is risk of harm.
- While antipsychotics have an FDA black box warning for increased mortality in elderly patients with dementia and recent evidence questions their efficacy in delirium, they remain indicated for **acute agitation with safety concerns** as a short-term intervention.
- Haloperidol is preferred over atypical antipsychotics in acute hospital settings due to availability in parenteral forms and lower anticholinergic burden.
*Morphine*
- While the patient mentions knee pain (likely from osteoarthritis), his **primary issue** is acute agitation and delirium, not pain management.
- **Opioids** can worsen delirium and confusion in elderly patients through anticholinergic effects and sedation.
- Pain should be addressed, but not as the primary intervention for violent, agitated behavior.
*Lorazepam*
- **Benzodiazepines** are generally **contraindicated in delirium** as they worsen confusion, increase fall risk, and can cause paradoxical agitation in elderly patients.
- The **only exceptions** are delirium from alcohol or benzodiazepine withdrawal, or seizures—none of which apply to this patient.
- Lorazepam would likely exacerbate rather than improve this patient's mental status.
*Rivastigmine*
- **Rivastigmine** is an acetylcholinesterase inhibitor for chronic management of **dementia symptoms**, not acute delirium.
- It has **no role** in managing acute behavioral disturbances and takes weeks to show any effect.
- Studies have not shown benefit of cholinesterase inhibitors in preventing or treating delirium.
*Physical restraints*
- Physical restraints should be used only as a **last resort** when pharmacological and non-pharmacological interventions have failed and there is immediate, serious risk of harm.
- Restraints can **increase agitation**, cause injuries, lead to delirium worsening, and are associated with increased morbidity and mortality.
- They do not address the underlying cause and should be avoided when other options are available.
More Caregiver support and education US Medical PG questions available in the OnCourse app. Practice MCQs, flashcards, and get detailed explanations.
