Polypharmacy and Deprescribing — MCQs
Which of the following drugs is not useful in the rehabilitation of alcoholic patients?
The therapeutic index of a drug is defined as the ratio between the toxic dose and the effective dose.
Which of the following is the most appropriate treatment for an overactive bladder in a patient with dementia?
Which of the following drugs should be given in a sustained-release oral dosage form?
Which of the following best describes a Type B adverse drug reaction?
A 56-year-old man is brought to the emergency department by his wife because of memory loss and difficulty walking. She has noticed personality changes, truancy from work, and lack of personal care over the past 1 year. On examination, he appears unkempt, smells of urine, and is uncooperative. He cannot recall the date or season and gets angry when asked questions. His answers are often fabricated when checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is diaphoretic and tremulous. His gait is wide-based, and motor strength and reflexes are normal. His ocular movements are normal, but there is nystagmus on lateral gaze. In the past, he has had multiple admissions for alcohol withdrawal. Which of the following is the most appropriate next step in management?
The drug that causes fall in elderly patients with postural hypotension is:-
A 45-year-old man presents with a history of frequent falls. He has difficulty in looking down also. What is the most probable diagnosis -
Which of the following is the most common cause of reversible dementia in the geriatric population?
Which of the following does not change in old age?
Polypharmacy and Deprescribing Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following drugs is not useful in the rehabilitation of alcoholic patients?
- A. Acamprosate
- B. Rimonabant (Correct Answer)
- C. Naltrexone
- D. Varenicline
Explanation: Rimonabant - Rimonabant is an inverse agonist of the cannabinoid CB1 receptor that was used as an anti-obesity drug. [1] - It was withdrawn from the market due to significant psychiatric side effects, including depression and suicidal ideation. [1] - Rimonabant has absolutely no role in alcohol rehabilitation and is no longer available for clinical use. Acamprosate - Acamprosate is commonly used in alcohol rehabilitation to reduce alcohol cravings and promote abstinence in detoxified alcohol-dependent individuals. [2] - It is thought to act by restoring the balance between excitation and inhibition in the brain, particularly by modulating glutamate and GABA neurotransmission. - It is FDA-approved for maintenance of alcohol abstinence. Naltrexone - Naltrexone is an opioid receptor antagonist used to reduce alcohol craving and relapse by blocking the pleasurable effects of alcohol. [2], [3] - It is available in both oral and intramuscular long-acting injectable forms and is FDA-approved for alcohol use disorder. [3] - It can also be used for opioid use disorder. [3] Varenicline - Varenicline is a partial agonist of the nicotinic acetylcholine receptor and is primarily FDA-approved for smoking cessation. - Some research has explored its potential for reducing alcohol consumption due to its effects on reward pathways, though it is not FDA-approved for alcohol dependence. - Unlike rimonabant (which is withdrawn and has no role), varenicline has some supporting evidence in alcohol treatment, though it remains off-label use.
Question 2: The therapeutic index of a drug is defined as the ratio between the toxic dose and the effective dose.
- A. Margin of safety
- B. Ratio of toxic dose to effective dose (Correct Answer)
- C. Efficacy of the drug
- D. Drug potency
Explanation: ***Ratio of toxic dose to effective dose***- The **therapeutic index (TI)** is quantitatively defined as the ratio of the toxic dose (TD50 or LD50) to the effective dose (ED50) [1, 2].- This ratio provides a measure of **drug safety**, indicating the range between the therapeutic and toxic concentrations [1, 3].*Margin of safety*- While related to safety, the **margin of safety** is a different concept, often calculated as (TD1 - ED99) / ED99, focusing on the overlap between very few people experiencing toxicity and almost everyone receiving benefit [2].- The therapeutic index is a broader, simpler ratio that doesn't explicitly guarantee overlap safety but indicates overall drug risk.*Efficacy of the drug*- **Efficacy** refers to the maximal effect a drug can produce regardless of the dose, and it is independent of the therapeutic index [2].- A drug can have high efficacy but a narrow therapeutic index, meaning it is very effective but also very toxic at doses slightly above the therapeutic range.*Drug potency*- **Potency** is the amount of drug needed to produce a given effect (e.g., ED50), reflecting its affinity for receptors and efficiency of action [2].- It is distinct from the therapeutic index, which assesses the separation between desired and undesired effects, not the concentration required to achieve a therapeutic effect.
Question 3: Which of the following is the most appropriate treatment for an overactive bladder in a patient with dementia?
- A. Tolterodine (Correct Answer)
- B. Mirabegron
- C. Behavioral therapy/bladder training
- D. Oxybutynin
- E. Trospium
Explanation: ***Tolterodine*** - **Tolterodine** is a **muscarinic antagonist** that blocks acetylcholine receptors in the bladder, reducing detrusor muscle contractions and overactive bladder symptoms. - Unlike some other anticholinergics like oxybutynin, it has a **lower propensity to cross the blood-brain barrier** and thus a reduced risk of exacerbating cognitive impairment in patients with dementia. *Mirabegron* - **Mirabegron** is a **beta-3 adrenergic agonist** that relaxes the detrusor muscle, increasing bladder capacity. - While it has a different mechanism of action and is less likely to cause anticholinergic cognitive side effects than older anticholinergics, it can still cause **hypertension** and **tachycardia**, which may be problematic in elderly patients with comorbidities. *Behavioral therapy/bladder training* - **Behavioral therapy** and **bladder training** are important first-line treatments for overactive bladder. - However, for patients with **dementia**, cognitive impairment often makes adherence to and understanding of these complex therapies challenging or impossible without significant caregiver support. *Oxybutynin* - **Oxybutynin** is an **anticholinergic drug** that is effective for overactive bladder. - However, it has a **high affinity for muscarinic receptors** in the brain and readily crosses the blood-brain barrier, significantly increasing the risk of **cognitive impairment, confusion, and delirium** in elderly patients, especially those with pre-existing dementia. *Trospium* - **Trospium** is a **quaternary amine anticholinergic** that is hydrophilic and has minimal blood-brain barrier penetration. - While theoretically safer than oxybutynin in terms of CNS effects, it has **lower bladder selectivity** compared to tolterodine and may cause more peripheral anticholinergic side effects (dry mouth, constipation).
Question 4: Which of the following drugs should be given in a sustained-release oral dosage form?
- A. An anti-arrhythmic drug with a plasma half life of 10 seconds used for acute treatment of PSVT
- B. Anti inflammatory drugs with the plasma half life of 24 hours
- C. Hypnotic drugs with a plasma half life of 2 hours
- D. An antihypertensive with a plasma half-life of 3 hours (Correct Answer)
Explanation: *An anti-arrhythmic drug with a plasma half life of 10 seconds used for acute treatment of PSVT* - An extremely short **half-life** (10 seconds) indicates a drug suitable for **rapid-onset, acute interventions**, where the effect is needed immediately and for a very brief duration, making sustained release impractical. - Drugs like **adenosine**, used for acute PSVT, are given intravenously as a rapid bolus due to their ultra-short half-life, not in an oral sustained-release form. *Anti inflammatory drugs with the plasma half life of 24 hours* - A long **half-life** (24 hours) typically means the drug can be administered **once daily** to maintain therapeutic concentrations, rendering a sustained-release formulation unnecessary. - Such drugs already provide **prolonged action** and do not benefit significantly from further extension of release. *Hypnotic drugs with a plasma half life of 2 hours* - While a 2-hour half-life for a hypnotic might suggest potential for sustained release to prolong sleep, the goal of hypnotics is often a **rapid onset and relatively short duration** to avoid hangover effects. - Sustained release might cause **daytime sedation** and interfere with normal wakefulness, which is generally undesirable for this class of drugs. ***An antihypertensive with a plasma half-life of 3 hours*** - A short **half-life** (e.g., 3 hours) often necessitates frequent dosing to maintain therapeutic levels, making a **sustained-release formulation desirable** for patient compliance and consistent drug exposure. - Sustained-release dosage forms are particularly useful for drugs requiring **long-term, stable plasma concentrations**, such as antihypertensives, to manage chronic conditions effectively.
Question 5: Which of the following best describes a Type B adverse drug reaction?
- A. Augmented effect of drug
- B. Effect seen on chronic use of drug
- C. Delayed effect of drug
- D. Unpredictable bizarre reaction (Correct Answer)
Explanation: ***Unpredictable bizarre reaction*** - Type B reactions are **unpredictable**, **bizarre**, and not directly related to the drug's known pharmacological actions. - They often involve **immunological reactions** or genetic predispositions, such as allergies or idiosyncratic responses. *Augmented effect of drug* - This describes a **Type A** adverse drug reaction, which is predictable and results from an **exaggerated pharmacological effect** of the drug. - It is typically dose-dependent and can be managed by adjusting the dosage. *Effect seen on chronic use of drug* - This description can apply to several types of adverse reactions, but it commonly relates to **Type C (chronic) reactions**, where effects occur only after prolonged exposure. - These reactions might be due to **cumulative toxicity** or adaptive changes in the body. *Delayed effect of drug* - This aligns with **Type D (delayed) adverse drug reactions**, which manifest long after the drug exposure has ended or after a period of latency. - Examples include **carcinogenesis** or teratogenesis, occurring months or years later.
Question 6: A 56-year-old man is brought to the emergency department by his wife because of memory loss and difficulty walking. She has noticed personality changes, truancy from work, and lack of personal care over the past 1 year. On examination, he appears unkempt, smells of urine, and is uncooperative. He cannot recall the date or season and gets angry when asked questions. His answers are often fabricated when checked with his wife. The blood pressure is 150/90 mm Hg, pulse 100/min, and he is diaphoretic and tremulous. His gait is wide-based, and motor strength and reflexes are normal. His ocular movements are normal, but there is nystagmus on lateral gaze. In the past, he has had multiple admissions for alcohol withdrawal. Which of the following is the most appropriate next step in management?
- A. Calcium administration
- B. Prophylactic carbamazepine administration
- C. Prophylactic phenytoin administration
- D. Prophylactic diazepam administration (Correct Answer)
Explanation: ***Prophylactic diazepam administration*** - The patient presents with symptoms highly suggestive of **Wernicke-Korsakoff syndrome** (memory loss, ataxia, nystagmus) superimposed on chronic alcohol abuse with a history of alcohol withdrawal, indicating a high risk for further withdrawal seizures or delirium tremens [1], [3]. - **Benzodiazepines** like diazepam are the cornerstone of treatment for alcohol withdrawal syndrome due to their anxiolytic, anticonvulsant, and sedative properties, preventing progression to more severe withdrawal manifestations [2]. *Prophylactic phenytoin administration* - **Phenytoin** is generally not recommended for the prevention or treatment of alcohol withdrawal seizures unless there is an underlying seizure disorder unrelated to alcohol. - Its efficacy in preventing recurrent alcohol withdrawal seizures is limited compared to benzodiazepines. *Prophylactic carbamazepine administration* - While **carbamazepine** can be used in some cases of alcohol withdrawal, particularly to reduce seizure risk and improve sleep, it is not considered first-line for acute prophylaxis against severe withdrawal or delirium tremens, especially in a patient with active tremulousness and autonomic hyperactivity. - Benzodiazepines offer a broader spectrum of action against the diverse symptoms of alcohol withdrawal. *Calcium administration* - There is no indication that the patient has a **calcium deficiency** or hypocalcemia related to alcohol withdrawal symptoms. - Calcium administration would not address the underlying neurochemical imbalances associated with acute alcohol withdrawal or the progression to Wernicke-Korsakoff syndrome.
Question 7: The drug that causes fall in elderly patients with postural hypotension is:-
- A. Acarbose
- B. Prazosin (Correct Answer)
- C. Nor-adrenaline
- D. Metformin
Explanation: ***Prazosin*** - **Alpha-1 adrenergic blocker** used to treat hypertension and benign prostatic hyperplasia (BPH) - Commonly causes **orthostatic hypotension (postural hypotension)** as a side effect by blocking alpha-1 receptors on vascular smooth muscle, preventing compensatory vasoconstriction upon standing - Leads to **dizziness, lightheadedness, and falls**, especially in elderly patients who have reduced baroreceptor sensitivity - **First-dose phenomenon** is particularly notable, with marked hypotension after the initial dose *Acarbose* - Alpha-glucosidase inhibitor used to treat type 2 diabetes by reducing carbohydrate absorption in the intestine - Primary side effects are **gastrointestinal** (flatulence, diarrhea, abdominal discomfort) - Does not affect blood pressure or cause postural hypotension *Nor-adrenaline (Norepinephrine)* - **Vasopressor** and sympathomimetic agent that causes vasoconstriction through alpha-adrenergic receptor stimulation - **Increases blood pressure** and is used to treat severe hypotension in critical care settings - Would not cause falls due to postural hypotension; rather, it counteracts hypotension *Metformin* - **Biguanide** oral hypoglycemic agent for type 2 diabetes that primarily decreases hepatic glucose production and increases insulin sensitivity - Main side effects include gastrointestinal disturbances and rare lactic acidosis - Not associated with postural hypotension or increased risk of falls
Question 8: A 45-year-old man presents with a history of frequent falls. He has difficulty in looking down also. What is the most probable diagnosis -
- A. Alzheimer's disease
- B. Normal pressure hydro-cephalus
- C. Parkinson's disease
- D. Progressive supranuclear palsy (Correct Answer)
Explanation: ***Progressive supranuclear palsy*** - The combination of **frequent falls** and **difficulty looking down** (supranuclear ophthalmoplegia, especially affecting vertical gaze) is a classic presentation of progressive supranuclear palsy (PSP). - PSP is a **tauopathy** characterized by **postural instability**, early falls, and distinctive ocular motor dysfunction. *Alzheimer's disease* - Primarily presents with **progressive memory loss** and cognitive decline, not typically early or prominent falls or vertical gaze palsy. - While falls can occur in later stages, they are not usually an initial hallmark symptom associated with restricted eye movements. *Normal pressure hydrocephalus* - Characterized by the triad of **gait disturbance** (often described as magnetic gait), **urinary incontinence**, and **dementia** [2]. - While gait disturbance can lead to falls, the specific difficulty in looking down is not a feature of NPH. *Parkinson's disease* - Characterized by **bradykinesia**, **rigidity**, **tremor**, and **postural instability** leading to falls later in the disease [1]. - However, difficulty looking down (vertical gaze palsy) is not a typical feature of Parkinson's disease, and falls tend to occur later in the disease course compared to PSP.
Question 9: Which of the following is the most common cause of reversible dementia in the geriatric population?
- A. Depression (Correct Answer)
- B. Normal Pressure Hydrocephalus
- C. Hypothyroidism
- D. Vitamin B12 deficiency
Explanation: The correct answer is **Depression**. In the geriatric population, depression often presents with cognitive impairment, memory loss, and poor concentration, a clinical entity known as **Pseudodementia**. It is the most common cause of reversible cognitive decline [1]. Unlike true dementia (e.g., Alzheimer’s), patients with pseudodementia typically provide "I don't know" answers during testing, appear distressed by their deficits, and show significant improvement with antidepressant therapy or ECT. Analysis of Incorrect Options: **Normal Pressure Hydrocephalus (NPH):** Characterized by the triad of gait ataxia, urinary incontinence, and dementia ("Wet, Wobbly, and Wacky"). While reversible via a ventriculoperitoneal shunt, it is statistically less common than depression [1]. **Hypothyroidism:** Can cause cognitive slowing and "myxedema madness." While a standard part of the dementia workup (checking TSH), it is a less frequent cause of isolated reversible dementia compared to psychiatric illness. **Vitamin B12 Deficiency:** Leads to Subacute Combined Degeneration of the spinal cord and cognitive changes. While common in the elderly due to atrophic gastritis, it ranks below depression in prevalence as a primary cause of reversible cognitive impairment [1].
Question 10: Which of the following does not change in old age?
- A. GFR
- B. Glucose tolerance
- C. Haematocrit (Correct Answer)
- D. Blood pressure
Explanation: In geriatric medicine, distinguishing between normal physiological aging and pathological changes is crucial for the NEET-PG exam. ### **Explanation of the Correct Answer** **C. Haematocrit:** Under normal conditions, **Haematocrit (and Hemoglobin levels) does not significantly change with age.** While the bone marrow becomes more fatty and its "reserve" capacity to respond to stress (like acute hemorrhage) decreases, the baseline production of red blood cells remains stable. If an elderly patient presents with anemia, it should always be investigated as a pathological process (e.g., iron deficiency, occult GI bleed, or chronic disease) rather than being dismissed as "normal aging." ### **Analysis of Incorrect Options** * **A. GFR (Glomerular Filtration Rate):** GFR decreases progressively after the age of 30-40 at a rate of approximately **0.75–1 mL/min/year**. This is due to nephrosclerosis and a reduction in the number of functional nephrons. [1] * **B. Glucose Tolerance:** Peripheral insulin resistance increases and pancreatic beta-cell sensitivity decreases with age. [1] This leads to a decline in glucose tolerance, often resulting in higher postprandial blood glucose levels in the elderly. * **C. Blood Pressure:** Both systolic blood pressure and pulse pressure typically **increase** with age due to the loss of arterial elasticity and increased stiffness of large conduit arteries (arteriosclerosis). [1] ### **High-Yield Clinical Pearls for NEET-PG** * **Unchanged Parameters:** Along with Haematocrit, other parameters that remain relatively stable include **Blood Volume, Serum Electrolytes, and Liver Function Tests (LFTs)**. * **Creatinine Paradox:** Serum Creatinine may remain in the "normal range" in the elderly despite a decreased GFR because of a concurrent decrease in muscle mass (sarcopenia). * **Vital Capacity:** While Total Lung Capacity remains constant, **Vital Capacity decreases** and **Residual Volume increases** due to loss of elastic recoil. [1]
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