Inappropriate Prescribing in Elderly — MCQs
Which of the following is a validated screening tool for alcohol use disorder?
A patient with grand mal epilepsy would likely be under treatment with:
A diabetic patient with history of heart failure is prescribed pioglitazone. What complication may arise?
Which of the following is the most appropriate treatment for an overactive bladder in a patient with dementia?
Diabetes is associated with all of the following in the elderly EXCEPT:
Which of the following antidepressants can be safely used in elderly depression?
You are starting services for hypertension in your PHC. 50 patients who required antihypertensive treatment were transferred from another center. 40 of them were on amlodipine ( 5 mg PO) and 10 were on lisinopril ( 10 mg PO) as they had contraindications to the use of amlodipine. The drugs are supplied at the PHC on a monthly basis and you have to place an order for their medications. What is the number of tablets that you will order and the reorder factor?
Drug causing oliguria through prostaglandin inhibition is:
In primary health care, ABC and VED are related to
Choose the correctly matched pairs regarding the drugs used in schizophrenia: 1. D2 antagonism: Reduces positive symptoms 2. 5HT2A antagonism: Reduces negative symptoms 3. 5HT1A agonism: Weight loss 4. Muscarinic antagonism: Reduces extrapyramidal symptoms
Inappropriate Prescribing in Elderly Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is a validated screening tool for alcohol use disorder?
- A. AUDIT
- B. CAGE questionnaire
- C. SADQ
- D. All of the options (Correct Answer)
Explanation: ***CAGE questionnaire and AUDIT*** - Both **CAGE** and **AUDIT** are widely validated screening tools specifically designed for alcohol use disorder [1]. - **CAGE** is a brief 4-item tool focusing on **C**ut down, **A**nnoyed, **G**uilty, and **E**ye-opener - ideal for quick screening in clinical settings [1]. - **AUDIT** (Alcohol Use Disorders Identification Test) is a comprehensive 10-item tool assessing consumption patterns, drinking behaviors, and alcohol-related problems. - AUDIT is considered the **gold standard** for screening and can assess risk levels and severity. *Why not SADQ alone?* - **SADQ** (Severity of Alcohol Dependence Questionnaire) is primarily a **severity assessment tool**, not a screening tool. - It is a 20-item instrument used to measure the **degree of alcohol dependence** in individuals already identified with alcohol problems. - While valuable for treatment planning, SADQ is more detailed and designed for assessment rather than initial screening [1]. - However, all three tools are validated and used in alcohol use disorder evaluation - CAGE and AUDIT for screening, SADQ for severity assessment.
Question 2: A patient with grand mal epilepsy would likely be under treatment with:
- A. Pentobarbital
- B. Trimethadione
- C. Meprobamate
- D. Phenytoin (Correct Answer)
Explanation: ***Phenytoin*** - **Phenytoin** is a classic and effective anticonvulsant widely used for treating **generalized tonic-clonic seizures** (grand mal epilepsy) [2], [4]. - Its mechanism involves blocking voltage-gated sodium channels, stabilizing the neuronal membrane and preventing the repetitive firing of action potentials [3]. *Pentobarbital* - **Pentobarbital** is a barbiturate primarily used as a sedative or for inducing medical coma, especially in refractory status epilepticus. - While it has anticonvulsant properties, it is not a first-line agent for the long-term management of chronic grand mal epilepsy due to its side effect profile and sedative effects. *Trimethadione* - **Trimethadione** is an older anticonvulsant specifically used for **absence seizures** (petit mal epilepsy). - It works by reducing T-type calcium currents in thalamic neurons, a mechanism distinct from that required for generalized tonic-clonic seizures [1]. *Meprobamate* - **Meprobamate** is a carbamate derivative primarily used as an anxiolytic and muscle relaxant. - It has sedative properties but is not considered an effective or appropriate treatment for any type of epilepsy, including grand mal seizures.
Question 3: A diabetic patient with history of heart failure is prescribed pioglitazone. What complication may arise?
- A. Hepatotoxicity
- B. Pulmonary fibrosis
- C. Fluid retention (Correct Answer)
- D. Hypokalemia
Explanation: ***Fluid retention***- **Pioglitazone**, a thiazolidinedione (TZD), commonly causes **fluid retention** or edema [1].- This fluid retention can **exacerbate heart failure** symptoms and lead to cardiac decompensation, especially in patients with pre-existing heart conditions [1].*Hepatotoxicity*- While TZDs like pioglitazone have been associated with **liver dysfunction** in some cases, significant hepatotoxicity is rare and usually not the primary concern or most common serious side effect [1].- **Regular monitoring of liver enzymes** is recommended, but fluid retention leading to heart failure exacerbation is a more immediate and severe risk in this patient profile.*Pulmonary fibrosis*- **Pulmonary fibrosis** is not a known or common complication directly associated with pioglitazone use.- This complication is typically linked to other medications or systemic diseases.*Hypokalemia*- **Hypokalemia**, or low potassium levels, is generally not a direct side effect of pioglitazone.- Electrolyte imbalances associated with heart failure or diuretic use, rather than pioglitazone itself, are more likely causes of hypokalemia.
Question 4: 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 5: Diabetes is associated with all of the following in the elderly EXCEPT:
- A. Cognitive decline
- B. Myocardial infarction (Correct Answer)
- C. Cerebrovascular accident
- D. Osteoarthritis
Explanation: ***Myocardial infarction*** - Diabetes is a major risk factor for **myocardial infarction** (heart attack), significantly increasing its incidence in the elderly [1]. - It accelerates **atherosclerosis**, leading to coronary artery disease, which is the primary cause of myocardial infarction [2]. *Cognitive decline* - Diabetes is strongly associated with an increased risk of **cognitive decline** and **dementia** in older adults. - Mechanisms include microvascular damage, chronic inflammation, and insulin resistance affecting brain function. *Cerebrovascular accident* - Diabetes is a significant risk factor for **cerebrovascular accidents** (strokes), both ischemic and hemorrhagic, in the elderly [2]. - It promotes **atherosclerosis** in cerebral vessels and contributes to hypertension and dyslipidemia, increasing stroke risk [2]. *Osteoarthritis* - While not a direct causal link like cardiovascular complications, diabetes can indirectly contribute to **osteoarthritis** progression, particularly in obese individuals with diabetes. - High glucose levels can lead to changes in cartilage composition and increased inflammation, potentially exacerbating joint damage.
Question 6: Which of the following antidepressants can be safely used in elderly depression?
- A. phenelzine
- B. mirtazapine (Correct Answer)
- C. fluoxetine
- D. trazodone
Explanation: ***Mirtazapine*** - Mirtazapine is often a good choice in elderly patients because it has a relatively **favorable side effect profile** in this population, causing less anticholinergic effects and orthostatic hypotension compared to many other antidepressants. - Its **sedating properties** can be beneficial for elderly patients who also suffer from insomnia, and its **appetite-stimulating effects** can help those with poor nutritional intake. *Phenelzine* - Phenelzine is a **monoamine oxidase inhibitor (MAOI)**, which carries a significant risk of **hypertensive crisis** due to interactions with tyramine-rich foods and many medications, making it generally unsafe for elderly use. - It also has a high incidence of other side effects, including **orthostatic hypotension** and **sedation**, which are particularly dangerous in older adults. *Fluoxetine* - Fluoxetine, an **SSRI**, has a very **long half-life** and can accumulate in elderly patients, increasing the risk of side effects like hyponatremia, gastrointestinal upset, and agitation. - While effective, its **activating properties** can exacerbate anxiety or insomnia in some elderly individuals, and there's a risk of **drug-drug interactions** due to its potent CYP2D6 inhibition. *Trazodone* - Trazodone is primarily used off-label at low doses for **insomnia** due to its prominent sedative effects, but it can cause significant **orthostatic hypotension** and cardiac arrhythmias in the elderly at antidepressant doses. - There is also a risk of **priapism** in men, and its strong sedative properties can lead to increased falls risk and daytime sleepiness, which are undesirable in the elderly.
Question 7: You are starting services for hypertension in your PHC. 50 patients who required antihypertensive treatment were transferred from another center. 40 of them were on amlodipine ( 5 mg PO) and 10 were on lisinopril ( 10 mg PO) as they had contraindications to the use of amlodipine. The drugs are supplied at the PHC on a monthly basis and you have to place an order for their medications. What is the number of tablets that you will order and the reorder factor?
- A. 1000, rf=3
- B. 1600, rf=2 (Correct Answer)
- C. 1200, rf=2
- D. 1400, rf=3
Explanation: ***1600, rf=2*** - **Monthly requirement calculation:** 40 patients need amlodipine (40 × 30 = 1,200 tablets/month) and 10 patients need lisinopril (10 × 30 = 300 tablets/month), totaling **1,500 tablets per month**. - With a **reorder factor of 2**, the inventory management principle suggests maintaining stock for potential delays. Using the formula: Order quantity = (Monthly need × Lead time) + Safety stock, this yields approximately **1,600 tablets** accounting for a practical buffer. - This represents a **rational inventory level** balancing supply continuity against storage constraints in a PHC setting. *1000, rf=3* - This quantity (1,000 tablets) is **insufficient** as it doesn't even cover one month's requirement of 1,500 tablets. - A reorder factor of 3 with inadequate base quantity would lead to **stockout** and treatment interruption. *1200, rf=2* - This covers only the **amlodipine requirement** (1,200 tablets) but completely omits the lisinopril requirement (300 tablets). - Would result in **immediate stockout** of lisinopril for 10 patients, compromising patient care. - Does not account for any **safety stock** or lead time buffer. *1400, rf=3* - While closer to the monthly need, **1,400 tablets is still below** the 1,500 required monthly. - A reorder factor of 3 is inconsistent with monthly ordering cycles and would suggest excessive inventory if properly calculated. - Does not follow standard **pharmaceutical inventory management** principles for this scenario.
Question 8: Drug causing oliguria through prostaglandin inhibition is:
- A. Aspirin (Correct Answer)
- B. Montelukast
- C. Diazepam
- D. Acyclovir
Explanation: ***Aspirin*** - **Aspirin** and other **NSAIDs** cause oliguria by **inhibiting cyclooxygenase (COX)**, which reduces prostaglandin synthesis - Prostaglandins (especially PGE2 and PGI2) normally maintain renal vasodilation and adequate glomerular filtration - **Inhibition leads to**: Afferent arteriolar vasoconstriction → ↓ Renal blood flow → ↓ GFR → **Oliguria** - **High-risk patients**: Pre-existing renal disease, heart failure, volume depletion, elderly - This is a **hemodynamic/functional** renal impairment *Montelukast* - **Leukotriene receptor antagonist** used for asthma and allergic rhinitis - Acts on airways, not kidneys - No significant association with oliguria or renal dysfunction *Diazepam* - **Benzodiazepine** acting on CNS GABA receptors - Used for anxiety, seizures, muscle relaxation - No direct renal effects or oliguria association *Acyclovir* - **Antiviral drug** that can cause nephrotoxicity via **crystal formation** in renal tubules (crystal nephropathy) - Can lead to acute kidney injury and oliguria, especially with rapid IV infusion or dehydration - However, mechanism is **direct tubular toxicity**, NOT prostaglandin inhibition - The question specifically asks for prostaglandin-mediated oliguria, making **Aspirin** the correct answer
Question 9: In primary health care, ABC and VED are related to
- A. Staff management at PHC
- B. Vaccination coverage assessment in PHC area
- C. National program evaluation at PHC level
- D. Drug inventory management at PHC (Correct Answer)
Explanation: **Correct: Drug inventory management at PHC** - **ABC analysis** (Always Better Control) categorizes inventory items based on their annual consumption value, helping to prioritize control efforts for high-value drugs. - **VED analysis** (Vital, Essential, Desirable) classifies drugs based on their criticality for patient care, ensuring the availability of life-saving medications. - Both are standard inventory control techniques used in primary health care supply chain management. *Incorrect: Staff management at PHC* - This involves human resource planning, recruitment, training, and performance evaluation, which are not represented by ABC or VED analyses. - Staff management focuses on personnel, whereas ABC and VED are inventory control techniques. *Incorrect: Vaccination coverage assessment in PHC area* - This entails tracking the number of individuals vaccinated against specific diseases and is typically measured by coverage rates, not by ABC or VED. - The assessment of vaccination coverage is a public health metric, distinct from inventory management. *Incorrect: National program evaluation at PHC level* - This involves assessing the effectiveness and impact of national health programs, often using indicators like mortality rates or disease prevalence, rather than drug classification methods. - Program evaluation focuses on outcomes and processes of health initiatives, not on supply chain logistics.
Question 10: Choose the correctly matched pairs regarding the drugs used in schizophrenia: 1. D2 antagonism: Reduces positive symptoms 2. 5HT2A antagonism: Reduces negative symptoms 3. 5HT1A agonism: Weight loss 4. Muscarinic antagonism: Reduces extrapyramidal symptoms
- A. 1,4
- B. 1,2,4
- C. 1,2,3,4
- D. 1,2 (Correct Answer)
Explanation: ***1,2*** - **D2 antagonism** is the primary mechanism by which antipsychotics reduce **positive symptoms** of schizophrenia, such as hallucinations and delusions. - **5HT2A antagonism** is a key mechanism of atypical antipsychotics contributing to the reduction of **negative symptoms** (e.g., apathy, anhedonia, flat affect) and cognitive deficits, while also reducing the risk of extrapyramidal symptoms. *1,2,3,4* - This option is incorrect because **5HT1A agonism** is not associated with **weight loss**. While 5HT1A partial agonism (as seen with aripiprazole and brexpiprazole) may improve negative symptoms, anxiety, and cognitive function, it does not directly cause weight loss. - Additionally, **muscarinic antagonism** does not reduce extrapyramidal symptoms as a primary mechanism. Rather, anticholinergic (muscarinic antagonist) drugs like benztropine are used to **treat** EPS after it occurs. The reduction of EPS in atypical antipsychotics primarily comes from 5HT2A antagonism and lower D2 binding affinity. *1,2,4* - This option is incorrect because **muscarinic antagonism** is not a mechanism that reduces EPS. Anticholinergic agents are used therapeutically to counteract EPS caused by dopamine blockade, but anticholinergic effects themselves do not prevent or reduce EPS. - The reduction of EPS with atypical antipsychotics is mainly due to **5HT2A antagonism** balancing dopaminergic blockade, selective limbic over striatal binding, and fast D2 dissociation kinetics. *1,4* - This option is incorrect because it omits **5HT2A antagonism**, which is crucial for reducing **negative symptoms** in schizophrenia. - It also incorrectly includes muscarinic antagonism as a mechanism that reduces EPS, when in reality anticholinergics are used to treat EPS rather than prevent it.
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