Polypharmacy in the Elderly — MCQs
What is the mechanism of metabolism for alcohol, aspirin, and phenytoin at high doses?
To reduce mortality by CHD, best strategy -
In which of the following conditions is digoxin most likely to accumulate to toxic levels?
Which of the following drugs is associated with untoward side effect of renal tubular damage?
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?
Steps in review of patient's history during secondary survey of trauma care can be summarised as
Which of the following is false about the selection of essential drugs?
Rivastigmine & donepezil are drugs used predominantly in the management of ?
A drug is more likely to cause toxicity in elderly patients due to all of the following reasons except which of the following?
The following malformation in a baby due to drug intake by mother is classified as \qquad ADR?
Polypharmacy in the Elderly Indian Medical PG Practice Questions and MCQs
Question 1: What is the mechanism of metabolism for alcohol, aspirin, and phenytoin at high doses?
- A. First pass kinetics
- B. First order kinetics
- C. Zero order kinetics (Correct Answer)
- D. Second order kinetics
Explanation: ***Zero order kinetics*** - This mechanism occurs when the **metabolic enzymes become saturated at high drug concentrations**, leading to a constant amount (not a constant percentage) of drug being eliminated per unit time. - Alcohol, aspirin, and phenytoin are examples of drugs that exhibit **saturable metabolism**, transitioning from first-order to zero-order kinetics at higher doses. *First pass kinetics* - This describes the **metabolism of a drug by the liver or gut wall enzymes before it reaches systemic circulation** after oral administration. - While relevant to the oral bioavailability of these drugs, it does not describe the specific mechanism of elimination at high doses. *First order kinetics* - In this mechanism, a **constant fraction or percentage of the drug is eliminated per unit of time**, meaning the rate of elimination is directly proportional to the drug concentration. - Most drugs follow first-order kinetics at therapeutic doses because metabolizing enzymes are not saturated. *Second order kinetics* - This is a **less common pharmacokinetic model** where the rate of elimination is proportional to the square of the drug concentration or involves two reactants. - It does not typically describe the common elimination patterns of most drugs, including alcohol, aspirin, and phenytoin.
Question 2: To reduce mortality by CHD, best strategy -
- A. Secondary prevention
- B. Primordial prevention (Correct Answer)
- C. Tertiary prevention
- D. None of the options
Explanation: ***Primordial prevention*** * This strategy aims to prevent the **development of risk factors** for CHD in the first place, thus preventing the disease itself. * It focuses on promoting healthy lifestyles and environments from early life, targeting populations rather than individuals. *Secondary prevention* * This involves actions taken after an individual has developed **risk factors** for CHD or has been diagnosed with the disease, to prevent recurrence or worsening. * Examples include medication (e.g., statins, antiplatelets) for people with high cholesterol or a history of heart attack. *Tertiary prevention* * This strategy aims to reduce the **impact of an existing disease** on a patient's daily life and prevent further complications, disability, or death. * For CHD, this would include cardiac rehabilitation, surgical interventions like CABG, and managing co-morbidities to improve quality of life and prolong survival. *None of the options* * Given that primordial prevention directly addresses the prevention of risk factors and thus the disease itself, it is the most effective strategy for **reducing overall mortality** at the population level. * Therefore, one of the provided options is indeed the best strategy.
Question 3: In which of the following conditions is digoxin most likely to accumulate to toxic levels?
- A. Renal insufficiency (Correct Answer)
- B. Chronic hepatitis
- C. Advanced cirrhosis
- D. Chronic pancreatitis
Explanation: ***Renal insufficiency*** - **Digoxin** is primarily excreted unchanged by the **kidneys**, so impaired renal function significantly prolongs its half-life and leads to drug accumulation. - Patients with kidney failure require **dose adjustments** or closer monitoring of **digoxin levels** to prevent toxicity. *Chronic hepatitis* - **Chronic hepatitis** primarily affects the **liver's metabolic capacity**, which is not the primary route of **digoxin elimination**. - While severe hepatic dysfunction can subtly impact drug disposition, it's not the main reason for **digoxin accumulation** like **renal insufficiency**. *Advanced cirrhosis* - **Advanced cirrhosis** involves severe liver dysfunction, which can alter drug metabolism and protein binding. - However, **digoxin's elimination** is mainly renal, so liver disease alone does not typically lead to significant accumulation unless accompanied by **renal impairment**. *Chronic pancreatitis* - **Chronic pancreatitis** is a disorder of the pancreas and does not directly impact the **excretion or metabolism** of **digoxin**. - It would not be expected to cause **digoxin accumulation** to toxic levels.
Question 4: Which of the following drugs is associated with untoward side effect of renal tubular damage?
- A. Streptozotocin
- B. Methysergide
- C. Cyclophosphamide
- D. Cisplatin (Correct Answer)
Explanation: ***Cisplatin*** - **Cisplatin** is a platinum-based chemotherapy drug well-known for its dose-limiting nephrotoxicity, primarily causing **renal tubular damage**. - Its mechanism involves direct DNA damage within renal tubular cells, leading to **acute tubular necrosis** if not managed with aggressive hydration and other protective measures. *Streptozotocin* - **Streptozotocin** is an alkylating agent primarily used in treating **pancreatic neuroendocrine tumors**; its main toxicity is typically to pancreatic beta cells (leading to hypoglycemia) and to the liver. - While it can be nephrotoxic, its predominant and most recognized untoward side effect is not renal tubular damage, but rather **pancreatic beta-cell destruction**. *Methysergide* - **Methysergide** is an ergot alkaloid used for **migraine prophylaxis** but is largely discontinued due to severe side effects like **retroperitoneal fibrosis**. - Renal damage in the context of methysergide is typically due to this fibrosis compressing the ureters, rather than direct tubular toxicity. *Cyclophosphamide* - **Cyclophosphamide** is an alkylating agent known for its immunosuppressive and chemotherapeutic effects; its major side effects include **hemorrhagic cystitis** and myelosuppression. - While high doses can cause nephrotoxicity, its primary and most feared renal-related toxicity is hemorrhagic cystitis, not direct tubular damage as seen with cisplatin.
Question 5: 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 6: Steps in review of patient's history during secondary survey of trauma care can be summarised as
- A. TRIAGE
- B. ABCDE
- C. AMPLE (Correct Answer)
- D. None of the options
Explanation: ***AMPLE*** - The **AMPLE history** is a mnemonic used during the **secondary survey** in trauma care to gather crucial patient information - It stands for **Allergies, Medications, Past medical history/Pregnancy, Last meal, and Events** surrounding the injury. *TRIAGE* - **Triage** is the process of prioritizing patients based on the severity of their condition and the likelihood of benefit from immediate treatment. - It is an initial assessment done to determine the urgency of care, not a detailed historical review for a single patient. *ABCDE* - The **ABCDE approach** (**Airway, Breathing, Circulation, Disability, Exposure**) is part of the **primary survey** in trauma care. - It focuses on identifying and managing immediate life-threatening conditions. *None of the options* - This option is incorrect because **AMPLE** specifically describes the historical review process during the secondary survey.
Question 7: Which of the following is false about the selection of essential drugs?
- A. Cost to benefit has to be considered
- B. Fixed drug combination is preferred over single drugs (Correct Answer)
- C. An adequate safety profile needs to be established
- D. Disease prevalence is considered
Explanation: ***Fixed drug combination is preferred over single drugs*** - The statement that **fixed-drug combinations (FDCs)** are preferred over single drugs for essential drug selection is false. Generally, **single drugs are preferred** to allow for individual dose adjustments and minimize potential adverse effects from unnecessary components. - FDCs are only considered essential when they offer specific advantages, such as **improved adherence** (e.g., in tuberculosis treatment) or a **synergistic effect** not achievable with individual drugs. *Cost to benefit has to be considered* - This statement is true; the **cost-effectiveness** and **cost-benefit ratio** are crucial factors in selecting essential drugs. - Essential drugs aim to provide the most public health benefit at an **affordable cost**, ensuring access for a broad population. *An adequate safety profile needs to be established* - This statement is true; essential drugs must have a **well-established safety profile** with acceptable risks. - The benefits of the drug must significantly outweigh its potential harms, with minimal serious **adverse reactions**. *Disease prevalence is considered* - This statement is true; essential drugs are selected based on their ability to address the **most prevalent diseases** and health needs of a population. - Prioritizing drugs for common conditions ensures that public health resources are effectively allocated to where they are most needed.
Question 8: Rivastigmine & donepezil are drugs used predominantly in the management of ?
- A. Dissociation
- B. Dementia (Correct Answer)
- C. Delusions
- D. Depression
Explanation: ***Dementia*** - **Rivastigmine** and **donepezil** are **acetylcholinesterase inhibitors** that increase acetylcholine levels in the brain. - This mechanism is primarily used to improve **cognitive function** in patients with **Alzheimer's disease** and other forms of dementia. *Dissociation* - Dissociation involves a mental process causing a lack of connection between thoughts, memory, and identity, and is not typically treated with cholinesterase inhibitors. - Management often involves **psychotherapy** and sometimes anti-anxiety medications or antidepressants, if comorbid conditions are present. *Delusions* - Delusions are fixed, false beliefs often associated with psychotic disorders like **schizophrenia** or severe mood disorders. - Treatment primarily involves **antipsychotic medications**, not acetylcholinesterase inhibitors. *Depression* - Depression is a mood disorder characterized by persistent sadness and loss of interest. - It is typically treated with **antidepressants** (e.g., SSRIs, SNRIs), psychotherapy, or lifestyle changes, none of which include rivastigmine or donepezil.
Question 9: A drug is more likely to cause toxicity in elderly patients due to all of the following reasons except which of the following?
- A. decreased renal excretion of drugs
- B. decreased hepatic metabolism
- C. decreased volume of distribution (Correct Answer)
- D. increased receptor sensitivity
Explanation: ***decreased volume of distribution*** - A **decreased volume of distribution** would generally lead to a higher peak plasma concentration for a given dose, potentially increasing drug effect and thus toxicity, particularly for **hydrophilic drugs**. - However, for drugs that primarily distribute into **fat** or have a large volume of distribution, age-related changes in body composition (e.g., increased body fat, decreased total body water) can actually lead to an **increased volume of distribution** for some lipophilic drugs. *decreased renal excretion of drugs* - **Aging** is associated with a decline in **glomerular filtration rate (GFR)** and **renal tubular function**, leading to reduced drug clearance. - This results in a longer **half-life** and accumulation of renally excreted drugs, increasing the risk of **toxicity**. *decreased hepatic metabolism* - Liver size, blood flow, and the activity of some **cytochrome P450 enzymes** may decrease with age. - This leads to reduced **first-pass metabolism** and slower systemic clearance of many hepatically metabolized drugs, increasing their **bioavailability** and plasma concentrations. *increased receptor sensitivity* - Elderly patients often exhibit altered **pharmacodynamic responses**, including **increased sensitivity** to certain drugs. - This means a lower concentration of the drug at the receptor site can produce a greater therapeutic or toxic effect, making them more susceptible to **adverse drug reactions**.
Question 10: The following malformation in a baby due to drug intake by mother is classified as \qquad ADR?
- A. Type A
- B. Type D (Correct Answer)
- C. Type E
- D. Type F
Explanation: ***Type D*** - **Type D** ADRs are **delayed effects** that include **teratogenicity** and **carcinogenicity**, occurring after prolonged exposure or during critical developmental periods. - The image shows **phocomelia** (severe limb malformation), a classic example of drug-induced teratogenicity (e.g., **thalidomide**), which is classified as a Type D ADR. *Type A* - **Type A** ADRs are **augmented** reactions that are predictable, dose-dependent pharmacological effects of drugs. - Examples include **bleeding** with anticoagulants or **hypotension** with antihypertensives, not congenital malformations. *Type E* - **Type E** ADRs are **end-of-use** effects or **withdrawal symptoms** that occur when a drug is discontinued. - These reactions (like **opioid withdrawal**) are unrelated to developmental malformations from in-utero drug exposure. *Type F* - **Type F** is not a recognized category in standard ADR classification systems, which typically include only Types A through E. - The established classification covers predictable, unpredictable, chronic, delayed, and end-of-use effects without requiring a Type F category.
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