Geriatric Psychiatry — MCQs
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Which of the following antidepressants can be safely used in elderly depression?
"Sundowning" is seen in which of the following conditions?
A 72-year-old man complains of memory difficulties. He is worried that he has Alzheimer disease. He has trouble recalling the names of friends, and last month forgot his son's birthday, which had never happened before. On two occasions he became lost driving to a familiar department store. He is now afraid to make trips away from home. His children tell him that he has forgotten things they have discussed even 1 day previously. He lives independently and has not had any difficulty preparing meals, paying bills, using the telephone, or taking his medications. He takes lisinopril and hydrochlorothiazide for hypertension. He does not use alcohol. Folstein MMSE score is 27/30 and Montreal Cognitive Assessment (MoCA) score is 26/30. Neurologic examination is normal. Which of the following is the most appropriate next step?
Which of the following statements about Alzheimer's disease is false?
A disease occurring before 65 years of age is termed as:
An 82-year-old female with a history of age-related macular degeneration, hypertension, and hypercholesterolemia presents with a complaint of visual hallucinations. She reports seeing wild animals in her room, which has been occurring for a year since she lost her sight. She acknowledges that the hallucinations are not real. Her MMSE score is 28/30. What is the most likely diagnosis?
All of the following are true about dementia except:
All of the following are true of early onset Alzheimer's disease except?
A 68-year-old man presents with delirium secondary to a urinary tract infection. Following successful treatment of the infection, his mental status improved, but he exhibits persistent disorientation, impaired short-term memory, difficulty naming objects, and poor concentration. His family reports an 8-month history of gradual cognitive decline. He is now unable to manage finances and has a history of getting lost twice while driving. Post-discharge, he has urinary incontinence and an unsteady gait requiring assistance. Which disorder most likely accounts for this patient's dementia?
What is the annual conversion rate to dementia in patients with mild cognitive impairment?
Geriatric Psychiatry Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following antidepressants can be safely used in elderly depression?
- A. Trazodone
- B. Mianserin (Correct Answer)
- C. Fluoxetine
- D. Phenelzine
Explanation: In geriatric psychiatry, the choice of antidepressant is dictated by the side-effect profile, specifically the risk of anticholinergic effects, sedation, and cardiovascular complications. **Why Mianserin is correct:** Mianserin is a tetracyclic antidepressant (TeCA) that is frequently preferred in the elderly because it lacks significant **anticholinergic side effects** (which cause confusion, urinary retention, and glaucoma) and has minimal **cardiotoxicity**. It is particularly useful in elderly patients with insomnia or agitation due to its sedative properties, but it does not typically cause the severe orthostatic hypotension seen with older TCAs. **Analysis of Incorrect Options:** * **Fluoxetine (Option C):** While SSRIs are first-line for the elderly, Fluoxetine has a very **long half-life** (and active metabolites) which can lead to accumulation and prolonged side effects (like hyponatremia/SIADH or agitation) in patients with age-related renal or hepatic decline. Sertraline is generally preferred over Fluoxetine in this age group. * **Trazodone (Option A):** Though used for sleep, it is notorious for causing significant **orthostatic hypotension** in the elderly, increasing the risk of falls and hip fractures. * **Phenelzine (Option D):** As a non-selective MAOI, it requires strict dietary restrictions and carries a high risk of **hypertensive crisis** and drug-drug interactions, making it unsafe for the polypharmacy often seen in geriatric patients. **NEET-PG High-Yield Pearls:** * **Drug of Choice:** SSRIs (specifically **Sertraline** or **Escitalopram**) are generally the first-line treatment for elderly depression. * **Mianserin Risk:** Always monitor for **agranulocytosis** (rare but serious). * **Avoid:** Tertiary amines (Amitriptyline, Imipramine) due to high anticholinergic activity. * **Key Concern:** Always check for **hyponatremia** (SIADH) when starting an SSRI in an elderly patient.
Question 2: "Sundowning" is seen in which of the following conditions?
- A. Night blindness
- B. Parkinsonism
- C. Delirium (Correct Answer)
- D. Solar urticaria
Explanation: **Explanation:** **Sundowning** refers to a clinical phenomenon characterized by the emergence or worsening of neuropsychiatric symptoms—such as agitation, confusion, anxiety, and aggressiveness—specifically during the late afternoon or evening hours. **Why Delirium is the Correct Answer:** Sundowning is most commonly associated with **Delirium** and **Dementia** (particularly Alzheimer’s disease). It occurs due to a combination of factors: the loss of daylight (fading circadian cues), sensory deprivation in low light, and accumulated fatigue throughout the day. In patients with pre-existing cognitive impairment, the brain's ability to process environmental stimuli diminishes as light levels drop, leading to acute disorientation and behavioral disturbances. **Analysis of Incorrect Options:** * **A. Night blindness:** This is a physiological inability to see in low light (often due to Vitamin A deficiency) and does not involve the cognitive or behavioral agitation seen in sundowning. * **B. Parkinsonism:** While Parkinson’s patients may experience sleep disturbances or dementia-related confusion, sundowning is not a hallmark feature of the motor syndrome itself. * **D. Solar urticaria:** This is a physical dermatological condition (hives) triggered by exposure to ultraviolet radiation, the opposite of the "diminishing light" trigger of sundowning. **High-Yield Clinical Pearls for NEET-PG:** * **Management:** The first step in managing sundowning is optimizing the environment (e.g., keeping the room well-lit during the evening, reducing noise, and maintaining a strict routine). * **Differential:** Always rule out a "Medical Delirium" (UTI, electrolyte imbalance) if sundowning symptoms appear suddenly. * **Pharmacology:** If behavioral interventions fail, low-dose atypical antipsychotics (like Quetiapine) or Melatonin may be considered, though they are secondary to environmental modification.
Question 3: A 72-year-old man complains of memory difficulties. He is worried that he has Alzheimer disease. He has trouble recalling the names of friends, and last month forgot his son's birthday, which had never happened before. On two occasions he became lost driving to a familiar department store. He is now afraid to make trips away from home. His children tell him that he has forgotten things they have discussed even 1 day previously. He lives independently and has not had any difficulty preparing meals, paying bills, using the telephone, or taking his medications. He takes lisinopril and hydrochlorothiazide for hypertension. He does not use alcohol. Folstein MMSE score is 27/30 and Montreal Cognitive Assessment (MoCA) score is 26/30. Neurologic examination is normal. Which of the following is the most appropriate next step?
- A. Inform the patient that his symptoms are a normal consequence of aging and that his risk of Alzheimer disease is no higher than average.
- B. Tell the patient that he has dementia and must stop driving.
- C. Perform screening tests for vitamin deficiency and psychiatric disease. (Correct Answer)
- D. Begin donepezil.
Explanation: ### Explanation The patient presents with **Mild Cognitive Impairment (MCI)**. This is characterized by subjective and objective memory deficits (forgetting names, getting lost, MoCA score of 26) that are greater than expected for his age, but **without significant impairment in Activities of Daily Living (ADLs)**. He still manages his bills, meals, and medications independently. **1. Why Option C is Correct:** Before diagnosing a neurodegenerative condition like Alzheimer’s, it is mandatory to rule out **reversible causes of cognitive decline**. In geriatric psychiatry, the "pseudo-dementias" or secondary cognitive impairments must be excluded. The most common reversible causes include: * **Vitamin B12 deficiency** (Subacute combined degeneration/cognitive slowing). * **Hypothyroidism** (TSH levels). * **Depression** (Pseudodementia), where the patient is often distressed by their memory loss (as seen here). * **Metabolic derangements** or medication side effects. **2. Why Incorrect Options are Wrong:** * **Option A:** His symptoms (getting lost in familiar places, forgetting birthdays) exceed "normal aging." He meets the criteria for MCI, which carries a higher-than-average risk (approx. 10-15% annual conversion rate) of progressing to Alzheimer’s. * **Option B:** He does not meet the criteria for **Dementia (Major Neurocognitive Disorder)** because his functional independence (ADLs) is preserved. Driving cessation is premature at this stage. * **Option D:** Donepezil (Cholinesterase inhibitor) is FDA-approved for Alzheimer’s disease. It has **not** been proven to prevent progression from MCI to Alzheimer’s and is not indicated here. **Clinical Pearls for NEET-PG:** * **MCI vs. Dementia:** The key differentiator is the **preservation of independent functioning** in MCI. * **MoCA vs. MMSE:** MoCA is more sensitive than MMSE for detecting MCI (Cut-off <26). * **Rule of Thumb:** In any elderly patient with memory loss, always check **B12, TSH, and screening for Depression (GDS)** before labeling it as irreversible dementia.
Question 4: Which of the following statements about Alzheimer's disease is false?
- A. Down's syndrome is associated with an increased risk of Alzheimer's disease. (Correct Answer)
- B. Neurofibrillary tangles and senile plaques containing Ab amyloid are characteristic pathological findings.
- C. The hippocampus is severely affected, leading to memory impairment.
- D. Capgras syndrome is a rare delusion that may occur in patients with Alzheimer's disease.
Explanation: The question asks for the **false** statement regarding Alzheimer’s Disease (AD). However, based on clinical evidence, **Option A is a true statement**, making the question technically flawed or suggesting a typo in the provided key. In NEET-PG, it is crucial to recognize that all four options provided are actually **clinically true**. ### Explanation of Options: * **Option A (True):** Down’s syndrome (Trisomy 21) is a major risk factor for early-onset AD. The **Amyloid Precursor Protein (APP) gene** is located on **chromosome 21**. Having three copies of this gene leads to overproduction of beta-amyloid, resulting in AD pathology in almost all patients by age 40. * **Option B (True):** The hallmark pathology of AD includes extracellular **Senile (Amyloid) Plaques** and intracellular **Neurofibrillary Tangles (NFTs)**. NFTs are composed of hyperphosphorylated **Tau protein**. * **Option C (True):** The **Hippocampus** and Entorhinal cortex are the earliest and most severely affected areas. This explains why **anterograde amnesia** (inability to form new memories) is typically the first clinical symptom. * **Option D (True):** Psychotic symptoms are common in mid-to-late stage AD. **Capgras syndrome** (the "delusional misidentification" that a familiar person has been replaced by an identical impostor) occurs in approximately 10-15% of AD patients. ### High-Yield Clinical Pearls for NEET-PG: * **Neurotransmitters:** AD is characterized by a significant **decrease in Acetylcholine** (due to loss of neurons in the **Nucleus Basalis of Meynert**). * **Genetics:** Early-onset (familial) AD is linked to mutations in **APP (Chr 21), Presenilin 1 (Chr 14), and Presenilin 2 (Chr 1)**. Late-onset AD is associated with the **ApoE-ε4 allele**. * **Imaging:** MRI typically shows **hippocampal atrophy** and compensatory ventricular enlargement (hydrocephalus ex-vacuo). * **Treatment:** First-line treatments are **Cholinesterase inhibitors** (Donepezil, Rivastigmine, Galantamine) and the NMDA antagonist **Memantine**.
Question 5: A disease occurring before 65 years of age is termed as:
- A. Senile
- B. Presenile (Correct Answer)
- C. Post adolescent
- D. Post senile
Explanation: In Geriatric Psychiatry and Neurology, the age of **65 years** is the traditional threshold used to differentiate between early-onset and late-onset neurodegenerative conditions, most notably dementia. ### **Explanation of the Correct Answer** * **B. Presenile:** This term refers to conditions (typically dementia or Alzheimer’s disease) that manifest **before the age of 65**. The "presenile" period is generally considered to be between ages 45 and 65. Clinically, presenile dementias often have a stronger genetic component (e.g., mutations in PSEN1, PSEN2, or APP genes) and may present with more rapid progression or atypical focal neurological features compared to senile forms. ### **Analysis of Incorrect Options** * **A. Senile:** This term refers to diseases occurring **after the age of 65**. Senile dementia (Late-onset Alzheimer’s) is the most common form and is primarily associated with the APOE-ε4 allele as a risk factor. * **C. Post-adolescent:** This refers to the period immediately following adolescence (roughly age 18-25). While many psychiatric disorders like Schizophrenia often debut here, it is not a term used to describe geriatric or degenerative onset. * **D. Post-senile:** This is not a standard medical or psychiatric term. Once a patient reaches the "senile" age bracket, they remain in that category. ### **High-Yield Clinical Pearls for NEET-PG** * **Alzheimer’s Disease (AD):** The most common cause of both presenile and senile dementia. * **Early-Onset AD:** Defined as onset <65 years; often shows a more aggressive course. * **Genetic Markers:** * **Presenile/Early Onset:** Chromosomes 21 (APP), 14 (Presenilin 1), and 1 (Presenilin 2). * **Senile/Late Onset:** Chromosome 19 (Apolipoprotein E4). * **Pseudodementia:** Always rule out Depression in elderly patients presenting with cognitive decline; unlike true dementia, patients with pseudodementia often complain extensively about their memory loss ("Don't know" answers).
Question 6: An 82-year-old female with a history of age-related macular degeneration, hypertension, and hypercholesterolemia presents with a complaint of visual hallucinations. She reports seeing wild animals in her room, which has been occurring for a year since she lost her sight. She acknowledges that the hallucinations are not real. Her MMSE score is 28/30. What is the most likely diagnosis?
- A. Hyperactive Delirium
- B. Vascular Dementia
- C. Alzheimer's Disease
- D. Charles-Bonnet Syndrome (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Charles-Bonnet Syndrome** **Why it is correct:** Charles-Bonnet Syndrome (CBS) is characterized by **complex visual hallucinations** in patients with significant **visual impairment** (most commonly age-related macular degeneration, as seen here). * **Key Concept:** The "Deafferentation Hypothesis" suggests that the loss of sensory input leads to spontaneous firing in the visual association cortex. * **Insight:** Crucially, patients maintain **insight** (they know the hallucinations are not real) and have **no cognitive impairment** (MMSE 28/30) or other psychotic symptoms. **Why the other options are incorrect:** * **A. Hyperactive Delirium:** Delirium involves an acute fluctuation in consciousness and attention, often with a physical trigger. This patient has a chronic (one-year) history and is cognitively intact. * **B & C. Vascular Dementia / Alzheimer's Disease:** While dementia can cause hallucinations, the patient’s high MMSE score (28/30) and preserved insight rule out significant cognitive decline. In dementia, hallucinations are usually accompanied by memory loss and executive dysfunction. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Visual impairment + Complex visual hallucinations + Preserved insight. * **Hallucination Type:** Usually "Lilliputian" (small people/animals) or vivid, colorful patterns. * **Management:** Reassurance is the first-line treatment. If distressing, low-dose antipsychotics or SSRIs may be used, though evidence is limited. * **Differential:** Unlike Schizophrenia, there are no auditory hallucinations or delusions. Unlike Lewy Body Dementia, there are no parkinsonian features or cognitive fluctuations.
Question 7: All of the following are true about dementia except:
- A. Loss of short-term memory
- B. Loss of long-term memory (Correct Answer)
- C. Deterioration of personality
- D. Impaired learning
Explanation: **Explanation** Dementia is a clinical syndrome characterized by a progressive and global decline in cognitive functions in a state of clear consciousness. The hallmark of dementia is the impairment of **short-term memory** (anterograde amnesia), where the patient loses the ability to form new memories and learn new information. **Why Option B is the correct answer:** In the early and middle stages of dementia (such as Alzheimer’s disease), **long-term memory (remote memory) is typically preserved.** Patients can often vividly recall events from their childhood or decades ago, even while forgetting what they ate for breakfast. Long-term memory only deteriorates in the very advanced or terminal stages of the disease. Therefore, "loss of long-term memory" is not a defining or early feature of dementia. **Analysis of Incorrect Options:** * **Option A (Loss of short-term memory):** This is usually the first and most prominent symptom. Patients struggle with "recent memory," such as forgetting appointments or repeating questions. * **Option C (Deterioration of personality):** Frontal lobe involvement or progressive cortical atrophy leads to changes in social behavior, disinhibition, or apathy, which are common features of various dementias. * **Option D (Impaired learning):** Due to the failure of encoding new information (short-term memory deficit), the ability to learn new skills or information is significantly impaired. **High-Yield Clinical Pearls for NEET-PG:** * **Ribot’s Law:** States that there is a time gradient in memory loss; recent memories are lost first, while remote memories are the last to go. * **Dementia vs. Delirium:** Consciousness is **intact** in dementia but **clouded/impaired** in delirium. * **Pseudo-dementia:** Refers to cognitive impairment secondary to **Depression** in the elderly; unlike true dementia, these patients often complain extensively about their memory loss ("I don't know" answers). * **Most common cause:** Alzheimer’s Disease (characterized by Amyloid plaques and Neurofibrillary tangles).
Question 8: All of the following are true of early onset Alzheimer's disease except?
- A. Associated with chromosomal anomalies
- B. Profound intellectual disability is seen
- C. Necrosis of brain neurons is seen
- D. None of the above (Correct Answer)
Explanation: **Explanation:** In Alzheimer’s Disease (AD), "Early Onset" refers to cases occurring before age 65. The question asks for the "except" statement, and since all options provided (A, B, and C) are actually **true** characteristics of the disease, the correct answer is **D (None of the above).** 1. **Associated with Chromosomal Anomalies (True):** Early-onset AD (EOAD) is strongly linked to genetic mutations. Key associations include **Presenilin 1 (Chromosome 14)**—the most common mutation—**Presenilin 2 (Chromosome 1)**, and **Amyloid Precursor Protein (APP) (Chromosome 21)**. This explains why patients with Down Syndrome (Trisomy 21) almost universally develop AD pathology by age 40. 2. **Profound Intellectual Disability (True):** While AD is primarily a neurodegenerative dementia, in the context of EOAD associated with Down Syndrome, profound intellectual disability is a baseline clinical feature. Furthermore, EOAD typically follows a more aggressive course with rapid cognitive decline compared to late-onset cases. 3. **Necrosis of Brain Neurons (True):** The fundamental pathology of AD involves the accumulation of Amyloid-beta plaques and Tau tangles, leading to neurotoxicity, synaptic loss, and eventually **neuronal necrosis** (cell death), resulting in gross cerebral atrophy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of dementia:** Alzheimer's Disease. * **Genetic Risk Factor (Late-onset):** Apolipoprotein E4 (APOE-ε4) on Chromosome 19. * **Protective Factor:** APOE-ε2. * **Neurotransmitter change:** Significant **decrease in Acetylcholine** (due to loss of neurons in the Nucleus Basalis of Meynert). * **Histopathology:** Extracellular Senile Plaques (Amyloid-beta) and Intracellular Neurofibrillary Tangles (Hyperphosphorylated Tau).
Question 9: A 68-year-old man presents with delirium secondary to a urinary tract infection. Following successful treatment of the infection, his mental status improved, but he exhibits persistent disorientation, impaired short-term memory, difficulty naming objects, and poor concentration. His family reports an 8-month history of gradual cognitive decline. He is now unable to manage finances and has a history of getting lost twice while driving. Post-discharge, he has urinary incontinence and an unsteady gait requiring assistance. Which disorder most likely accounts for this patient's dementia?
- A. Creutzfeldt-Jakob disease
- B. Huntington disease
- C. Normal pressure hydrocephalus (Correct Answer)
- D. Parkinson disease
Explanation: **Explanation:** The clinical presentation highlights the classic triad of **Normal Pressure Hydrocephalus (NPH)**, often remembered by the mnemonic **"Wet, Wobbly, and Wacky."** 1. **Wacky (Cognitive Decline):** The patient has an 8-month history of gradual cognitive impairment (disorientation, memory loss, and executive dysfunction like inability to manage finances). 2. **Wobbly (Gait Disturbance):** He exhibits an unsteady gait requiring assistance. In NPH, this is typically a "magnetic gait" (short steps, feet appearing stuck to the floor). 3. **Wet (Urinary Incontinence):** The development of incontinence post-infection indicates a persistent neurological issue rather than just the acute UTI. **Why the other options are incorrect:** * **Creutzfeldt-Jakob Disease (CJD):** Characterized by *rapidly* progressive dementia (weeks to months) and myoclonus. An 8-month gradual decline is too slow for typical CJD. * **Huntington Disease:** Presents with choreiform movements and psychiatric symptoms, usually in younger patients (30s–40s), with a strong autosomal dominant family history. * **Parkinson Disease:** While it features gait issues, the primary symptoms are resting tremor, rigidity, and bradykinesia. Dementia in PD typically occurs many years *after* the onset of motor symptoms. **NEET-PG High-Yield Pearls:** * **Pathophysiology:** NPH is caused by impaired CSF resorption at the arachnoid villi, leading to ventricular enlargement with *normal* opening pressure on lumbar puncture. * **Diagnosis:** MRI shows ventriculomegaly out of proportion to sulcal atrophy (Evans Index >0.3). * **Treatment:** It is a **reversible cause of dementia**. The "Miller Fisher Test" (large volume lumbar puncture) is used to see if symptoms improve; definitive treatment is a **Ventriculoperitoneal (VP) shunt**.
Question 10: What is the annual conversion rate to dementia in patients with mild cognitive impairment?
- A. 10% (Correct Answer)
- B. 20%
- C. 30%
- D. 40%
Explanation: ### Explanation **Mild Cognitive Impairment (MCI)** is a clinical state where an individual has objective memory or cognitive impairment beyond what is expected for their age, but their activities of daily living (ADLs) remain intact. It is considered a "prodromal" or transitional stage between normal aging and dementia. **1. Why 10% is Correct:** Epidemiological studies and clinical trials (such as those by Petersen et al.) consistently show that patients diagnosed with MCI convert to clinically diagnosable dementia (most commonly Alzheimer’s disease) at a rate of approximately **10% to 15% per year**. In contrast, the conversion rate for healthy elderly individuals is significantly lower, at about 1% to 2% per year. Therefore, Option A is the most accurate representation of the annual progression risk. **2. Why Other Options are Incorrect:** * **Options B, C, and D (20%, 30%, 40%):** These figures significantly overestimate the *annual* conversion rate. While the *cumulative* conversion rate over 3 to 5 years may reach 30% to 50%, the question specifically asks for the **annual** rate. Overestimating this risk can lead to unnecessary patient anxiety and incorrect clinical prognosis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Amnestic MCI:** The subtype where memory loss is the primary symptom; it has the highest risk of progressing to **Alzheimer’s Disease**. * **Non-amnestic MCI:** Affects other domains (language, executive function); it may progress to Frontotemporal Dementia or Lewy Body Dementia. * **Reversibility:** Unlike dementia, MCI can sometimes be stable or even revert to normal cognition if the underlying cause (e.g., Vitamin B12 deficiency, depression, or hypothyroidism) is treated. * **Key Diagnostic Difference:** In MCI, **ADLs are preserved**; in Dementia, **ADLs are significantly impaired**.
Practice by Chapter
Normal Aging Process
Practice Questions
Dementia: Alzheimer's Type
Practice Questions
Other Neurocognitive Disorders
Practice Questions
Delirium in the Elderly
Practice Questions
Late-Life Depression
Practice Questions
Anxiety Disorders in the Elderly
Practice Questions
Psychosis in the Elderly
Practice Questions
Sleep Disorders in the Elderly
Practice Questions
Pharmacotherapy Considerations in the Elderly
Practice Questions
Elder Abuse and Neglect
Practice Questions
End-of-Life Issues
Practice Questions
Long-term Care Issues
Practice Questions
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