Geriatric Psychiatry Practice Questions

Q: An elderly woman is brought to psychiatry OPD by her daughter with complaints of forgetfulness. For the past one year, she has been seeing people and animals in nearby house that has been unoccupied during this period. Also has rigidity. What is the mos t likely type of dementia?

Lewy body dementia. ***Lewy body dementia*** - Characterized by the clinical triad of **visual hallucinations** (often of people or animals), **fluctuating cognition**, and **parkinsonism** (such as rigidity). - Diagnosis relies on the presence of these core features and the **dementia** occurring within a year of the onset of motor symptoms. *Alzheimer’s disease* - Primarily presents with **progressive memory loss** and executive dysfunction without early prominent motor features. - **Visual hallucinations** are typically a late-stage finding rather than an early, characteristic feature like in Lewy body dementia. *Parkinson’s disease* - Features **tremor**, **rigidity**, and **bradykinesia** as the primary symptoms, with cognitive decline occurring much later in the disease course. - If cognitive impairment occurs within one year of motor symptoms, it is clinically classified as **Dementia with Lewy Bodies** (DLB) rather than **Parkinson's Disease Dementia**. *Vascular dementia* - Characterized by a **stepwise decline** in cognitive function associated with **cerebrovascular disease** or stroke events. - Clinical findings usually show **focal neurological deficits** rather than the specific pattern of hallucinations and parkinsonism seen here.

Q: An elderly patient dies, and autopsy reveals neuritic plaques in the brain. What is the most likely diagnosis?

Alzheimer’s disease. ***Alzheimer’s disease*** - The presence of **neuritic plaques** (composed of extracellular **beta-amyloid** deposits) and **neurofibrillary tangles** (intracellular hyperphosphorylated **tau protein**) is the pathologic hallmark of **Alzheimer’s disease**. - These findings lead to widespread **cortical atrophy**, particularly in the **hippocampus** and temporal lobes, correlating with the progressive dementia seen in this condition. *Parkinson’s disease* - The pathological hallmark is **Lewy bodies**, which are intracellular inclusions of **alpha-synuclein** found primarily in the **substantia nigra**. - Clinically manifests with motor symptoms like **bradykinesia**, **resting tremor**, and **rigidity** rather than primarily memory loss. *Creutzfeldt-Jakob disease* - Characterized pathologically by **spongiform changes** (vacuolation) in the cerebral cortex and grey matter. - This is a **prion disease** that typically presents with rapidly progressive dementia and **myoclonus**, often showing characteristic **periodic sharp wave complexes** on EEG. *Huntington’s disease* - Pathologically characterized by severe atrophy of the **caudate nucleus** and putamen (striatum) due to neuronal degeneration. - Clinically presents with **chorea**, behavioral disturbances, and dementia, usually displaying an **autosomal dominant** inheritance pattern.

Q: Which of the following antidepressants can be safely used in elderly depression?

Mianserin. 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.

Q: Vascular dementia is characterised by all except?

Visual hallucination. **Explanation:** Vascular Dementia (VaD) is the second most common cause of dementia after Alzheimer’s disease. It is caused by chronic cerebral ischemia or multiple infarcts (Multi-infarct dementia). **Why Option A is the Correct Answer:** Visual hallucinations are **not** a characteristic feature of Vascular Dementia. While they can occur in advanced stages or during episodes of delirium, they are the hallmark clinical feature of **Dementia with Lewy Bodies (DLB)**. In DLB, visual hallucinations are typically well-formed, detailed, and occur early in the disease course. **Analysis of Other Options:** * **Memory Deficit (Option B):** This is a core requirement for the diagnosis of any dementia. In VaD, memory loss may be less severe initially compared to Alzheimer’s, often showing a "patchy" distribution of cognitive deficits depending on the location of the strokes. * **Emotional Lability (Option C):** Also known as pseudobulbar affect, this is a classic feature of Vascular Dementia. Patients often exhibit sudden, exaggerated, or inappropriate emotional responses (e.g., uncontrollable crying or laughing) due to the disruption of cortico-bulbar pathways. **NEET-PG High-Yield Pearls:** 1. **Hachinski Ischemic Score:** Used to clinically differentiate VaD from Alzheimer’s. A score **>7** suggests Vascular Dementia. 2. **Step-ladder progression:** VaD typically follows a "step-wise" decline (sudden drops in function followed by plateaus), unlike the gradual, continuous decline in Alzheimer’s. 3. **Neuroimaging:** MRI typically shows multiple infarcts or extensive white matter hyperintensities (leukoaraiosis). 4. **Risk Factors:** Hypertension (most important), diabetes, and smoking. Management focuses on controlling these cardiovascular risks.

Q: "Sundowning" is seen in which of the following conditions?

Delirium. **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.

Q: How does delirium differ from schizophrenia?

Consciousness level. The fundamental distinction between delirium and schizophrenia lies in the **level of consciousness and sensorium**. ### 1. Why "Consciousness Level" is Correct Delirium is an acute neuropsychiatric syndrome characterized by a **clouding of consciousness** and a fluctuating level of awareness. Patients with delirium have impaired arousal and attention. In contrast, schizophrenia is a primary psychiatric disorder where the patient remains **fully conscious and alert** (clear sensorium), despite having disordered thought content (delusions) or perceptions (hallucinations). ### 2. Analysis of Incorrect Options * **A. Mood changes:** Both delirium and schizophrenia can present with significant mood disturbances (e.g., irritability, anxiety, or apathy). Therefore, mood is not a reliable pathognomonic feature to differentiate the two. * **C. Thought process tangentiality:** Disorganized thinking and tangentiality are common to both conditions. While the *content* of thoughts differs, the *process* of formal thought disorder can overlap, making it an unreliable differentiator. ### 3. NEET-PG High-Yield Pearls * **Onset & Course:** Delirium is **acute** (hours to days) and **fluctuating** (worse at night/sundowning). Schizophrenia is **chronic** (symptoms must last >6 months for diagnosis) and generally stable. * **Etiology:** Delirium is always secondary to an underlying **organic/medical cause** (e.g., infection, electrolyte imbalance, drug withdrawal). Schizophrenia is a functional idiopathic disorder. * **Hallucinations:** Delirium typically features **visual** hallucinations; Schizophrenia typically features **auditory** (third-person) hallucinations. * **Reversibility:** Delirium is usually reversible once the underlying medical cause is treated; Schizophrenia is a long-term neurodevelopmental condition.

Question 1

An elderly woman is brought to psychiatry OPD by her daughter with complaints of forgetfulness. For the past one year, she has been seeing people and animals in nearby house that has been unoccupied during this period. Also has rigidity. What is the mos t likely type of dementia?

Accepted Answer

Lewy body dementia

Answer

Alzheimer’s disease

Answer

Parkinson’s disease

Answer

Vascular dementia

Question 2

An elderly patient dies, and autopsy reveals neuritic plaques in the brain. What is the most likely
diagnosis?

Accepted Answer

Alzheimer’s disease

Answer

Parkinson’s disease

Answer

Creutzfeldt-Jakob disease

Answer

Huntington’s disease

Question 3

Which of the following antidepressants can be safely used in elderly depression?

Accepted Answer

Mianserin

Answer

Trazodone

Answer

Fluoxetine

Answer

Phenelzine

Question 4

Delirium is a disorder of:

Accepted Answer

Cognition

Answer

Thought

Answer

Perception

Answer

Insight

Question 5

Vascular dementia is characterised by all except?

Accepted Answer

Visual hallucination

Answer

Memory deficit

Answer

Emotional liability

Answer

None of the above

Question 6

"Sundowning" is seen in which of the following conditions?

Accepted Answer

Delirium

Answer

Night blindness

Answer

Parkinsonism

Answer

Solar urticaria

Question 7

A 52-year-old man with no history of psychiatric illness presents with recent onset of disorientation, fluctuating mental status, abnormal autonomic signs, tremor, and visual hallucinations described as 'little snakes' in his house. He has no known history of substance abuse. What is the most likely diagnosis?

Accepted Answer

Delirium

Answer

Schizophrenia

Answer

Dementia

Answer

Depression with psychotic features

Question 8

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?

Accepted Answer

Perform screening tests for vitamin deficiency and psychiatric disease.

Answer

Inform the patient that his symptoms are a normal consequence of aging and that his risk of Alzheimer disease is no higher than average.

Answer

Tell the patient that he has dementia and must stop driving.

Answer

Begin donepezil.

Question 9

How does delirium differ from schizophrenia?

Accepted Answer

Consciousness level

Answer

Mood changes

Answer

Thought process tangenitality

Answer

All of the above

Question 10

A 70-year-old male presents with a history of third-person auditory hallucinations and no prior psychiatric history. What is the most likely diagnosis?

Accepted Answer

Dementia

Answer

Delusional disorder

Answer

Schizophrenia

Answer

Acute psychosis

Geriatric Psychiatry — MCQs

Geriatric Psychiatry — MCQs

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