Geriatric Psychiatry — MCQs

A 72-year-old man is brought to the clinic by his daughter due to concerns about his memory. A careful history, mini-mental status examination, and physical examination confirm suspicions of Alzheimer disease. Which of the following investigations is included in the initial workup for reversible causes of dementia?

Q16Easy

Which of the following is the most common cause of reversible dementia in the geriatric population?

Q17Medium

A 77-year-old man presents with confusion, poor judgment, and bizarre behavior. Investigations reveal a urinary tract infection, which partially improves with treatment. However, the behavioral changes persist, with a history of 8 years of progressive bizarre behavior including inappropriate sexual advances, urinating in hallways, and rapid eating. Neuro-imaging studies are normal. Which of the following is the most likely diagnosis?

Q18Easy

Which of the following is NOT a feature of dementia?

Q19Medium

A 70-year-old male patient presented with forgetfulness of keys and difficulty performing household chores. The patient has trouble driving and takes longer to recognize family members' faces. On examination, the Mini-Mental State Examination (MMSE) score was 20/30. Consciousness was intact, and no focal neurological deficits were present. A Bielschowsky stain revealed characteristic findings. Which anatomical region typically shows the earliest pathological changes in this condition?

Q20Medium

An 80-year-old person has started forgetting the names of familiar persons and places. There has been confabulation and forgetfulness about recent events like meals. Clinical and neurological examination reveals no abnormality. CT scan of the brain showed symmetrical enlargement of lateral ventricles and wider sulci. What is the most likely diagnosis?

Geriatric Psychiatry Indian Medical PG Practice Questions and MCQs

Question 11: Presenile dementia is defined as dementia that occurs below the age of which of the following years?

A. 50
B. 55
C. 60 (Correct Answer)
D. 65

Explanation: ### Explanation **Correct Option: C (60 years)** The classification of dementia based on the age of onset is a traditional clinical distinction used to categorize neurodegenerative disorders, most notably Alzheimer’s Disease. * **Presenile Dementia:** This refers to the onset of dementia symptoms in individuals **below the age of 60**. Historically, this term was used to describe cases that appeared earlier than expected, often associated with a more rapid progression and a stronger genetic component (e.g., mutations in Presenilin 1, 2, or APP genes). * **Senile Dementia:** This refers to the onset of dementia at or **after the age of 60**. **Analysis of Incorrect Options:** * **Options A (50) and B (55):** These ages are too low for the standard definition. While "Early-onset Alzheimer’s" can occur in the 40s or 50s, the formal cutoff for the "presenile" category remains 60. * **Option D (65):** While 65 is often used as the threshold for "geriatric" or "retirement age" in many social and medical contexts (and is sometimes used to define "Early-onset" vs. "Late-onset" Alzheimer's in modern research), the classical psychiatric definition for **Presenile Dementia** specifically uses the **60-year** cutoff. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** Alzheimer’s Disease is the most common cause of both presenile and senile dementia. * **Genetic Link:** Presenile dementia is more likely to have an **Autosomal Dominant** inheritance pattern compared to senile dementia. * **Reversible Causes:** In younger patients (presenile), always rule out reversible causes like Vitamin B12 deficiency, Hypothyroidism, and Normal Pressure Hydrocephalus (NPH). * **Pseudodementia:** In elderly patients, severe Depression can mimic dementia; this is termed "Depressive Pseudodementia" and is characterized by a "don't know" attitude toward questions and a rapid onset.

Question 12: What is the most common cause of dementia in adults?

A. Alzheimer's disease (Correct Answer)
B. Multi-infarct dementia
C. Pick's disease
D. Metabolic causes

Explanation: **Explanation:** **1. Why Alzheimer’s Disease (AD) is Correct:** Alzheimer’s disease is the leading cause of dementia worldwide, accounting for approximately **60–80% of all cases** in the elderly. It is a neurodegenerative disorder characterized by the extracellular accumulation of **amyloid-beta plaques** and intracellular **tau protein neurofibrillary tangles**. Clinically, it presents with progressive memory loss (starting with short-term memory), followed by cognitive decline in language and executive function. **2. Why the Other Options are Incorrect:** * **B. Multi-infarct (Vascular) Dementia:** This is the **second most common** cause of dementia. It is characterized by a "step-wise" decline in cognition resulting from multiple small strokes or chronic cerebral ischemia. * **C. Pick’s Disease (Frontotemporal Dementia):** This is a rarer cause of dementia that typically occurs at a younger age (40–60 years). It is distinguished by early changes in personality, social behavior, and language rather than memory loss. * **D. Metabolic Causes:** These include Vitamin B12 deficiency, hypothyroidism, and hepatic encephalopathy. While important to rule out because they are often **reversible**, they represent a small minority of total dementia cases. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common risk factor:** Advancing age. * **Genetic association:** **APOE-ε4** allele increases risk; **APP, PSEN1, and PSEN2** mutations are linked to early-onset familial AD. * **Neurobiology:** There is a significant deficiency of **Acetylcholine** in the nucleus basalis of Meynert. * **Imaging:** MRI typically shows **hippocampal atrophy** and compensatory ventricular enlargement (hydrocephalus ex-vacuo). * **Drug of Choice:** Donepezil (Cholinesterase inhibitor) for mild-to-moderate; Memantine (NMDA antagonist) for moderate-to-severe cases.

Question 13: Which of the following is a reversible cause of dementia?

A. Toxic dementia (Correct Answer)
B. Alzheimer's disease
C. Multi-infarct dementia
D. Pick's disease

Explanation: **Explanation:** Dementia is clinically categorized into **irreversible (degenerative)** and **reversible (secondary)** causes. Identifying reversible causes is a critical step in geriatric psychiatry because timely intervention can restore cognitive function. **Why Toxic Dementia is Correct:** Toxic dementia refers to cognitive impairment caused by exogenous substances such as heavy metals (lead, mercury), chronic alcohol abuse, or medications (anticholinergics, benzodiazepines). Since these are external insults, removing the offending agent or treating the toxicity can lead to partial or complete reversal of cognitive deficits. Other classic reversible causes include Vitamin B12 deficiency, hypothyroidism, and Normal Pressure Hydrocephalus (NPH). **Why the other options are Incorrect:** * **B. Alzheimer’s Disease:** The most common cause of dementia. It is a progressive, neurodegenerative condition characterized by amyloid plaques and tau tangles. It is irreversible. * **C. Multi-infarct Dementia:** A type of Vascular Dementia caused by multiple strokes. While further progression can be slowed by managing risk factors (like hypertension), the brain tissue already lost to infarction cannot be recovered. * **D. Pick’s Disease:** Now classified under Frontotemporal Dementia (FTD). It involves progressive atrophy of the frontal and temporal lobes and is irreversible. **NEET-PG High-Yield Pearls:** * **Pseudodementia:** A high-yield "reversible" mimic of dementia caused by **Depression** in the elderly. Patients typically complain of memory loss (unlike true dementia) and answer "I don't know" to questions. * **Wernicke-Korsakoff Syndrome:** Alcohol-related cognitive impairment. Wernicke’s (acute) is reversible with Thiamine, but Korsakoff’s (chronic) is often permanent. * **Rule of thumb:** Always screen for "DEMENTIA" (Drugs, Emotional, Metabolic, Eyes/Ears, Nutrition, Tumors, Infection, Arterial) to find reversible causes.

Question 14: Which of the following is NOT seen in Alzheimer's Disease?

A. Cerebral atrophy
B. Ventricular shrinkage (Correct Answer)
C. Sun downing
D. Apraxia

Explanation: ### Explanation In Alzheimer’s Disease (AD), the fundamental pathological process involves progressive neurodegeneration. **Why "Ventricular shrinkage" is the correct answer:** In neurodegenerative conditions like AD, there is a significant loss of neurons and synapses, leading to **cerebral atrophy**. As the brain parenchyma (tissue) shrinks, the fluid-filled spaces within the brain—the ventricles—undergo **compensatory enlargement** to fill the resulting void. This phenomenon is known as **hydrocephalus ex-vacuo**. Therefore, one would see **ventricular enlargement (dilation)**, not shrinkage. **Analysis of incorrect options:** * **Cerebral atrophy (A):** This is a hallmark feature of AD. It typically begins in the hippocampus and entorhinal cortex (causing memory loss) before progressing to the frontal, temporal, and parietal lobes. * **Sun downing (C):** This refers to the phenomenon where neuropsychiatric symptoms (agitation, confusion, and anxiety) worsen in the late afternoon or evening. It is a common clinical feature in dementia patients. * **Apraxia (D):** This is the inability to carry out purposeful motor activities despite intact motor function. It is one of the "4 A's" of Alzheimer’s (Amnesia, Aphasia, Apraxia, Agnosia) and indicates parietal lobe involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Microscopic Hallmarks:** Amyloid (senile) plaques (extracellular) and Neurofibrillary tangles (intracellular, composed of hyperphosphorylated **tau protein**). * **Neurochemistry:** Significant **decrease in Acetylcholine** levels due to loss of neurons in the **Nucleus Basalis of Meynert**. * **Imaging:** MRI typically shows atrophy of the **hippocampus** (earliest sign). * **Genetics:** Early-onset AD is associated with mutations in *APP*, *PSEN1*, and *PSEN2*; late-onset is associated with the **ApoE4** allele.

Question 15: A 72-year-old man is brought to the clinic by his daughter due to concerns about his memory. A careful history, mini-mental status examination, and physical examination confirm suspicions of Alzheimer disease. Which of the following investigations is included in the initial workup for reversible causes of dementia?

A. Electroencephalogram (EEG)
B. Urine tests for heavy metals
C. Thyroid function tests (Correct Answer)
D. Red blood cell (RBC) folate

Explanation: **Explanation:** In the evaluation of a patient with suspected Alzheimer’s disease, the primary goal of the initial workup is to exclude **reversible (secondary) causes of dementia**. These are conditions that mimic cognitive decline but can be treated or cured. **1. Why Thyroid Function Tests (TFTs) are correct:** Hypothyroidism is a classic, treatable cause of cognitive impairment (often termed "pseudodementia"). Patients may present with psychomotor slowing, memory loss, and depression. International guidelines (such as AAN and NICE) recommend screening for **Thyroid Stimulating Hormone (TSH)** and **Vitamin B12 levels** in all patients undergoing a dementia workup because these metabolic derangements are common and easily reversible. **2. Why other options are incorrect:** * **EEG (A):** Not a routine screening tool for dementia. It is primarily used if Creutzfeldt-Jakob Disease (CJD), seizures, or delirium are suspected. * **Urine tests for heavy metals (B):** These are not part of the standard initial workup. They are only indicated if there is a specific occupational or environmental history suggesting toxicity (e.g., lead or mercury exposure). * **RBC Folate (D):** While Vitamin B12 deficiency is a standard screen, routine folate testing is no longer recommended in the initial workup unless the patient has specific risk factors (like severe malnutrition or alcoholism), as folate deficiency is an extremely rare cause of isolated dementia. **Clinical Pearls for NEET-PG:** * **Standard Initial Workup:** CBC, Serum Electrolytes, Blood Glucose, TSH, Vitamin B12, and Neuroimaging (MRI or CT). * **Neuroimaging:** MRI is preferred over CT to look for hippocampal atrophy (Alzheimer's), vascular changes, or Normal Pressure Hydrocephalus (NPH). * **NPH Triad:** "Wet, Wacky, and Wobbly" (Urinary incontinence, Dementia, and Magnetic Gait). This is a high-yield reversible cause. * **Depression:** Always rule out "Depressive Pseudodementia" in the elderly, where cognitive deficits improve with antidepressants.

Question 16: 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: **Explanation:** The correct answer is **Depression**. In the geriatric population, depression often presents with cognitive deficits (memory loss, poor concentration, and executive dysfunction) that mimic true dementia. This clinical entity is known as **Pseudodementia** (Depressive Pseudodementia). **Why Depression is the Correct Answer:** While all the options listed are causes of reversible dementia, **depression is statistically the most common**. Unlike neurodegenerative conditions like Alzheimer’s, the cognitive impairment in depression is secondary to a primary mood disorder. When the depression is treated effectively with antidepressants or ECT, the cognitive symptoms typically resolve, making it "reversible." **Analysis of Incorrect Options:** * **Normal Pressure Hydrocephalus (NPH):** Characterized by the triad of "wet, wobbly, and wacky" (urinary incontinence, gait ataxia, and dementia). While reversible via a ventriculoperitoneal shunt, it is much rarer than depression. * **Hypothyroidism:** Can cause "myxedema madness" or cognitive slowing. It is a standard part of a dementia workup but is less frequent than depressive symptoms in the elderly. * **Vitamin B12 Deficiency:** Leads to Subacute Combined Degeneration of the spinal cord and cognitive decline. Though important to rule out, it is not the most common cause. **High-Yield Clinical Pearls for NEET-PG:** * **Pseudodementia vs. Dementia:** In pseudodementia, patients often complain extensively about their memory loss ("I don't know" answers), whereas true dementia patients often try to hide or minimize deficits (confabulation). * **Onset:** Pseudodementia has a relatively **subacute/rapid onset**, whereas true dementia is insidious and progressive. * **Screening:** The Geriatric Depression Scale (GDS) is a useful tool for differentiating these conditions in clinical practice.

Question 17: A 77-year-old man presents with confusion, poor judgment, and bizarre behavior. Investigations reveal a urinary tract infection, which partially improves with treatment. However, the behavioral changes persist, with a history of 8 years of progressive bizarre behavior including inappropriate sexual advances, urinating in hallways, and rapid eating. Neuro-imaging studies are normal. Which of the following is the most likely diagnosis?

A. Alzheimer's disease
B. Frontotemporal dementia (Correct Answer)
C. Dementia with diffuse Lewy bodies
D. Vascular dementia

Explanation: ### Explanation The core of this clinical scenario is a long-standing (8-year), progressive decline characterized by **profound personality changes and social disinhibition** rather than primary memory loss. **1. Why Frontotemporal Dementia (FTD) is correct:** FTD (specifically the behavioral variant) typically presents with early changes in personality, executive dysfunction, and a loss of social decorum. Key features in this patient—**inappropriate sexual advances, urinating in public, and hyperphagia (rapid eating)**—are classic signs of "frontal lobe release" and loss of impulse control. While the UTI caused an acute delirium (confusion), the persistence of these specific behavioral symptoms for 8 years points to an underlying neurodegenerative process. Notably, early-stage FTD may show normal neuroimaging before focal atrophy of the frontal and temporal lobes becomes apparent. **2. Why the other options are incorrect:** * **Alzheimer’s Disease:** Typically presents first with **episodic memory deficits** (forgetfulness). Social behavior and personality are usually preserved until the later stages. * **Dementia with Lewy Bodies (DLB):** Characterized by a triad of fluctuating cognition, visual hallucinations, and spontaneous parkinsonism. The behavioral disinhibition described here is not the hallmark. * **Vascular Dementia:** Usually follows a **"step-wise" decline** with a history of hypertension or stroke. Imaging would typically show infarcts or white matter changes, which are absent here. **Clinical Pearls for NEET-PG:** * **Pick’s Disease:** A subtype of FTD characterized by **Pick bodies** (silver-staining tau inclusions). * **Klüver-Bucy Syndrome:** Can be seen in FTD, manifesting as hyperorality, hypersexuality, and docility. * **Age of Onset:** FTD often occurs at a younger age (45–65) than Alzheimer’s, though it can present in older patients. * **Management:** Unlike Alzheimer’s, SSRIs are often used to manage the behavioral symptoms of FTD; Cholinesterase inhibitors may actually worsen agitation.

Question 18: Which of the following is NOT a feature of dementia?

A. Forgetfulness
B. Loss of neurons in the brain
C. Loss of sensorium (Correct Answer)
D. Wearing dirty clothes

Explanation: **Explanation:** The core concept in differentiating **Dementia** from **Delirium** lies in the state of consciousness (sensorium). **Why "Loss of Sensorium" is the correct answer:** In Dementia (Major Neurocognitive Disorder), the **sensorium remains clear** until the very terminal stages of the disease. Patients are typically alert and oriented to their surroundings despite cognitive deficits. In contrast, a "clouding of consciousness" or **loss of sensorium** is the hallmark feature of **Delirium**. Therefore, loss of sensorium is NOT a feature of dementia. **Analysis of other options:** * **A. Forgetfulness:** Impairment of memory (especially short-term memory) is the most common presenting symptom of dementia, particularly Alzheimer’s type. * **B. Loss of neurons in the brain:** Dementia is characterized by progressive, irreversible neurodegeneration. For example, in Alzheimer’s, there is significant atrophy of the hippocampus and cerebral cortex due to neuronal loss. * **C. Wearing dirty clothes:** This represents a decline in **Activities of Daily Living (ADLs)** and poor self-care. Loss of executive function and "Self-Care Deficit" are diagnostic criteria for dementia as the disease progresses. **High-Yield Clinical Pearls for NEET-PG:** 1. **Dementia vs. Delirium:** Dementia is chronic, progressive, and has a clear sensorium. Delirium is acute, fluctuating, and has an impaired sensorium. 2. **Reversible Dementias:** Always rule out Vitamin B12 deficiency, Hypothyroidism, and Normal Pressure Hydrocephalus (NPH). 3. **Pseudodementia:** This refers to Depression in the elderly where the patient complains of memory loss ("I don't know" answers) but sensorium is intact. 4. **Mini-Mental State Examination (MMSE):** A score of <24 is suggestive of cognitive impairment.

Question 19: A 70-year-old male patient presented with forgetfulness of keys and difficulty performing household chores. The patient has trouble driving and takes longer to recognize family members' faces. On examination, the Mini-Mental State Examination (MMSE) score was 20/30. Consciousness was intact, and no focal neurological deficits were present. A Bielschowsky stain revealed characteristic findings. Which anatomical region typically shows the earliest pathological changes in this condition?

A. Mammillary body
B. Thalamus
C. Hippocampus (Correct Answer)
D. Caudate nucleus

Explanation: **Explanation:** The clinical presentation of progressive memory loss, executive dysfunction (difficulty with chores), and prosopagnosia (difficulty recognizing faces) in an elderly patient with an MMSE score of 20/30 is classic for **Alzheimer’s Disease (AD)**. The mention of **Bielschowsky silver stain** is a high-yield histological clue, as it is used to visualize **Senile (Neuritic) Plaques** and **Neurofibrillary Tangles (NFTs)**, the pathological hallmarks of AD. **Why Hippocampus is Correct:** In Alzheimer’s Disease, the neurodegenerative process follows a predictable anatomical progression. The earliest pathological changes (NFTs) typically begin in the **entorhinal cortex**, followed rapidly by the **hippocampus** (part of the medial temporal lobe). This explains why episodic memory impairment is the earliest clinical symptom. **Analysis of Incorrect Options:** * **A. Mammillary body:** Atrophy of the mammillary bodies is a hallmark of **Wernicke-Korsakoff Syndrome** (due to Thiamine deficiency), not AD. * **B. Thalamus:** While involved in various dementias and metabolic encephalopathies, it is not the primary or earliest site of pathology in AD. * **D. Caudate nucleus:** Atrophy of the caudate nucleus is the characteristic finding in **Huntington’s Disease**, leading to boxcar ventricles on imaging. **NEET-PG High-Yield Pearls:** * **Pathology:** Extracellular Amyloid-beta plaques and Intracellular Tau protein (hyperphosphorylated) tangles. * **Genetics:** Early-onset AD is associated with APP (Chr 21), Presenilin 1 (Chr 14), and Presenilin 2 (Chr 1). Late-onset is associated with **ApoE4**. * **Neurochemistry:** Significant decrease in **Acetylcholine** levels due to degeneration of the **Nucleus Basalis of Meynert**. * **Imaging:** MRI shows bilateral hippocampal atrophy and compensatory ventriculomegaly.

Question 20: An 80-year-old person has started forgetting the names of familiar persons and places. There has been confabulation and forgetfulness about recent events like meals. Clinical and neurological examination reveals no abnormality. CT scan of the brain showed symmetrical enlargement of lateral ventricles and wider sulci. What is the most likely diagnosis?

A. Confusional state
B. Alzheimer's disease (Correct Answer)
C. Alcoholic dementia
D. Chronic cerebrovascular insufficiency

Explanation: ### Explanation The clinical presentation describes a classic case of **Alzheimer’s Disease (AD)**, the most common cause of dementia in the elderly. **Why Alzheimer’s Disease is Correct:** 1. **Memory Impairment:** The patient shows loss of memory for familiar names and recent events (anterograde amnesia), which is the hallmark early symptom. 2. **Confabulation:** While often associated with Korsakoff’s, confabulation can occur in AD as a compensatory mechanism to fill memory gaps. 3. **Imaging Findings:** Symmetrical enlargement of lateral ventricles (ventriculomegaly) and widening of cortical sulci are indicative of **generalized cortical atrophy**, a characteristic finding in AD. 4. **Normal Neurological Exam:** Unlike vascular dementia, AD typically presents with a "clean" neurological exam in early-to-mid stages (no focal deficits). **Why Other Options are Incorrect:** * **Confusional State (Delirium):** This is an acute, fluctuating disturbance in consciousness and attention, usually triggered by a medical illness. The chronic, progressive nature of this patient's memory loss points toward dementia. * **Alcoholic Dementia:** While it involves memory loss and confabulation (Korsakoff’s), it is usually associated with a history of heavy alcohol use and specific nutritional deficiencies (Thiamine). * **Chronic Cerebrovascular Insufficiency (Vascular Dementia):** This typically presents with a "step-ladder" decline and **focal neurological deficits** (e.g., hemiparesis, gait changes) on examination, which are absent here. **NEET-PG High-Yield Pearls:** * **Microscopic Hallmarks:** Amyloid plaques (extracellular) and Neurofibrillary tangles (intracellular Tau protein). * **Brain Regions:** Atrophy starts in the **Hippocampus** and Entorhinal cortex. * **Neurotransmitters:** Significant decrease in **Acetylcholine** (hence the use of Donepezil/Rivastigmine). * **Genetics:** Early-onset is linked to APP, PSEN1, and PSEN2; Late-onset is linked to **ApoE4**.

Practice by Chapter

Normal Aging Process

Practice Questions

Dementia: Alzheimer's Type

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Other Neurocognitive Disorders

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Delirium in the Elderly

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Late-Life Depression

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Anxiety Disorders in the Elderly

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Psychosis in the Elderly

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Sleep Disorders in the Elderly

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Pharmacotherapy Considerations in the Elderly

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Elder Abuse and Neglect

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End-of-Life Issues

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Long-term Care Issues

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