Geriatric Psychiatry — MCQs

A 68-year-old male presents with a 6-month history of increasing forgetfulness, difficulty organizing finances and paying bills, social withdrawal, and recent inappropriate behavior towards a neighbor. His wife reports these changes are uncharacteristic. He has a history of hypertension and type 2 diabetes mellitus, and a family history of Alzheimer disease. His Mini-Mental State Examination (MMSE) score is 23. What is the most likely diagnosis?

Q27Easy

Alzheimer's disease is associated with:

Q28

Which of the following disorders is characterized by intense nihilism, somatization and agitation in old age?

Q29

True about dementia is:

Q30

Which of the following is not a feature of delirium?

Geriatric Psychiatry Indian Medical PG Practice Questions and MCQs

Question 21: Which of the following is a preventable risk factor for dementia?

A. Hypertension (Correct Answer)
B. Apolipoprotein E4
C. Advanced age
D. Lowered homocysteine levels

Explanation: **Explanation:** The prevention of dementia is a high-yield topic in geriatric psychiatry. According to the **Lancet Commission on Dementia Prevention**, approximately 40% of dementia cases are attributable to 12 modifiable risk factors. **Why Hypertension is correct:** Mid-life **hypertension** (typically defined as systolic BP ≥140 mmHg) is a major **preventable** risk factor. Chronic high blood pressure leads to cerebrovascular damage, white matter lesions, and microinfarcts, which contribute significantly to both Vascular Dementia and Alzheimer’s Disease. Controlling BP with antihypertensives is proven to reduce the risk of cognitive decline. **Analysis of Incorrect Options:** * **B. Apolipoprotein E4 (ApoE4):** This is a genetic risk factor. While it significantly increases the risk of late-onset Alzheimer’s, it is **non-modifiable**. * **C. Advanced age:** This is the **strongest non-modifiable risk factor** for dementia. The prevalence of dementia doubles every five years after the age of 65. * **D. Lowered homocysteine levels:** High levels of homocysteine (Hyperhomocysteinemia) are associated with increased dementia risk. Therefore, *lowered* levels would be considered protective, not a risk factor. **NEET-PG High-Yield Pearls:** * **Most common cause of dementia:** Alzheimer’s Disease. * **Most common preventable risk factor:** Mid-life hypertension and hearing loss (hearing loss is often cited as the single largest modifiable risk factor in mid-life). * **Other modifiable factors:** Diabetes, obesity, smoking, depression, physical inactivity, and low education levels. * **Protective factors:** High education, physical exercise, and "cognitive reserve."

Question 22: Vascular dementia is characterized by which of the following?

A. Disorientation
B. Memory deficits (Correct Answer)
C. Emotional lability
D. Visual hallucinations

Explanation: **Explanation:** **Vascular Dementia (VaD)** is the second most common cause of dementia after Alzheimer’s disease. According to the **ICD-10 and DSM-5 criteria**, the core clinical feature required for a diagnosis of any dementia, including vascular dementia, is the presence of **memory deficits** along with impairment in at least one other cognitive domain (aphasia, apraxia, agnosia, or executive functioning) that interferes with daily life. * **Why Memory Deficits is Correct:** While VaD often presents with prominent executive dysfunction (due to subcortical involvement), memory impairment remains a fundamental diagnostic requirement. It typically follows a "step-wise" decline resulting from multiple cerebrovascular accidents (infarcts). * **Why other options are incorrect:** * **Disorientation:** While it occurs as dementia progresses, it is a non-specific feature and not the primary diagnostic hallmark. * **Emotional lability:** Also known as "pseudobulbar affect," this is common in VaD due to frontal-subcortical disruption, but it is a supportive clinical sign rather than a defining diagnostic criterion. * **Visual hallucinations:** These are highly characteristic of **Lewy Body Dementia (LBD)** and are not a primary feature of vascular dementia. **High-Yield Clinical Pearls for NEET-PG:** * **Hachinski Ischemic Score:** A score >7 suggests Vascular Dementia; <4 suggests Alzheimer’s. * **Key Presentation:** Step-wise deterioration, focal neurological deficits (e.g., hemiparesis, gait changes), and "patchy" cognitive deficits. * **Risk Factors:** Hypertension (most significant), diabetes, and smoking. * **Neuroimaging:** MRI typically shows multiple infarcts or extensive white matter hyperintensities (leukoaraiosis).

Question 23: True about dementia is:

A. Alzheimer's disease is due to multiple small strokes in the cerebral cortex.
B. Dementia is the loss of distant memory. (Correct Answer)
C. Dementia due to atherosclerosis does not progress like Alzheimer's.
D. Alzheimer's disease is associated with an increase in acetylcholine release in the cerebral cortex.

Explanation: **Explanation:** **Dementia** is a clinical syndrome characterized by a progressive decline in cognitive functions (memory, language, executive function) severe enough to interfere with daily life, occurring in clear consciousness. **Why Option B is correct:** In the progression of dementia, particularly Alzheimer’s, memory loss follows **Ribot’s Law**, where recent memories are lost first while **distant (remote) memories** are initially preserved. However, as the disease advances to moderate and severe stages, there is a progressive loss of distant memories, including personal history and long-term facts. While "loss of recent memory" is the earliest sign, "loss of distant memory" is a definitive feature of established dementia. **Analysis of Incorrect Options:** * **Option A:** This describes **Vascular Dementia** (specifically Multi-infarct dementia), not Alzheimer’s. Alzheimer’s is a neurodegenerative disease characterized by amyloid plaques and tau tangles. * **Option C:** Dementia due to atherosclerosis (Vascular Dementia) typically follows a **"step-ladder" progression** (sudden drops in function followed by plateaus), whereas Alzheimer’s follows a **slow, continuous decline**. Both are progressive, but the pattern differs. * **Option D:** Alzheimer’s is associated with a **decrease** (deficiency) in acetylcholine. This is the basis for using Acetylcholinesterase inhibitors (e.g., Donepezil, Rivastigmine) as treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of dementia:** Alzheimer’s Disease (AD). * **Earliest symptom of AD:** Loss of recent memory (Anterograde amnesia). * **Genetic markers:** APP (Chr 21), Presenilin 1 (Chr 14), Presenilin 2 (Chr 1), and APOE-ε4 (risk factor). * **Reversible causes of dementia:** Hypothyroidism, Vitamin B12 deficiency, and Normal Pressure Hydrocephalus (NPH). * **Pseudodementia:** Depression in the elderly that mimics dementia; unlike true dementia, these patients often complain extensively about their memory loss ("I don't know" answers).

Question 24: An elderly widow reports auditory hallucinations of her deceased husband speaking to her. She often discusses daily matters with him, which provokes anxiety and sadness. What is the most appropriate initial treatment for this patient?

A. Clomipramine
B. Alprazolam
C. Electroconvulsive therapy
D. Haloperidol (Correct Answer)

Explanation: ### Explanation The patient is presenting with **Late-Life Psychosis** (likely secondary to a psychotic depression or a late-onset psychotic disorder), characterized by auditory hallucinations and associated distress (anxiety and sadness). **1. Why Haloperidol is Correct:** In geriatric patients presenting with active psychotic symptoms (hallucinations) that cause significant distress or functional impairment, **Antipsychotics** are the first-line treatment. **Haloperidol**, a high-potency typical antipsychotic, is frequently used in clinical scenarios and exams to manage acute psychosis. While atypical antipsychotics (like Risperidone or Quetiapine) are often preferred in modern practice due to a lower risk of Extrapyramidal Symptoms (EPS), Haloperidol remains a classic correct choice in MCQ formats for the rapid control of psychotic symptoms. **2. Why Incorrect Options are Wrong:** * **Clomipramine (A):** This is a Tricyclic Antidepressant (TCA). While the patient has sadness, TCAs are generally avoided in the elderly due to strong anticholinergic side effects (confusion, urinary retention, falls). Furthermore, an antidepressant alone will not treat hallucinations. * **Alprazolam (B):** A benzodiazepine used for anxiety. While it may temporarily reduce her distress, it does not treat the underlying psychosis and carries a high risk of sedation, cognitive impairment, and paradoxical agitation in the elderly. * **Electroconvulsive therapy (C):** ECT is highly effective for psychotic depression or treatment-resistant psychosis, but it is typically reserved for cases where pharmacological treatment fails or when there is an urgent risk (e.g., suicidal ideation or refusal to eat). It is not the *initial* treatment. **3. Clinical Pearls for NEET-PG:** * **"Start Low, Go Slow":** The primary rule for prescribing any psychotropic medication in the elderly. * **Pseudodementia:** Always differentiate between depression-induced cognitive impairment (reversible) and true Dementia in geriatric psychiatry. * **Bereavement vs. Psychosis:** While "sensing" the presence of a deceased spouse can be a normal part of grief (Illusion/Hypnagogic hallucination), persistent auditory conversations that cause distress indicate a pathological psychotic process. * **Black Box Warning:** Antipsychotics carry an increased risk of stroke and mortality in elderly patients with dementia-related psychosis.

Question 25: Which of the following are treatable causes of dementia?

A. Alzheimer's disease
B. Hypothyroidism
C. Multi-infarct dementia (Correct Answer)
D. Subdural hematoma Hydrocephalus

Explanation: **Explanation:** The concept of "treatable" or **reversible dementia** refers to cognitive impairment caused by conditions that, when addressed, can lead to significant improvement or resolution of symptoms. **Why Multi-infarct Dementia is the Correct Answer:** Multi-infarct dementia (a subtype of Vascular Dementia) is considered "treatable" in the context of **secondary prevention**. While existing brain damage from previous strokes cannot be reversed, the progression of the disease can be halted or significantly slowed by treating underlying cardiovascular risk factors such as hypertension, diabetes, and hyperlipidemia. By managing these triggers, further "infarcts" are prevented, making it a modifiable and manageable form of cognitive decline compared to purely neurodegenerative conditions. **Analysis of Other Options:** * **Alzheimer’s Disease (A):** This is a progressive, irreversible neurodegenerative disorder. Current treatments (Cholinesterase inhibitors) only provide symptomatic relief and do not stop the underlying pathology. * **Hypothyroidism (B), Subdural Hematoma (D), and Normal Pressure Hydrocephalus (E):** These are classic examples of **reversible** dementias. If the thyroid hormone is replaced, the hematoma evacuated, or a shunt placed for hydrocephalus, the cognitive symptoms can often be completely reversed. *Note: In many standard medical classifications, B, D, and E are considered "more" treatable/reversible than Multi-infarct dementia. However, in the context of this specific question format, Multi-infarct dementia is highlighted for its focus on preventive management.* **High-Yield Clinical Pearls for NEET-PG:** * **Hachinski Ischemic Score:** Used to differentiate Alzheimer’s (low score) from Vascular Dementia (high score >7). * **Reversible Dementia Mnemonic (DEMENTIA):** **D**rugs, **E**motional (Pseudo-dementia), **M**etabolic (Hypothyroid), **E**yes/Ears (Sensory deprivation), **N**utritional (B12 deficiency), **T**umor/Trauma (SDH), **I**nfection (Neurosyphilis/HIV), **A**lcohol. * **Normal Pressure Hydrocephalus Triad:** Wet (Incontinence), Wacky (Dementia), and Wobbly (Ataxic gait).

Question 26: A 68-year-old male presents with a 6-month history of increasing forgetfulness, difficulty organizing finances and paying bills, social withdrawal, and recent inappropriate behavior towards a neighbor. His wife reports these changes are uncharacteristic. He has a history of hypertension and type 2 diabetes mellitus, and a family history of Alzheimer disease. His Mini-Mental State Examination (MMSE) score is 23. What is the most likely diagnosis?

A. Alzheimer disease
B. Creutzfeldt-Jakob disease
C. Dementia with Lewy bodies
D. Frontotemporal dementia (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Frontotemporal Dementia (FTD)** The clinical presentation highlights a significant shift in **personality and social conduct** (inappropriate behavior, social withdrawal) alongside executive dysfunction (difficulty organizing finances), which are the hallmarks of the **behavioral variant of Frontotemporal Dementia (bvFTD)**. In FTD, behavioral changes and executive deficits often precede significant memory loss. The patient's "uncharacteristic" inappropriate behavior toward a neighbor indicates **loss of social inhibition**, a classic diagnostic feature. While the MMSE score (23) indicates cognitive impairment, the focal involvement of the frontal lobes explains the early decline in social cognition and executive function. **Why incorrect options are wrong:** * **A. Alzheimer Disease:** Typically presents with **early episodic memory loss** (forgetting recent events). While this patient has forgetfulness, the prominent early personality changes and social disinhibition point more strongly toward FTD. * **B. Creutzfeldt-Jakob Disease:** Characterized by **rapidly progressive** dementia (weeks to months) usually accompanied by myoclonus and ataxia. A 6-month course with primary behavioral symptoms is less typical. * **C. Dementia with Lewy Bodies (DLB):** Requires the presence of **visual hallucinations**, parkinsonism, and fluctuating levels of consciousness. None of these are present here. **High-Yield Clinical Pearls for NEET-PG:** * **FTD vs. Alzheimer’s:** FTD occurs at a younger age (typically 45–65) and presents with "Personality first, Memory later." Alzheimer’s is "Memory first, Personality later." * **Pick’s Disease:** A subtype of FTD characterized histologically by **Pick bodies** (silver-staining tau inclusions) and **Knife-edge atrophy** of the frontal and temporal lobes. * **Neuroimaging:** Look for selective atrophy of the frontal and anterior temporal lobes on MRI.

Question 27: Alzheimer's disease is associated with:

A. Delerium
B. Delusion
C. Dementia (Correct Answer)
D. All of the above

Explanation: **Explanation:** **1. Why Dementia is the Correct Answer:** Alzheimer’s Disease (AD) is the most common cause of **Dementia** worldwide, accounting for 60-80% of cases. Dementia is a clinical syndrome characterized by a progressive, irreversible decline in cognitive functions (memory, language, executive function) that is severe enough to interfere with daily activities. The underlying pathology involves the accumulation of **amyloid plaques** and **neurofibrillary tangles** (tau protein), leading to neuronal death, particularly in the hippocampus and cerebral cortex. **2. Why Other Options are Incorrect:** * **Delirium (Option A):** Delirium is an *acute*, fluctuating disturbance in attention and awareness, usually caused by an underlying medical condition (e.g., infection, electrolyte imbalance). While a patient with Alzheimer’s can develop delirium (delirium superimposed on dementia), Alzheimer’s itself is a chronic neurodegenerative process, not an acute one. * **Delusion (Option B):** Delusions are fixed false beliefs. While they are common *behavioral and psychological symptoms of dementia* (BPSD) occurring in the middle-to-late stages of Alzheimer’s, they are secondary features and not the defining characteristic of the disease. * **All of the Above (Option D):** Since Delirium is a distinct clinical entity with a different temporal onset (acute vs. chronic), it is not inherently "associated" as a defining feature of Alzheimer’s. **3. NEET-PG High-Yield Pearls:** * **Earliest Sign:** Loss of recent memory (Anterograde amnesia). * **Neurotransmitter Change:** Significant **decrease in Acetylcholine** (due to loss of neurons in the Nucleus Basalis of Meynert). * **Genetics:** Early-onset (APP, PSEN1, PSEN2 genes); Late-onset (**ApoE4** is a risk factor; ApoE2 is protective). * **Brain Imaging:** Generalized cortical atrophy with compensatory **ventriculomegaly** (Hydrocephalus ex-vacuo). * **Treatment:** Cholinesterase inhibitors (Donepezil, Rivastigmine) and NMDA antagonists (Memantine).

Question 28: Which of the following disorders is characterized by intense nihilism, somatization and agitation in old age?

A. Atypical depression
B. Bipolar depression
C. Involutional melancholia (Correct Answer)
D. Somatized depression

Explanation: ***Involutional melancholia*** - This term refers to a severe depressive disorder in **late adulthood** characterized by profound **nihilism** (belief in the meaninglessness of existence), **somatization** (physical symptoms without a physical cause), and **agitation**. - It often involves prominent **psychotic features** like delusional guilt, nihilistic delusions (e.g., believing one's organs are rotting), and severe anxiety, distinguishing it from other forms of depression in older adults. - **Note**: This is a **historical diagnostic term** no longer used in DSM-5/ICD-11. The condition is now classified as **Major Depressive Disorder with melancholic features** or **with psychotic features** (when delusions are present). *Atypical depression* - Characterized by mood reactivity (mood improves in response to positive events), **increased appetite**, **hypersomnia**, leaden paralysis, and interpersonal rejection sensitivity. - This presentation is largely opposite to the **agitation** and severe **nihilism** seen in the described disorder. *Bipolar depression* - Occurs as part of **bipolar disorder**, involving episodes of both depression and mania/hypomania. - While it can be severe, the specific constellation of **intense nihilism**, prominent **somatization**, and persistent **agitation** in old age is more characteristic of what was historically termed involutional melancholia. *Somatized depression* - Refers to depression where **physical symptoms** are prominent. While somatization is present in the question, the defining features of **intense nihilism** and **agitation** are not specific to somatized depression. - This term usually emphasizes the physical presentation, whereas involutional melancholia describes a broader, severe depressive syndrome typical of later life.

Question 29: True about dementia is:

A. Dementia due to atherosclerosis progresses in the same gradual manner as Alzheimer's disease
B. Alzheimer's disease is due to multiple small strokes in the cerebral cortex
C. Alzheimer's disease is associated with an increase in ACh release in the cerebral cortex
D. Dementia involves a decline in memory and other cognitive functions affecting daily living (Correct Answer)

Explanation: ***Dementia involves a decline in memory and other cognitive functions affecting daily living*** - This statement accurately defines **dementia** as a significant decline in **cognitive functions**, including memory, language, problem-solving, and executive function, severe enough to interfere with daily activities. - The progressive nature of this decline leads to impaired independence and functional disability. *Dementia due to atherosclerosis progresses in the same gradual manner as Alzheimer's disease* - **Vascular dementia**, often caused by atherosclerosis leading to stroke or chronic cerebral ischemia, typically has a **stepped or fluctuating progression** rather than the gradual, continuous decline seen in Alzheimer's disease. - This is a key distinguishing feature between vascular dementia and Alzheimer's disease. *Alzheimer's disease is due to multiple small strokes in the cerebral cortex* - This describes **vascular dementia**, which is distinct from Alzheimer's disease. - **Alzheimer's disease** is characterized by the accumulation of **amyloid plaques** and **neurofibrillary tangles** in the brain, not by strokes. *Alzheimer's disease is associated with an increase in ACh release in the cerebral cortex* - **Alzheimer's disease** is associated with a significant **reduction in acetylcholine (ACh) levels** in the cerebral cortex, particularly in regions vital for memory and learning. - Many treatments for Alzheimer's aim to inhibit **acetylcholinesterase**, thereby increasing ACh availability to compensate for this deficit.

Question 30: Which of the following is not a feature of delirium?

A. Disturbed sleep
B. Intact attention (Correct Answer)
C. Illusion
D. Memory loss

Explanation: ***Intact attention*** - Delirium is fundamentally characterized by an **acute disturbance of attention** and awareness, making intact attention an incorrect feature. - Patients with delirium often struggle to focus, sustain, or shift attention, leading to disorientation and difficulty with cognitive tasks. *Disturbed sleep* - **Sleep-wake cycle disturbances** are a common feature of delirium, often manifesting as insomnia, hypersomnia, or reversal of the sleep cycle. - This disordered sleep pattern contributes to the overall cognitive impairment and agitation seen in delirious patients. *Illusion* - **Perceptual disturbances**, including illusions and hallucinations (especially visual), are hallmark symptoms of delirium. - Patients misinterpret real sensory stimuli (illusions) or perceive things that are not present (hallucinations). *Memory loss* - While not the primary deficit, **memory impairment**, particularly for recent events, is a significant feature of delirium due to the global cognitive dysfunction. - Patients often have difficulty recalling events that occurred during the delirious episode when they recover.

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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