Pharmacotherapy for cognitive disorders — MCQs

A 31-year-old male presents to the emergency room following an altercation with patrons at a local grocery store. He is acting aggressively toward hospital staff and appears to be speaking to non-existent individuals. On examination he is tachycardic and diaphoretic. Horizontal and vertical nystagmus is noted. The patient eventually admits to taking an illegal substance earlier in the evening. Which of the following mechanisms of action is most consistent with the substance this patient took?

A 63-year-old woman is brought to the clinic by her husband with complaints of cognitive decline. The patient's husband says that she has had intermittent problems with her memory for the past few years. He says she has occasional 'bad days' where her memory deteriorates to the point where she cannot perform activities of daily living. She is also sometimes found conversing in an empty room and, when inquired, she confirms that she is talking to a friend. There have also been some recent falls. There is no history of fever, recent head trauma, loss of consciousness, or illicit drug use. Past medical history is significant for bronchial asthma and osteoarthritis, both managed medically. Her mother died due to metastatic breast cancer at age 71 and her father was diagnosed with Alzheimer's disease at age 65. The patient is afebrile and her vital signs are within normal limits. Physical examination reveals a tremor present in both her hands that attenuates with voluntary movement. Deep tendon reflexes are 2+ bilaterally. Romberg's sign is negative. She has a slow gait with a mild stooped posture. Her laboratory findings are significant for the following: Hemoglobin 12.9 g/dL White cell count 8,520/mm³ Platelets 295,000/mm³ Serum creatinine 1.0 mg/dL Glucose 94 mg/dL Sodium 141 mEq/L Potassium 3.9 mEq/L Calcium 92 mg/dL Ferritin 125 ng/mL Serum B12 305 ng/L TSH 2.1 µU/mL Ceruloplasmin 45 mg/dL Which of the following is the most appropriate management for this patient?

A 70-year-old female presents to you for an office visit with complaints of forgetfulness. The patient states that over the last several years, the patient has stopped cooking for herself even though she lives alone. Recently, she also forgot how to drive back home from the grocery store and has difficulty paying her bills. The patient says she has been healthy over her whole life and does not take any medications. Her vitals are normal and her physical exam does not reveal any focal neurological deficits. Her mini-mental status exam is scored 19/30 and her MRI reveals diffuse cortical atrophy. What is the best initial treatment for this patient's condition?

A 72-year-old man is brought to the physician by his wife for forgetfulness, confusion, and mood changes for the past 4 months. His symptoms started with misplacing items such as his wallet and keys around the house. Two months ago, he became unable to manage their finances as it became too difficult for him. Last week, he became lost while returning home from the grocery store. His wife reports that he shows “no emotion” and that he is seemingly not concerned by his recent symptoms. He has hypertension, type 2 diabetes mellitus, and coronary artery disease. Current medications include aspirin, metoprolol, lisinopril, metformin, and rosuvastatin. His pulse is 56/min and blood pressure is 158/76 mm Hg. Neurologic examination shows loss of sensation on his right leg and an unsteady gait. When asked to stand with his eyes closed and palms facing upward, his right arm rotates inward. An MRI of the brain shows multiple deep white matter lesions. Which of the following is the most likely diagnosis?

A 45-year-old woman comes to the physician because of a 6-month history of worsening involuntary movement of the left hand. Her symptoms are worse when she feels stressed at work. She has no history of serious illness and takes no medications. Neurological examination shows difficulty initiating movement and a tremor in the left hand at rest. The tremor decreases when the patient is asked to draw a circle. Which of the following is the most appropriate pharmacotherapy?

A 7-year-old boy is brought in to clinic by his parents with a chief concern of poor performance in school. The parents were told by the teacher that the student often does not turn in assignments, and when he does they are partially complete. The child also often shouts out answers to questions and has trouble participating in class sports as he does not follow the rules. The parents of this child also note similar behaviors at home and have trouble getting their child to focus on any task such as reading. The child is even unable to watch full episodes of his favorite television show without getting distracted by other activities. The child begins a trial of behavioral therapy that fails. The physician then tries pharmacological therapy. Which of the following is most likely the mechanism of action of an appropriate treatment for this child's condition?

A 65-year-old woman presents with memory problems for the past few weeks. Patient vividly describes how she forgot where she put her car keys this morning and did not remember to wish her grandson a happy birthday last week. Patient denies any cognitive problems, bowel/bladder incontinence, tremors, gait problems, or focal neurologic signs. Patient mentions she wants to take Ginkgo because her friend told her that it can help improve her brain function and prevent memory loss. Past medical history is significant for an acute cardiac event several years ago. Current medications are aspirin, carvedilol, and captopril. Patient denies any history of smoking, alcohol or recreational drug use. Patient is a widow, lives alone, and is able to perform all activities of daily living (ADLs) easily. No significant family history. Patient is afebrile and vital signs are within normal limits. Physical examination is unremarkable. Which of the following would be the most appropriate response to this patient’s request to take Ginkgo?

A 78-year-old man is brought to the physician by his daughter for a follow-up examination. The daughter noticed that he has gradually become more forgetful and withdrawn over the last year. He frequently misplaces his car keys and forgets the names of his neighbors, whom he has known for 30 years. He has difficulty recalling his address and telephone number. He recently had an episode of urinary and fecal incontinence. Last week, his neighbor found him wandering the parking lot of the grocery store. He has hypertension and hyperlipidemia. He had smoked one pack of cigarettes daily for 40 years but quit 18 years ago. His current medications include hydrochlorothiazide and atorvastatin. He appears healthy; BMI is 23 kg/m2. His temperature is 37.2°C (99.0°F), pulse is 86/min, respirations are 14/min, and blood pressure is 136/84 mm Hg. Mini-mental state examination score is 19/30. He is not bothered by his forgetfulness. Cranial nerves II–XII are intact. He has 5/5 strength and full sensation to light touch in all extremities. His patellar, Achilles, and biceps reflexes are 2+ bilaterally. His gait is steady. MRI scan of the brain shows ventriculomegaly and prominent cerebral sulci. Which of the following is the most appropriate pharmacotherapy?

A 68-year-old man seeks evaluation by a physician with complaints of worsening forgetfulness and confusion for 1 year. According to his wife, he has always been in good health and is generally very happy; however, he has started to forget important things. He recently had his driving license revoked because of multiple tickets, but he cannot recall having done anything wrong. This morning, he neglected to put on his socks and was quite agitated when she pointed this out to him. He denies having a depressed mood, sleep problems, or loss of interest. He occasionally has a glass of wine with dinner and has never smoked or used recreational drugs. His medical history and family medical history are unremarkable. His pulse is 68/min, respirations are 14/min, and blood pressure is 130/84 mm Hg. Except for a mini-mental state examination (MMSE) score of 20/30, the remainder of the physical examination is unremarkable. Imaging studies, including a chest X-ray and CT of the brain, reveal no pathologic findings. An electrocardiogram (ECG) is also normal. Laboratory testing showed the following: Serum glucose (fasting) 76 mg/dL Serum electrolytes: Sodium 140 mEq/L Potassium 4.1 mEq/L Chloride 100 mEq/L Serum creatinine 0.9 mg/dL Blood urea nitrogen 11 mg/dL Cholesterol, total: 180 mg/dL HDL-cholesterol 45 mg/dL LDL-cholesterol 75 mg/dL Triglycerides 135 mg/dL Hemoglobin (Hb%) 16 g/dL Mean corpuscular volume (MCV) 85 fL Reticulocyte count 0.9% Erythrocyte count 5 million/mm³ Thyroid-stimulating hormone 3.5 µU/mL Urinalysis Glucose Negative Ketones Negative Leucocytes Negative Nitrite Negative RBCs Negative Casts Negative Which of the following is the most likely diagnosis?

A 12-year-old boy is brought by his mother to a neurologist for continuing evaluation of seizures. His seizures were previously well-controlled on medication but over the last month he has been having seizures several times per week. The boy is non-verbal and has had severe developmental delays and cognitive disability since birth. On exam, the boy is found to be enthusiastically playing with the toys in the office and laughing at almost any stimulus. Furthermore, his movements are found to be uncoordinated with a wide based gait. Previous genetic testing has revealed an abnormality in an E3 ubiquitin ligase gene. Compared to unaffected individuals, which of the following patterns of gene expression is most likely seen in this patient?