Geriatric Psychiatry Practice Questions

Q: Which of the following is a common cause of delirium?

Infection. **Explanation:** Delirium is an acute, transient, and reversible syndrome characterized by a disturbance in consciousness, attention, and cognition. It is always secondary to an underlying medical condition, substance intoxication, or withdrawal. **1. Why Infection is the Correct Answer:** Infections (especially **Urinary Tract Infections (UTIs)** in the elderly and **Pneumonia**) are the most common systemic causes of delirium. The pathophysiology involves the release of pro-inflammatory cytokines that cross the blood-brain barrier, leading to neuroinflammation and neurotransmitter imbalances (primarily cholinergic deficiency and dopaminergic excess). **2. Analysis of Incorrect Options:** * **B. Liver Failure:** While hepatic encephalopathy is a known cause of delirium, it is categorized as a metabolic cause. Statistically, systemic infections are more frequent triggers in a general clinical setting. * **C. Belladonna Poisoning:** This causes anticholinergic toxicity. While it presents with "delirium-like" symptoms (the "mad as a hatter" mnemonic), it is a specific toxicological cause rather than the most common general cause. * **D. None of the above:** Incorrect, as infection is a primary etiology. **High-Yield Clinical Pearls for NEET-PG:** * **Core Feature:** Clouding of consciousness (altered sensorium) with a fluctuating course (worse at night, known as "sundowning"). * **EEG Finding:** Characterized by **generalized slowing** of background activity (except in Alcohol Withdrawal/Delirium Tremens, where there is low-amplitude fast activity). * **Visual Hallucinations:** These are the most common type of hallucinations in delirium. * **Management:** The priority is treating the **underlying cause** (e.g., antibiotics for infection). Low-dose Haloperidol is the drug of choice for symptomatic agitation (avoid benzodiazepines unless it is alcohol withdrawal).

Q: The Mini-Mental State Examination (MMSE) is primarily used in the diagnosis of which condition?

Dementia. **Explanation:** The **Mini-Mental State Examination (MMSE)**, also known as the Folstein test, is a 30-point questionnaire used extensively in clinical practice to measure **cognitive impairment**. It is primarily used as a screening tool for **Dementia** (specifically Alzheimer’s disease) to assess the severity of cognitive decline and monitor the progression of the disease over time. It evaluates domains such as orientation, registration, attention/calculation, recall, and language. **Analysis of Options:** * **Dementia (Correct):** MMSE is the gold standard bedside screening tool for dementia. A score of <24 is typically suggestive of cognitive impairment. * **Delirium:** While MMSE scores are low in delirium, it is not the primary diagnostic tool. The **Confusion Assessment Method (CAM)** is the preferred instrument for delirium, which is characterized by fluctuating consciousness and acute onset. * **Mania:** Diagnosis is clinical, based on ICD/DSM criteria (elevated mood, pressured speech, grandiosity). MMSE is not used as these patients usually do not have primary cognitive deficits, though they may be too distracted to complete it. * **Depression:** Diagnosis is based on clinical history and scales like the **Hamilton Depression Rating Scale (HAM-D)** or PHQ-9. While "pseudodementia" occurs in elderly depressed patients, MMSE is not the primary diagnostic tool for depression itself. **High-Yield Clinical Pearls for NEET-PG:** * **Max Score:** 30; **Normal:** 24–30; **Mild Impairment:** 18–23; **Severe:** <10. * **Components:** Orientation (10), Registration (3), Attention/Calculation (5), Recall (3), Language & Praxis (9). * **Limitation:** MMSE is highly influenced by the patient’s **education level** and age. It is less sensitive for detecting Mild Cognitive Impairment (MCI) compared to the **MoCA (Montreal Cognitive Assessment)**.

Q: Which one of the following is NOT a feature of Delirium?

Catastrophic reaction. **Explanation:** **Delirium** (Acute Confusional State) is an etiologically non-specific organic cerebral syndrome characterized by concurrent disturbances of consciousness, attention, perception, thinking, memory, psychomotor behavior, emotion, and the sleep-wake schedule. **Why "Catastrophic Reaction" is the correct answer:** A **Catastrophic Reaction** is a feature typically associated with **Dementia** (most commonly Alzheimer’s), not Delirium. It refers to an extreme emotional outburst, anxiety, or aggression triggered when a patient with cognitive impairment is overwhelmed by a task or situation they can no longer handle. **Analysis of other options:** * **A. Impairment of consciousness and attention:** This is the **hallmark** of delirium. There is a reduced clarity of awareness of the environment and a decreased ability to focus, sustain, or shift attention. * **B. Global disturbance of cognition:** Delirium involves widespread cognitive deficits, including perceptual distortions, illusions, and hallucinations (most commonly visual), as well as impairment of abstract thinking and memory. * **C. Disturbance of sleep-wake cycle:** This is a core diagnostic feature. Patients often experience insomnia, daytime drowsiness, or a total reversal of the sleep-wake cycle, often worsening at night (**Sundowning**). **High-Yield Clinical Pearls for NEET-PG:** * **Onset:** Delirium is acute (hours to days) and **fluctuating** in nature, whereas Dementia is chronic and progressive. * **EEG:** In delirium, the EEG typically shows **generalized slowing** of background activity (except in Delirium Tremens, where it shows low-voltage fast activity). * **Visual Hallucinations:** These are much more common in Delirium than in Schizophrenia. * **Reversibility:** Delirium is usually reversible once the underlying medical cause (infection, metabolic imbalance, drug toxicity) is treated.

Q: Which of the following neurotransmitters are decreased in Alzheimer's disease?

All the above. **Explanation:** Alzheimer’s Disease (AD) is a neurodegenerative disorder characterized by the accumulation of amyloid-beta plaques and tau neurofibrillary tangles [1]. While the **cholinergic hypothesis** is the most well-known, AD involves a complex, multi-system neurotransmitter deficit. 1. **Acetylcholine (ACh):** This is the primary neurotransmitter affected. There is a profound loss of cholinergic neurons in the **Nucleus Basalis of Meynert**. This deficit is the basis for using Cholinesterase inhibitors (Donepezil, Rivastigmine) as first-line treatment [1]. 2. **Norepinephrine (NE):** Degeneration occurs in the **Locus Coeruleus**, the brain's primary source of NE. This loss contributes to cognitive decline and the behavioral/psychological symptoms of dementia (BPSD) [1]. 3. **Corticotropin-Releasing Factor (CRF):** Studies have consistently shown reduced levels of CRF (and somatostatin) in the cerebral cortex of AD patients. This reflects widespread cortical neuronal damage. **Why "All the above" is correct:** While Acetylcholine is the "classic" answer, NEET-PG often tests the broader neurochemical profile of AD. The disease is not limited to one system; it involves a global reduction in several excitatory and modulatory neurotransmitters [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of dementia:** Alzheimer's Disease. * **Earliest symptom:** Loss of short-term memory (Anterograde amnesia). * **Brain Atrophy:** Predominantly involves the **Hippocampus** (earliest) and the Temporoparietal lobes. * **Glutamate:** While other transmitters decrease, there is often **excessive** NMDA receptor stimulation (excitotoxicity), which is why **Memantine** (an NMDA antagonist) is used in moderate-to-severe cases [2]. * **Histology:** Hirano bodies, Senile plaques (Amyloid), and Neurofibrillary tangles (Tau) [1].

Q: Which of the following is not used in the management of delirium?

Lithium. ### Explanation **Delirium** is an acute, fluctuating syndrome of altered consciousness and cognitive dysfunction, usually secondary to an underlying medical condition. The primary management involves treating the underlying cause and managing behavioral symptoms. **Why Lithium is the Correct Answer:** **Lithium** is a mood stabilizer used primarily for Bipolar Disorder. It is **not** used in delirium for several reasons: 1. **Neurotoxicity:** Lithium has a narrow therapeutic index and can worsen confusion or cause "Lithium-induced delirium." 2. **Renal/Electrolyte Sensitivity:** Delirious patients are often dehydrated or have electrolyte imbalances, which significantly increases the risk of Lithium toxicity. 3. **Onset:** It takes days to reach a steady state, making it useless for acute behavioral emergencies. **Analysis of Other Options:** * **Haloperidol (Option A):** The traditional **drug of choice** for delirium. It has minimal respiratory depression and few anticholinergic side effects, making it safe for elderly or medically ill patients. * **Diazepam (Option B):** While benzodiazepines can worsen delirium in most cases (due to paradoxical agitation), they are the **first-line treatment for delirium tremens** (Alcohol Withdrawal Delirium) and sedative-hypnotic withdrawal. * **Olanzapine (Option D):** An atypical antipsychotic often used as an alternative to Haloperidol. It is effective for agitation and has a lower risk of Extrapyramidal Symptoms (EPS). **High-Yield Clinical Pearls for NEET-PG:** * **DOC for Delirium:** Haloperidol (low dose). * **DOC for Alcohol Withdrawal Delirium:** Benzodiazepines (e.g., Diazepam, Lorazepam). * **Avoid:** Drugs with strong anticholinergic properties (e.g., Chlorpromazine, Amitriptyline) as they worsen delirium. * **Non-pharmacological management:** Reorientation, adequate lighting, and correcting sleep-wake cycles are essential first steps.

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

Hypertension. **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 1

Which of the following is a common cause of delirium?

Accepted Answer

Infection

Answer

Liver failure

Answer

Belladonna poisoning

Answer

None of the above

Question 2

Which of the following is true about delirium?

Accepted Answer

Disorientation

Answer

Clouding of consciousness

Answer

Visual perceptual disturbances

Answer

All are true

Question 3

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?

Accepted Answer

Frontotemporal dementia

Answer

Alzheimer's disease

Answer

Dementia with diffuse Lewy bodies

Answer

Vascular dementia

Question 4

The Mini-Mental State Examination (MMSE) is primarily used in the diagnosis of which condition?

Accepted Answer

Dementia

Answer

Delirium

Answer

Mania

Answer

Depression

Question 5

Which one of the following is NOT a feature of Delirium?

Accepted Answer

Catastrophic reaction

Answer

Impairment of consciousness and attention

Answer

Global disturbance of cognition

Answer

Disturbance of sleep-wake cycle

Question 6

Which of the following neurotransmitters are decreased in Alzheimer's disease?

Accepted Answer

All the above

Answer

Acetylcholine

Answer

Norepinephrine

Answer

Corticotropin

Question 7

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?

Accepted Answer

Alzheimer's disease

Answer

Confusional state

Answer

Alcoholic dementia

Answer

Chronic cerebrovascular insufficiency

Question 8

All are true about dementia except:

Accepted Answer

Loss of short-term memory

Answer

Loss of long-term memory

Answer

Deterioration of personality

Answer

Impaired learning

Question 9

Which of the following is not used in the management of delirium?

Accepted Answer

Lithium

Answer

Haloperidol

Answer

Diazepam

Answer

Olanzapine

Question 10

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

Accepted Answer

Hypertension

Answer

Apolipoprotein E4

Answer

Advanced age

Answer

Lowered homocysteine levels

Geriatric Psychiatry — MCQs

Geriatric Psychiatry — MCQs

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