Geriatric Psychiatry Practice Questions

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

Involutional melancholia. ***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.

Q: Which of the following is not a feature of delirium?

Intact attention. ***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.

Q: A 60-year-old man had undergone cardiac bypass surgery 2 days back. Now he started forgetting things and was not able to recall names and phone numbers of his relatives. What is the probable diagnosis?

Delirium. ***Delirium*** - The **acute onset** of memory loss and confusion **2 days after cardiac bypass surgery** is characteristic of **postoperative delirium**. - Delirium is a disturbance in **attention**, **awareness**, and **cognition** that develops over a short period (hours to days) and is directly related to a medical condition or procedure. - **Cardiac surgery** is a well-known risk factor, with delirium occurring in **10-50%** of cardiac bypass patients due to factors like anesthesia, hypoperfusion, inflammation, and physiological stress. - Key features here: **acute onset**, **temporal relationship to surgery**, and **memory/cognitive deficits** without psychotic symptoms. *Alzheimer's disease* - Alzheimer's is a **chronic, progressive neurodegenerative disorder** with **gradual onset** over months to years. - The **sudden appearance** of symptoms immediately after surgery cannot be explained by Alzheimer's disease. - While Alzheimer's causes memory impairment, it does not present acutely in the postoperative setting. *Depression* - Depression can cause **pseudodementia** with cognitive complaints, but the primary features would be **persistent low mood**, **anhedonia**, **sleep disturbance**, and **appetite changes**. - The **acute temporal link** to surgery and absence of mood symptoms make depression unlikely. - Cognitive symptoms in depression are typically subjective complaints rather than objective deficits. *Post-traumatic psychosis* - This would involve **psychotic symptoms** such as **hallucinations**, **delusions**, or **disorganized behavior**, which are not described in this case. - The presentation of simple **memory deficits** without psychotic features does not support this diagnosis. - Surgery itself is not typically considered a psychologically traumatic event that would trigger psychosis.

Q: Which of the following dementia is associated with visual hallucinations?

Lewy body dementia. ***Lewy body dementia*** - **Visual hallucinations**, particularly of well-formed and detailed images, are a **core clinical feature** of Lewy body dementia (LBD). - Other key features include **fluctuating cognition** with pronounced variations in attention and alertness, and **spontaneous parkinsonism**. *AIDS related Dementia* - Primarily presents with cognitive and motor slowing, **apathy**, and difficulty with complex tasks, rather than prominent visual hallucinations. - It is a subcortical dementia caused by **HIV infection** directly affecting the brain. *Mixed dementia* - This typically refers to a combination of **Alzheimer's disease** and **vascular dementia**, where hallucinations are not a prominent or early feature. - While visual hallucinations can occur in advanced stages of any dementia, they are not a defining characteristic of mixed dementia. *Huntington's disease* - Characterized by **chorea**, psychiatric disturbances, and cognitive decline, primarily affecting executive function. - **Visual hallucinations** are not a typical feature of Huntington's disease, although psychiatric symptoms like psychosis can occur.

Q: True about delirium is all Except:

Preserved attention. ***Preserved attention*** - A key feature of **delirium** is a **disturbance in attention**, making it difficult to focus, sustain, or shift attention. - Therefore, **preserved attention** is inconsistent with a diagnosis of delirium. *Hallucination* - **Hallucinations**, particularly visual, are common in delirium and often contribute to the patient's distress and altered perception of reality. - They tend to be vivid, fleeting, and can be frightening. *Disturbed sleep* - **Sleep-wake cycle disturbances** are a hallmark of delirium, often manifesting as insomnia, daytime sleepiness, or a disrupted, fragmented sleep pattern. - This disturbance is part of the global alteration in brain activity. *Disorientation* - **Disorientation**, especially to time, place, and sometimes person, is a frequent symptom of delirium, reflecting the patient's impaired cognitive function. - It indicates a significant impairment in awareness of one's surroundings.

Q: A 70-year-old man presents with a 1-year history of progressive memory loss, difficulty finding words, and getting lost in familiar places. His family reports he sometimes sees people in the room who are not there. On examination, deep tendon reflexes are normal, and the mini-mental state examination score is 20/30. What is the most likely diagnosis?

Alzheimer's disease. ***Alzheimer's disease*** - Alzheimer's disease is characterized by **progressive memory loss**, particularly affecting recent memory and episodic memory. - **Language difficulties** (anomia, word-finding difficulty) and **visuospatial deficits** (getting lost) are common early cognitive symptoms. - **Visual hallucinations** can occur in moderate to advanced stages, though less common than in Lewy body dementia. - The **gradual progressive course** over months to years is typical of Alzheimer's disease. - MMSE of 20/30 indicates moderate cognitive impairment consistent with Alzheimer's dementia. *Dissociative amnesia* - This is a **psychiatric condition** involving memory loss for specific autobiographical information, usually related to psychological trauma. - It does not explain the **progressive cognitive decline**, language difficulties, visuospatial deficits, or hallucinations. - Neurological examination is typically normal, and there is no dementia pattern on cognitive testing. *Schizophrenia* - While schizophrenia can present with **hallucinations and delusions**, it typically manifests in late adolescence or early adulthood, not at age 70. - The primary feature is **psychosis**, not progressive memory loss and cognitive decline. - **Late-onset schizophrenia** is rare and would not explain the prominent memory and visuospatial deficits. *Psychotic disorder* - A primary psychotic disorder would explain **hallucinations** but not the **progressive cognitive decline** affecting memory, language, and visuospatial functions. - The MMSE score of 20/30 indicates significant cognitive impairment beyond what would be expected in a primary psychotic disorder. - The clinical picture suggests a **neurodegenerative process** rather than a primary psychiatric condition.

Q: A 68-year-old man who was a diagnosed case of HIV infection for last 12 years was brought to outpatient department for evaluation. His wife reports that for last 6 months she has been noticing changes in his behaviour. She further added that 'He appears uninterested and doesn't seem to care about anything. I haven't seen him crying or saying something negative, but may be he is getting depressed. He is also having difficulty remembering things ' The patient has been irregular with his HIV medications. His last CD4+ cell count, measured 5 months ago, was 210/mm3. While walking , patient was observed to have subtle jerking movements. Which of the following is the likely diagnosis?

HIV-associated dementia. ***HIV-associated dementia*** - The patient's **HIV infection for 12 years**, **low CD4+ count (210/mm3)**, **behavioral changes (apathy, memory difficulties)**, and **subtle jerking movements** are all classic features of HIV-associated dementia (HAD). - HAD is a **subcortical dementia** that presents with cognitive slowing, motor dysfunction, and behavioral changes, often seen in advanced HIV disease. *Alzheimer's disease* - While Alzheimer's involves memory loss and behavioral changes, the patient's **long-standing HIV infection with a low CD4+ count** and **motor symptoms (jerking movements)** make HAD a more direct and likely diagnosis. - Alzheimer's typically presents with more prominent **cortical deficits** like aphasia and apraxia, which are not described here, and is not directly linked to HIV status. *Major depressive disorder* - The patient exhibits **apathy and lack of interest**, which can be symptoms of depression. However, the presence of **memory difficulties, jerking movements**, and a **low CD4+ count** points towards an organic brain pathology rather than solely a mood disorder. - While depression can coexist with HIV, it does not explain the **neurological and motor symptoms** observed. *Delirium* - **Delirium** is characterized by an **acute onset of fluctuating attention and cognition**, often with altered consciousness, and typically has a clear underlying medical cause. - The described symptoms are more insidious (over 6 months), chronic, and progressive rather than acute and fluctuating, making delirium less likely.

Q: Dementia is present in all except:

Ganser syndrome. ***Ganser syndrome*** - Ganser syndrome is a **factitious disorder** characterized by approximate answers, not true dementia. - Patients with Ganser syndrome often present with dramatic, but ultimately **nonsensical responses** to simple questions, without a clear underlying organic cause of cognitive decline. *Lewy body* - **Lewy body dementia** is characterized by fluctuating cognition, recurrent visual hallucinations, and spontaneous parkinsonism. - It involves the presence of **Lewy bodies** in cortical and subcortical regions leading to progressive cognitive decline. *Pick's disease* - Pick's disease, a type of frontotemporal dementia, is characterized by language and **behavioral changes** due to neuronal loss. - It results in progressive **atrophy of the frontal and temporal lobes**, leading to profound cognitive deficits over time. *Alzheimer's disease* - **Alzheimer's disease** is the most common cause of dementia, characterized by progressive memory loss and cognitive impairment. - It is pathologically defined by the presence of **amyloid plaques** and **neurofibrillary tangles** in the brain.

Question 1

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

Accepted Answer

Involutional melancholia

Answer

Atypical depression

Answer

Bipolar depression

Answer

Somatized depression

Question 2

True about dementia is:

Accepted Answer

Dementia involves a decline in memory and other cognitive functions affecting daily living

Answer

Dementia due to atherosclerosis progresses in the same gradual manner as Alzheimer's disease

Answer

Alzheimer's disease is due to multiple small strokes in the cerebral cortex

Answer

Alzheimer's disease is associated with an increase in ACh release in the cerebral cortex

Question 3

Which of the following is not a feature of delirium?

Accepted Answer

Intact attention

Answer

Disturbed sleep

Answer

Illusion

Answer

Memory loss

Question 4

A 60-year-old man had undergone cardiac bypass surgery 2 days back. Now he started forgetting things and was not able to recall names and phone numbers of his relatives. What is the probable diagnosis?

Accepted Answer

Delirium

Answer

Alzheimer's disease

Answer

Depression

Answer

Post-traumatic psychosis

Question 5

Which of the following dementia is associated with visual hallucinations?

Accepted Answer

Lewy body dementia

Answer

AIDS related Dementia

Answer

Mixed dementia

Answer

Huntington's disease

Question 6

True about delirium is all Except:

Accepted Answer

Preserved attention

Answer

Hallucination

Answer

Disturbed sleep

Answer

Disorientation

Question 7

A 70-year-old man presents with a 1-year history of progressive memory loss, difficulty finding words, and getting lost in familiar places. His family reports he sometimes sees people in the room who are not there. On examination, deep tendon reflexes are normal, and the mini-mental state examination score is 20/30. What is the most likely diagnosis?

Accepted Answer

Alzheimer's disease

Answer

Dissociative amnesia

Answer

Schizophrenia

Answer

Psychotic disorder

Question 8

A 68-year-old man who was a diagnosed case of HIV infection for last 12 years was brought to outpatient department for evaluation. His wife reports that for last 6 months she has been noticing changes in his behaviour. She further added that 'He appears uninterested and doesn't seem to care about anything. I haven't seen him crying or saying something negative, but may be he is getting depressed. He is also having difficulty remembering things ' The patient has been irregular with his HIV medications. His last CD4+ cell count, measured 5 months ago, was 210/mm3. While walking , patient was observed to have subtle jerking movements. Which of the following is the likely diagnosis?

Accepted Answer

HIV-associated dementia

Answer

Alzheimer's disease

Answer

Major depressive disorder

Answer

Delirium

Question 9

Dementia is present in all except:

Accepted Answer

Ganser syndrome

Answer

Lewy body dementia

Answer

Pick's disease

Answer

Alzheimer's disease

Question 10

A 65-year-old male is brought to the outpatient clinic with one year illness characterized by marked forgetfulness, visual hallucinations, suspiciousness, personality decline, poor self care and progressive deterioration in his condition. His Mini Mental Status Examination (MMSE) score 21. His most likely diagnosis is:

Accepted Answer

Dementia

Answer

Schizophrenia

Answer

Depression

Answer

Mania

Geriatric Psychiatry — MCQs

Geriatric Psychiatry — MCQs

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