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  • Question 1 - NICE recommends the following for primary prevention of dementia. ...

    Correct

    • NICE recommends the following for primary prevention of dementia.

      Your Answer: None of the above

      Explanation:

      Dementia Prevention

      The NICE Guidelines on Dementia, 2006 (amended March 2011) state that certain interventions should not be recommended as specific treatments for the primary prevention of dementia. These interventions include statins, hormone replacement therapy, vitamin E, and non-steroidal anti-inflammatory drugs. It is important to note that while these interventions may have other health benefits, they should not be relied upon as a means of preventing dementia.

    • This question is part of the following fields:

      • Old Age Psychiatry
      2.4
      Seconds
  • Question 2 - A woman is worried about her 55 year old husband who has been...

    Correct

    • A woman is worried about her 55 year old husband who has been experiencing unusual movements and has become anxious and depressed. She remembers that his father had a similar issue and eventually developed dementia. What is the probable diagnosis?

      Your Answer: Huntington's disease

      Explanation:

      Psychiatric and Behavioural Symptoms of Huntington’s Disease

      Huntington’s disease is a condition that affects individuals with a triad of symptoms, including motor, cognitive, and psychiatric symptoms. While the symptoms typically begin in the third and fourth decades of life, individuals with a high number of CAG repeats may experience symptoms before the age of 20, known as juvenile Huntington’s disease.

      The psychiatric symptoms of Huntington’s disease can include depression, apathy, dementia, psychosis, anxiety, mania, sexual dysfunction, and even suicide. These symptoms can significantly impact an individual’s quality of life and require appropriate treatment. Advances in psychiatric treatment have been made to address these symptoms and improve the overall well-being of individuals with Huntington’s disease.

    • This question is part of the following fields:

      • Old Age Psychiatry
      4.8
      Seconds
  • Question 3 - What is a true statement about depression after a stroke? ...

    Incorrect

    • What is a true statement about depression after a stroke?

      Your Answer: Post-stroke depression is seen in 10-20% of survivors of stroke

      Correct Answer: Antidepressants used in post-stroke depression may enhance motor recovery

      Explanation:

      The use of mianserin for post-stroke depression has been found to be ineffective.

      Depression is a common occurrence after a stroke, affecting 30-40% of patients. The location of the stroke lesion can play a crucial role in the development of major depression. Treatment for post-stroke depression must take into account the cause of the stroke, medical comorbidities, and potential interactions with other medications. The Maudsley guidelines recommend SSRIs as the first-line treatment, with paroxetine being the preferred choice. Nortriptyline is also an option, as it does not increase the risk of bleeding. If the patient is on anticoagulants, citalopram and escitalopram may be preferred. Antidepressant prophylaxis has been shown to be effective in preventing post-stroke depression, with nortriptyline, fluoxetine, escitalopram, duloxetine, sertraline, and mirtazapine being effective options. Mianserin, however, appears to be ineffective.

    • This question is part of the following fields:

      • Old Age Psychiatry
      5.8
      Seconds
  • Question 4 - What is the most efficient medication for managing Parkinson's-related psychosis? ...

    Correct

    • What is the most efficient medication for managing Parkinson's-related psychosis?

      Your Answer: Clozapine

      Explanation:

      In Parkinson’s disease, only clozapine and quetiapine are appropriate antipsychotic medications, and if one is not well-tolerated, the other may be considered.

      Parkinson’s Disease: Presentation, Aetiology, Medical Treatment, and Psychiatric Aspects

      Parkinson’s disease is a degenerative disease of the brain that is characterised by motor symptoms such as rigidity, bradykinesia, and tremor. It has a long prodromal phase and early symptoms generally present asymmetrically. The tremor associated with Parkinson’s disease is classically described as ‘pill rolling’. The principle abnormality is the degeneration of dopaminergic neurons in the pars compacta of the substantia nigra, which leads to an accumulation of alpha-synuclein in these abnormal dopaminergic cells. The majority of cases of Parkinson’s disease are idiopathic, but single gene mutations occur in a minority of cases. Pesticide, herbicide, and heavy metal exposures are linked to an increased risk of Parkinson’s disease in some epidemiologic studies, whereas smoking and caffeine use are associated with decreased risks.

      Treatment for Parkinson’s disease predominantly focuses on symptomatic relief with drugs aiming to either restore the level of dopamine in the striatum of to act on striatal postsynaptic dopamine receptors. However, as dopamine is not the only neurotransmitter involved in Parkinson’s disease, many other drugs are also being used to target specific symptoms, such as depression of dementia. Psychiatric symptoms are common in Parkinson’s disease and range from mild to severe. Factors associated with severe symptoms include age, sleep disturbance, dementia, and disease severity. Hallucinations are common in Parkinson’s disease and tend to be visual but can be auditory of tactile. In the majority of patients, psychotic symptoms are thought to be secondary to dopaminergic medication rather than due to the Parkinson’s disease itself. Anticholinergics and dopamine agonists seem to be associated with a higher risk of inducing psychosis than levodopa of catechol-O-methyltransferase inhibitors. Medications used for psychotic symptoms may worsen movement problems. Risperidone and the typicals should be avoided completely. Low dose quetiapine is the best tolerated. Clozapine is the most effective antipsychotic drug for treating psychosis in Parkinson’s disease but its use in clinical practice is limited by the need for monitoring and the additional physical risks.

    • This question is part of the following fields:

      • Old Age Psychiatry
      7
      Seconds
  • Question 5 - A 67-year-old woman presents with a history of forgetfulness, frequent stumbling, occasional disorientation,...

    Correct

    • A 67-year-old woman presents with a history of forgetfulness, frequent stumbling, occasional disorientation, and seeing things that aren't there. During the physical examination, she exhibits slow movements and a tremor that resembles rolling a pill between her fingers. Which imaging technique would be the most suitable to confirm the probable diagnosis based on the given symptoms?

      Your Answer: Single photon emission computerised tomography (SPECT)

      Explanation:

      According to the National Institute for Health and Care Excellence (NICE) guideline for managing Dementia (CG42), if Lewy body dementia is suspected based on symptoms such as falls, fluctuating consciousness, visual hallucinations, and parkinsonism, SPECT scanning should be used to detect dopaminergic deterioration. Additionally, CT/MRI should be used to distinguish between Alzheimer’s dementia and vascular dementia.

    • This question is part of the following fields:

      • Old Age Psychiatry
      9.9
      Seconds
  • Question 6 - A 61 year old male recently started on a new treatment has suddenly...

    Correct

    • A 61 year old male recently started on a new treatment has suddenly started texting his wife rude text messages and binge eating. Which of the following treatment would you suspect he has been started on?:

      Your Answer: Ropinirole

      Explanation:

      Dopamine Agonists

      Dopamine receptor agonists are medications that directly affect dopamine receptors and are commonly used to treat Parkinson’s disease. Examples of these drugs include apomorphine and ropinirole. However, these medications are known to have psychiatric side effects, particularly impulse control disorders such as pathological gambling, binge eating, and hypersexuality. This information is according to the British National Formulary (BNF) from March 2012.

    • This question is part of the following fields:

      • Old Age Psychiatry
      27.5
      Seconds
  • Question 7 - Anterior deficits on the SPECT scan are linked to what condition? ...

    Correct

    • Anterior deficits on the SPECT scan are linked to what condition?

      Your Answer: Frontotemporal dementia

      Explanation:

      Anterior deficits in frontotemporal dementia.

      Dementia is a condition that can be diagnosed and supported with the use of neuroimaging techniques. In Alzheimer’s disease, MRI and CT scans are used to assess volume changes in specific areas of the brain, such as the mesial temporal lobe and temporoparietal cortex. SPECT and PET scans can also show functional changes, such as hypoperfusion and glucose hypometabolism. Vascular dementia can be detected with CT and MRI scans that show atrophy, infarcts, and white matter lesions, while SPECT scans reveal a patchy multifocal pattern of hypoperfusion. Lewy body dementia tends to show nonspecific and subtle changes on structural imaging, but SPECT and PET scans can reveal posterior deficits and reduced D2 receptor density. Frontotemporal dementia is characterized by frontal lobe atrophy, which can be seen on CT and MRI scans, while SPECT scans show anterior perfusion deficits. NICE recommends the use of MRI for early diagnosis and detection of subcortical vascular changes, SPECT for differentiating between Alzheimer’s disease, vascular dementia, and frontotemporal dementia, and DaTscan for establishing a diagnosis of dementia with Lewy bodies.

    • This question is part of the following fields:

      • Old Age Psychiatry
      3.1
      Seconds
  • Question 8 - What is the relationship between depression and myocardial infarction? ...

    Incorrect

    • What is the relationship between depression and myocardial infarction?

      Your Answer: Mirtazapine does not increase bleeding risk in those using anticoagulant therapy for secondary prevention

      Correct Answer: Sertraline has been shown to be safe for use in patients who have recently had a myocardial infarction

      Explanation:

      According to a study, the combination of clopidogrel and an SSRI was found to be more effective in reducing the risk of cardiovascular events compared to dual antiplatelet therapy alone. However, the risk of bleeding was higher among patients taking clopidogrel and an SSRI, although the sample size was not sufficient to confirm this finding. The results were consistent regardless of the affinity of the SSRI. (Labos, 2011)

      SSRI for Post-MI Depression

      Post-myocardial infarction (MI), approximately 20% of people develop depression, which can worsen prognosis if left untreated. Selective serotonin reuptake inhibitors (SSRIs) are the preferred antidepressant group for post-MI depression. However, they can increase the risk of bleeding, especially in those using anticoagulation. Mirtazapine is an alternative option, but it is also associated with bleeding. The SADHART study found sertraline to be a safe treatment for depression post-MI. It is important to consider the bleeding risk when choosing an antidepressant for post-MI depression.

      References:
      – Davies, P. (2004). Treatment of anxiety and depressive disorders in patients with cardiovascular disease. BMJ, 328, 939-943.
      – Glassman, A. H. (2002). Sertraline treatment of major depression in patients with acute MI of unstable angina. JAMA, 288, 701-709.
      – Goodman, M. (2008). Incident and recurrent major depressive disorder and coronary artery disease severity in acute coronary syndrome patients. Journal of Psychiatric Research, 42, 670-675.
      – Na, K. S. (2018). Can we recommend mirtazapine and bupropion for patients at risk for bleeding? A systematic review and meta-analysis. Journal of Affective Disorders, 225, 221-226.

    • This question is part of the following fields:

      • Old Age Psychiatry
      9
      Seconds
  • Question 9 - Which of the following options is considered the least appropriate for managing behavioral...

    Incorrect

    • Which of the following options is considered the least appropriate for managing behavioral difficulties associated with dementia, as per the Maudsley Guidelines?

      Your Answer: Promethazine

      Correct Answer: Lorazepam

      Explanation:

      Management of Non-Cognitive Symptoms in Dementia

      Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

    • This question is part of the following fields:

      • Old Age Psychiatry
      5.8
      Seconds
  • Question 10 - What is the truth about psychosis in individuals with Parkinson's disease? ...

    Correct

    • What is the truth about psychosis in individuals with Parkinson's disease?

      Your Answer: Neuroleptics can worsen movement disorders in Parkinson's disease

      Explanation:

      Parkinson’s Disease: Presentation, Aetiology, Medical Treatment, and Psychiatric Aspects

      Parkinson’s disease is a degenerative disease of the brain that is characterised by motor symptoms such as rigidity, bradykinesia, and tremor. It has a long prodromal phase and early symptoms generally present asymmetrically. The tremor associated with Parkinson’s disease is classically described as ‘pill rolling’. The principle abnormality is the degeneration of dopaminergic neurons in the pars compacta of the substantia nigra, which leads to an accumulation of alpha-synuclein in these abnormal dopaminergic cells. The majority of cases of Parkinson’s disease are idiopathic, but single gene mutations occur in a minority of cases. Pesticide, herbicide, and heavy metal exposures are linked to an increased risk of Parkinson’s disease in some epidemiologic studies, whereas smoking and caffeine use are associated with decreased risks.

      Treatment for Parkinson’s disease predominantly focuses on symptomatic relief with drugs aiming to either restore the level of dopamine in the striatum of to act on striatal postsynaptic dopamine receptors. However, as dopamine is not the only neurotransmitter involved in Parkinson’s disease, many other drugs are also being used to target specific symptoms, such as depression of dementia. Psychiatric symptoms are common in Parkinson’s disease and range from mild to severe. Factors associated with severe symptoms include age, sleep disturbance, dementia, and disease severity. Hallucinations are common in Parkinson’s disease and tend to be visual but can be auditory of tactile. In the majority of patients, psychotic symptoms are thought to be secondary to dopaminergic medication rather than due to the Parkinson’s disease itself. Anticholinergics and dopamine agonists seem to be associated with a higher risk of inducing psychosis than levodopa of catechol-O-methyltransferase inhibitors. Medications used for psychotic symptoms may worsen movement problems. Risperidone and the typicals should be avoided completely. Low dose quetiapine is the best tolerated. Clozapine is the most effective antipsychotic drug for treating psychosis in Parkinson’s disease but its use in clinical practice is limited by the need for monitoring and the additional physical risks.

    • This question is part of the following fields:

      • Old Age Psychiatry
      9
      Seconds
  • Question 11 - What is a true statement about transient global amnesia? ...

    Correct

    • What is a true statement about transient global amnesia?

      Your Answer: Repetitive questioning is a common feature

      Explanation:

      Transient Global Amnesia: Definition, Diagnostic Criteria, and Possible Causes

      Transient global amnesia (TGA) is a clinical syndrome characterized by sudden and severe amnesia, often accompanied by repetitive questioning, that lasts for several hours. The term was first coined in 1964 by Fisher and Adams. To diagnose TGA, the following criteria have been established: (1) the attack must be witnessed, (2) there must be clear anterograde amnesia, (3) clouding of consciousness and loss of personal identity must be absent, (4) there should be no accompanying focal neurological symptoms, (5) epileptic features must be absent, (6) attacks must resolve within 24 hours, and (7) patients with recent head injury of known active epilepsy are excluded.

      Epidemiological studies have shown that thromboembolic cerebrovascular disease does not play a role in the causation of TGA. However, the incidence of migraine in patients with TGA is higher than in the general population. A small minority of cases with unusually brief and recurrent attacks eventually manifest temporal lobe epilepsy. EEG recording is typically normal after an attack, even when performed during the attack.

      Possible causes of TGA include venous congestion with Valsalva-like activities before symptom onset, arterial thromboembolic ischemia, and vasoconstriction due to hyperventilation. Precipitants of TGA often include exertion, cold, pain, emotional stress, and sexual intercourse.

    • This question is part of the following fields:

      • Old Age Psychiatry
      12.2
      Seconds
  • Question 12 - Which of the options below is not a typical trigger for transient global...

    Correct

    • Which of the options below is not a typical trigger for transient global amnesia?

      Your Answer: Loud noises

      Explanation:

      Transient Global Amnesia: Definition, Diagnostic Criteria, and Possible Causes

      Transient global amnesia (TGA) is a clinical syndrome characterized by sudden and severe amnesia, often accompanied by repetitive questioning, that lasts for several hours. The term was first coined in 1964 by Fisher and Adams. To diagnose TGA, the following criteria have been established: (1) the attack must be witnessed, (2) there must be clear anterograde amnesia, (3) clouding of consciousness and loss of personal identity must be absent, (4) there should be no accompanying focal neurological symptoms, (5) epileptic features must be absent, (6) attacks must resolve within 24 hours, and (7) patients with recent head injury of known active epilepsy are excluded.

      Epidemiological studies have shown that thromboembolic cerebrovascular disease does not play a role in the causation of TGA. However, the incidence of migraine in patients with TGA is higher than in the general population. A small minority of cases with unusually brief and recurrent attacks eventually manifest temporal lobe epilepsy. EEG recording is typically normal after an attack, even when performed during the attack.

      Possible causes of TGA include venous congestion with Valsalva-like activities before symptom onset, arterial thromboembolic ischemia, and vasoconstriction due to hyperventilation. Precipitants of TGA often include exertion, cold, pain, emotional stress, and sexual intercourse.

    • This question is part of the following fields:

      • Old Age Psychiatry
      9.3
      Seconds
  • Question 13 - What is the most precise estimation for the occurrence of Charles Bonnet syndrome...

    Correct

    • What is the most precise estimation for the occurrence of Charles Bonnet syndrome among individuals with visual impairment?

      Your Answer: 12%

      Explanation:

      Creutzfeldt-Jakob dementia

    • This question is part of the following fields:

      • Old Age Psychiatry
      5.1
      Seconds
  • Question 14 - What is the most effective method for distinguishing between Alzheimer's disease and Lewy...

    Correct

    • What is the most effective method for distinguishing between Alzheimer's disease and Lewy body dementia?

      Your Answer: Dat scan

      Explanation:

      It’s important to note that DaT-SCAN and SPECT are not the same thing. DaT-SCAN specifically refers to the radioactive isotope called Ioflupane, which is utilized in the creation of a SPECT image.

      SPECT Imaging for Alzheimer’s Diagnosis

      SPECT imaging has been found to be a useful tool in differentiating between patients with Alzheimer’s disease and healthy older individuals. Studies have shown that temporal and parietal hypoperfusion can be indicative of Alzheimer’s disease. Additionally, SPECT imaging has been effective in distinguishing between Alzheimer’s disease and Lewy body dementia. A SPECT scan of a patient with Alzheimer’s disease versus one with Lewy body dementia showed lower perfusion in medial temporal areas for Alzheimer’s disease and lower perfusion in occipital cortex for Lewy body dementia. These findings suggest that SPECT imaging can be a valuable diagnostic tool for Alzheimer’s disease and related dementias.

    • This question is part of the following fields:

      • Old Age Psychiatry
      4.4
      Seconds
  • Question 15 - What is accurate about the psychiatric components of Parkinson's disease? ...

    Correct

    • What is accurate about the psychiatric components of Parkinson's disease?

      Your Answer: Anticholinergics and dopamine agonists are considered to have a higher risk of inducing psychosis than levodopa

      Explanation:

      Parkinson’s Disease: Presentation, Aetiology, Medical Treatment, and Psychiatric Aspects

      Parkinson’s disease is a degenerative disease of the brain that is characterised by motor symptoms such as rigidity, bradykinesia, and tremor. It has a long prodromal phase and early symptoms generally present asymmetrically. The tremor associated with Parkinson’s disease is classically described as ‘pill rolling’. The principle abnormality is the degeneration of dopaminergic neurons in the pars compacta of the substantia nigra, which leads to an accumulation of alpha-synuclein in these abnormal dopaminergic cells. The majority of cases of Parkinson’s disease are idiopathic, but single gene mutations occur in a minority of cases. Pesticide, herbicide, and heavy metal exposures are linked to an increased risk of Parkinson’s disease in some epidemiologic studies, whereas smoking and caffeine use are associated with decreased risks.

      Treatment for Parkinson’s disease predominantly focuses on symptomatic relief with drugs aiming to either restore the level of dopamine in the striatum of to act on striatal postsynaptic dopamine receptors. However, as dopamine is not the only neurotransmitter involved in Parkinson’s disease, many other drugs are also being used to target specific symptoms, such as depression of dementia. Psychiatric symptoms are common in Parkinson’s disease and range from mild to severe. Factors associated with severe symptoms include age, sleep disturbance, dementia, and disease severity. Hallucinations are common in Parkinson’s disease and tend to be visual but can be auditory of tactile. In the majority of patients, psychotic symptoms are thought to be secondary to dopaminergic medication rather than due to the Parkinson’s disease itself. Anticholinergics and dopamine agonists seem to be associated with a higher risk of inducing psychosis than levodopa of catechol-O-methyltransferase inhibitors. Medications used for psychotic symptoms may worsen movement problems. Risperidone and the typicals should be avoided completely. Low dose quetiapine is the best tolerated. Clozapine is the most effective antipsychotic drug for treating psychosis in Parkinson’s disease but its use in clinical practice is limited by the need for monitoring and the additional physical risks.

    • This question is part of the following fields:

      • Old Age Psychiatry
      6.1
      Seconds
  • Question 16 - Which condition is primarily associated with cortical dementia rather than subcortical dementia? ...

    Correct

    • Which condition is primarily associated with cortical dementia rather than subcortical dementia?

      Your Answer: Pick's disease

      Explanation:

      Distinguishing Cortical and Subcortical Dementia: A Contested Area

      Attempts have been made to differentiate between cortical and subcortical dementia based on clinical presentation, but this remains a contested area. Some argue that the distinction is not possible. Cortical dementia is characterized by impaired memory, visuospatial ability, executive function, and language. Examples of cortical dementias include Alzheimer’s disease, Pick’s disease, and Creutzfeldt-Jakob disease. On the other hand, subcortical dementia is characterized by general slowing of mental processes, personality changes, mood disorders, and abnormal movements. Examples of subcortical dementias include Binswanger’s disease, dementia associated with Huntington’s disease, AIDS, Parkinson’s disease, Wilson’s disease, and progressive supranuclear palsy. Despite ongoing debate, questions on this topic may appear in exams.

    • This question is part of the following fields:

      • Old Age Psychiatry
      7.4
      Seconds
  • Question 17 - A 67-year-old female with a history of dementia is brought in by her...

    Correct

    • A 67-year-old female with a history of dementia is brought in by her family due to an increase in aggressive behavior. She appears to be in good physical health. What is the most suitable treatment for her outbursts of aggression?

      Your Answer: Risperidone

      Explanation:

      Non-drug approaches should be the first line of defense in managing aggression in Alzheimer’s disease, including identifying triggers and utilizing behavioral techniques. However, in some cases, drug treatment may be necessary. Atypical neuroleptics like quetiapine and haloperidol are not recommended due to increased risk of death of stroke and potential cognitive decline. Risperidone is licensed for short-term treatment of persistent aggression in moderate to severe Alzheimer’s disease if non-pharmacological alternatives have been tried and there is a risk of harm. Valproate has been used for calming effects, but evidence of its efficacy is limited. Benzodiazepines are not recommended due to increased risk of falls and worsening cognitive decline.

    • This question is part of the following fields:

      • Old Age Psychiatry
      7.9
      Seconds
  • Question 18 - What treatment option has the strongest evidence for managing dementia in individuals with...

    Correct

    • What treatment option has the strongest evidence for managing dementia in individuals with Parkinson's disease?

      Your Answer: Rivastigmine

      Explanation:

      It is difficult to provide a definitive answer to this question as there is currently no consensus on the matter. However, the limited evidence available suggests that both rivastigmine and donepezil may be effective, although donepezil may be associated with higher dropout rates.

      Dementia with Parkinson’s Disease: Understanding Cognitive Symptoms

      Dementia with Parkinson’s disease is a syndrome that involves a decline in memory and other cognitive domains, leading to social and occupational dysfunction. Along with motor problems, non-motor symptoms such as cognitive, behavioral, and psychological issues can also arise. There is debate over whether Lewy body dementia and dementia due to Parkinson’s are different conditions. Drugs used to treat Parkinson’s can interfere with cognitive function, and people with this type of dementia tend to have marked problems with executive function. Cholinesterase inhibitors can improve cognitive performance, but they are not well tolerated and can cause side effects. Understanding the cognitive symptoms of dementia with Parkinson’s disease is crucial for effective clinical management.

    • This question is part of the following fields:

      • Old Age Psychiatry
      6.2
      Seconds
  • Question 19 - Which of the following is not considered a known factor that increases the...

    Incorrect

    • Which of the following is not considered a known factor that increases the risk of delirium?

      Your Answer: Anticholinergic drug use

      Correct Answer: Living alone

      Explanation:

      Risk Factors for Delirium

      Delirium is a common condition that affects many elderly individuals. There are several risk factors that can increase the likelihood of developing delirium. These risk factors include age, cognitive impairment, severe medical illness, previous history of delirium of neurological disease, psychoactive drug use, polypharmacy, and anticholinergic drug use.

      Medications are the most common reversible cause of delirium and dementia in the elderly. Certain classes of drugs, such as opioids, benzodiazepines, and anticholinergics, are strongly associated with the development of drug-induced dementia. Long-acting benzodiazepines are more troublesome than shorter-acting ones. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients. Pethidine, a member of the opioid class, appears to have a higher risk of delirium compared with other opioids due to its accumulation in individuals with impaired renal function and conversion to a metabolite with anticholinergic properties.

      Overall, it is important to be aware of these risk factors and to carefully monitor medication use in elderly individuals to prevent the development of delirium.

    • This question is part of the following fields:

      • Old Age Psychiatry
      9
      Seconds
  • Question 20 - What is the most suitable course of action for managing a patient with...

    Correct

    • What is the most suitable course of action for managing a patient with Alzheimer's disease who exhibits signs of psychosis and poses a threat to others?

      Your Answer: Risperidone

      Explanation:

      Risperidone has been approved as a viable treatment for behavioral issues associated with Alzheimer’s disease.

      Management of Non-Cognitive Symptoms in Dementia

      Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

    • This question is part of the following fields:

      • Old Age Psychiatry
      6.5
      Seconds
  • Question 21 - A middle-aged man is experiencing fluctuations in his levels of cognition. His wife...

    Correct

    • A middle-aged man is experiencing fluctuations in his levels of cognition. His wife has also noticed that he appears to be 'seeing things' and has become unable to turn himself over when in bed. What do you suspect could be the cause of these symptoms?

      Your Answer: Lewy body dementia

      Explanation:

      Lewy body dementia is a type of dementia that is becoming more recognized and accounts for up to 20% of cases. It is characterized by the presence of alpha-synuclein cytoplasmic inclusions (Lewy bodies) in certain areas of the brain. The relationship between Parkinson’s disease and Lewy body dementia is complex, as dementia is often seen in Parkinson’s disease and up to 40% of Alzheimer’s patients have Lewy bodies. Neuroleptics should be avoided in Lewy body dementia, except in cases of psychosis of aggression. Cholinesterase inhibitors are the first line of treatment for psychosis with Lewy body dementia, and antipsychotics are the second line. Clozapine is the preferred antipsychotic for Lewy body dementia, but if it is not appropriate, quetiapine is a reasonable choice. The features of Lewy body dementia include progressive cognitive impairment, parkinsonism, visual hallucinations, and other symptoms such as delusions and non-visual hallucinations. Additional features that support the diagnosis include fluctuating cognition, repeated falls, syncope, and neuroleptic sensitivity. Diagnosis is usually clinical, but single-photon emission computed tomography (SPECT) is increasingly used with a sensitivity of around 90% and a specificity of 100%.

    • This question is part of the following fields:

      • Old Age Psychiatry
      13
      Seconds
  • Question 22 - A 68-year-old woman is referred to your clinic.
    Her husband has noticed that she...

    Correct

    • A 68-year-old woman is referred to your clinic.
      Her husband has noticed that she has become more forgetful over the last six months and has also noticed that there are episodes of confusion. There is a history of repeated falls but no serious head injury.
      She does not drink alcohol but has a tremor and is slow in her movements. Her elderly husband is perplexed as his wife states that she sees a bird in the living room, which he cannot see. She is also convinced that their daughter is stealing money from them.
      What treatment option do you recommend?

      Your Answer: Rivastigmine

      Explanation:

      The man is exhibiting typical symptoms of Lewy body dementia, such as cognitive decline, sporadic confusion, motor parkinsonian features, frequent falls, and early visual hallucinations. While memantine has demonstrated some efficacy, acetylcholinesterase inhibitors are the preferred initial treatment for Lewy body dementia. There is limited high-quality evidence for treating this condition. Although donepezil may also be a suitable first-line therapy, it is not authorized in the UK for treating dementia in Parkinson’s disease, whereas rivastigmine is.

    • This question is part of the following fields:

      • Old Age Psychiatry
      10.8
      Seconds
  • Question 23 - What is the defining characteristic of delirium? ...

    Correct

    • What is the defining characteristic of delirium?

      Your Answer: Impairment of consciousness

      Explanation:

      Delirium is primarily characterized by a disturbance in consciousness, often accompanied by a widespread decline in cognitive abilities. Other common symptoms include changes in mood, perception, behavior, and motor function, such as tremors and nystagmus. This information is based on Kaplan and Sadock’s concise textbook of psychiatry, 10th edition, published in 2008.

      Delirium (also known as acute confusional state) is a condition characterized by a sudden decline in consciousness and cognition, with a particular impairment in attention. It often involves perceptual disturbances, abnormal psychomotor activity, and sleep-wake cycle impairment. Delirium typically develops over a few days and has a fluctuating course. The causes of delirium are varied, ranging from metabolic disturbances to medications. It is important to differentiate delirium from dementia, as delirium has a brief onset, early disorientation, clouding of consciousness, fluctuating course, and early psychomotor changes. Delirium can be classified into three subtypes: hypoactive, hyperactive, and mixed. Patients with hyperactive delirium demonstrate restlessness, agitation, and hyper vigilance, while those with hypoactive delirium present with lethargy and sedation. Mixed delirium demonstrates both hyperactive and hypoactive features. The hypoactive form is most common in elderly patients and is often misdiagnosed as depression of dementia.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 24 - What is the maximum duration for which Risperidone can be prescribed for persistent...

    Correct

    • What is the maximum duration for which Risperidone can be prescribed for persistent aggression in Alzheimer's patients?

      Your Answer: 6 weeks

      Explanation:

      Management of Non-Cognitive Symptoms in Dementia

      Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

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      • Old Age Psychiatry
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  • Question 25 - What is the correct approach to treating dementia? ...

    Correct

    • What is the correct approach to treating dementia?

      Your Answer: Memantine is considered a second-line option for the treatment of dementia with Lewy bodies

      Explanation:

      Treatment of Dementia: AChE Inhibitors and Memantine

      Dementia is a debilitating condition that affects millions of people worldwide. Acetylcholinesterase inhibitors (AChE inhibitors) and memantine are two drugs used in the management of dementia. AChE inhibitors prevent cholinesterase from breaking down acetylcholine, which is deficient in Alzheimer’s due to loss of cholinergic neurons. Donepezil, galantamine, and rivastigmine are AChE inhibitors used in the management of Alzheimer’s. Memantine is an NMDA receptor antagonist that blocks the effects of pathologically elevated levels of glutamate that may lead to neuronal dysfunction.

      NICE guidelines recommend the use of AChE inhibitors for managing mild to moderate Alzheimer’s and memantine for managing moderate to severe Alzheimer’s. For those already taking an AChE inhibitor, memantine can be added if the disease is moderate of severe. AChE inhibitors are also recommended for managing mild, moderate, and severe dementia with Lewy bodies, while memantine is considered if AChE inhibitors are not tolerated of contraindicated. AChE inhibitors and memantine are not recommended for vascular dementia, frontotemporal dementia, of cognitive impairment due to multiple sclerosis.

      The British Association for Psychopharmacology recommends AChE inhibitors as the first choice for Alzheimer’s and mixed dementia, while memantine is the second choice. AChE inhibitors and memantine are also recommended for dementia with Parkinson’s and dementia with Lewy bodies.

      In summary, AChE inhibitors and memantine are important drugs used in the management of dementia. The choice of drug depends on the type and severity of dementia, as well as individual patient factors.

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      • Old Age Psychiatry
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  • Question 26 - When should cholinesterase inhibitors not be used? ...

    Correct

    • When should cholinesterase inhibitors not be used?

      Your Answer: Frontotemporal dementia

      Explanation:

      Cholinesterase inhibitors are approved for treating Alzheimer’s dementia and Parkinson’s disease dementia (rivastigmine). However, their use in frontotemporal dementia can worsen behavior. According to NICE guidelines, these drugs can be used for non-cognitive symptoms in dementia with Lewy bodies if non-pharmacological methods are ineffective of unsuitable, and if antipsychotic drugs are not appropriate of have not been effective. They may also be used in mixed dementia with a primary Alzheimer’s pathology.

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      • Old Age Psychiatry
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  • Question 27 - Among the listed personality disorders, which one has the strongest association with suicide...

    Correct

    • Among the listed personality disorders, which one has the strongest association with suicide in elderly individuals?

      Your Answer: Anankastic

      Explanation:

      Despite the limited data available, the college remains interested in the topic. According to Harwood’s (2001) study, anankastic personality disorder appears to be more common among older individuals who die by suicide. The study was both descriptive and case-controlled. It was published in the International Journal of Geriatric Psychiatry and can be found in Volume 16, Issue 2, pages 155-165.

      Suicide in the Elderly

      Self-harm in older individuals should be approached with caution as approximately 20% of completed suicides occur in those over the age of 65. Studies have consistently found that more than half of those who commit suicide after the age of 65 are suffering from a depressive disorder at the time of death. Personality traits also appear to play a role, with an association between suicide in older individuals and anankastic (obsessional) and anxious personality traits observed in one study. Dissocial of borderline disorders are more commonly found in younger suicide victims. It is important to be aware of these factors when assessing and treating suicidal behavior in the elderly.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 28 - What eye condition is frequently linked to Charles Bonnet syndrome? ...

    Correct

    • What eye condition is frequently linked to Charles Bonnet syndrome?

      Your Answer: Macular degeneration

      Explanation:

      Macular degeneration is the sole condition among the options that typically results in notable visual impairment, which is often associated with Charles Bonnet syndrome.

      Charles Bonnet Syndrome: A Condition of Complex Visual Hallucinations

      Charles Bonnet Syndrome (CBS) is a condition characterized by persistent of recurrent complex visual hallucinations that occur in clear consciousness. This condition is observed in individuals who have suffered damage to the visual pathway, which can be caused by damage to any part of the pathway from the eye to the cortex. The hallucinations are thought to result from a release phenomenon secondary to the deafferentation of the cerebral cortex. CBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.

      Risk factors for CBS include advanced age, peripheral visual impairment, social isolation, sensory deprivation, and early cognitive impairment. Well-formed complex visual hallucinations are thought to occur in 10-30 percent of individuals with severe visual impairment. Only around a third of individuals find the hallucinations themselves an unpleasant or disturbing experience. The most effective treatment is reversal of the visual impairment. Antipsychotic drugs are commonly prescribed but are largely ineffective. CBS is a long-lasting condition, with 88% of individuals experiencing it for two years of more, and only 25% resolving at nine years.

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 29 - An 87-year-old male is admitted with increasing confusion and lethargy, and his family...

    Correct

    • An 87-year-old male is admitted with increasing confusion and lethargy, and his family have been particularly concerned that he has been unable to look after himself.
      He has a recent history of hypertension and diabetes for which he takes lisinopril, metformin and amlodipine. On examination, he has a temperature of 36.2°C, and is confused in time and place.
      His blood pressure is 140/80 mmHg and his pulse 60 bpm regular. Abdominal examination reveals little but PR examination reveals that the rectum is loaded with faeces. Examination of the CNS reveals blunted tendon reflexes but no focal neurology. Initial investigations reveal:
      Haemoglobin 130 g/L (120-160)
      MCV 98 fL (80-100)
      Platelets 200 ×109/L (150-400)
      White cell count 7.2 ×109/L (4-11)
      Sodium 135 mmol/L (135-145)
      Potassium 4.0 mmol/L (3.5-5.0)
      Urea 7.5 mmol/L (2.5-7.5)
      Creatinine 120 mmol/L (60-110)
      Glucose 10.5 mmol/L (4-7)
      Which one of the following is the most appropriate investigation for this patient?

      Your Answer: Thyroid function tests

      Explanation:

      The patient has a brief history of growing confusion and struggling to cope, with primary symptoms of confusion, constipation, hypothermia, and reduced tendon reflexes. The tests indicate a higher than normal mean corpuscular volume (MCV) and mild hyponatremia. These symptoms are consistent with hypothyroidism, and the most suitable test would be thyroid function tests, which should show a decrease in free thyroxine (T4) and an increase in thyroid-stimulating hormone (TSH).

    • This question is part of the following fields:

      • Old Age Psychiatry
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  • Question 30 - What is a true statement about Charles Bonnet syndrome? ...

    Correct

    • What is a true statement about Charles Bonnet syndrome?

      Your Answer: Visual hallucinations are not normally associated with an auditory component

      Explanation:

      While Charles Bonnet Syndrome (CBS) typically only presents with visual hallucinations, some experts have proposed diagnostic criteria that require the absence of hallucinations in other sensory modalities. However, there have been documented cases of CBS with auditory hallucinations, so the presence of such hallucinations should not necessarily exclude a diagnosis of CBS.

      Charles Bonnet Syndrome: A Condition of Complex Visual Hallucinations

      Charles Bonnet Syndrome (CBS) is a condition characterized by persistent of recurrent complex visual hallucinations that occur in clear consciousness. This condition is observed in individuals who have suffered damage to the visual pathway, which can be caused by damage to any part of the pathway from the eye to the cortex. The hallucinations are thought to result from a release phenomenon secondary to the deafferentation of the cerebral cortex. CBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.

      Risk factors for CBS include advanced age, peripheral visual impairment, social isolation, sensory deprivation, and early cognitive impairment. Well-formed complex visual hallucinations are thought to occur in 10-30 percent of individuals with severe visual impairment. Only around a third of individuals find the hallucinations themselves an unpleasant or disturbing experience. The most effective treatment is reversal of the visual impairment. Antipsychotic drugs are commonly prescribed but are largely ineffective. CBS is a long-lasting condition, with 88% of individuals experiencing it for two years of more, and only 25% resolving at nine years.

    • This question is part of the following fields:

      • Old Age Psychiatry
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SESSION STATS - PERFORMANCE PER SPECIALTY

Old Age Psychiatry (26/30) 87%
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