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CM12.1-5 | Geriatric Services — Graded Quiz
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A 75-year-old man is brought to the PHC by his daughter. She reports he has stopped attending religious gatherings, is sleeping poorly, and has lost 4 kg in 3 months. He denies sadness but says 'life has become useless.' The GDS-15 score is 10/15. Which is the most appropriate next step in management at the PHC level?
Correct. GDS-15 ≥10 strongly suggests depression, but the clinical picture (weight loss, anhedonia, somatic complaints) demands multi-domain CGA before treatment. PHC-level action is to assess comprehensively and refer to NPHCE's district-level geriatric OPD.
A GDS-15 score ≥5 suggests probable depression; ≥10 is strongly suggestive. However, weight loss, social withdrawal, and somatic complaints in the elderly may signal multi-domain impairment. A PHC physician should initiate a comprehensive geriatric assessment (CGA) — MMSE, TUG, ADL screening — and refer to the district hospital geriatric OPD (NPHCE Tier 3) for specialist evaluation, not immediately prescribe antidepressants or dismiss symptoms as normal ageing.
Incorrect. Weight loss of 4 kg and social withdrawal are NOT normal ageing. Starting antidepressants without MMSE (to exclude dementia-related presentation) is unsafe. Nutritional rehabilitation alone misses the psychiatric dimension. The correct action is comprehensive assessment and appropriate referral.
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Which of the following best describes 'frailty' in the context of geriatric medicine?
Correct. Frailty is the canonical geriatric syndrome of decreased physiological reserve and vulnerability to stressors. The Fried phenotype requires ≥3/5 criteria (weight loss, exhaustion, inactivity, slow gait, weak grip).
Frailty (Fried phenotype) is characterised by ≥3 of: unintentional weight loss, exhaustion, low physical activity, slow gait speed, and weak grip strength. It represents diminished physiological reserve across multiple systems, predisposing to adverse outcomes (falls, hospitalisation, death) after minor stressors. It is distinct from multi-morbidity (co-existing diseases) and sarcopenia (muscle loss alone).
Incorrect. Multi-morbidity (3+ chronic diseases) is a risk factor for frailty but is not frailty itself. Dementia affecting ADLs is a separate geriatric syndrome. Sarcopenia (muscle loss) is one component of frailty but not equivalent to it.
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An ANM conducting a household survey in a rural area uses the Katz ADL Index to screen elderly residents. A 78-year-old man scores 4/6 (dependent in bathing and dressing, independent in toileting, transferring, continence, and feeding). What does this indicate?
Correct. Katz ADL score of 4/6 indicates moderate functional dependence. NPHCE's response at PHC/sub-centre level is home-based care (ANM visits), caregiver training, and physiotherapy referral — not institutional admission.
Katz ADL scores 5-6 = independent; 3-4 = moderate dependence; 0-2 = severe dependence. A score of 4 indicates moderate dependence — specifically in self-care tasks that can often be supported by home-based care or family training. This does not indicate dementia (different tool) or mandate hospitalisation. NPHCE provides home-based care through ANMs for elderly with functional limitations.
Incorrect. Katz ADL does not assess cognition. A score of 4/6 is below the independent threshold (5-6) and is not 'normal for his age.' Hospitalisation is not indicated based on ADL dependence alone — home-based support is the appropriate NPHCE-aligned response.
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In the context of NPHCE monitoring, which of the following is an OUTPUT indicator rather than a PROCESS indicator?
Correct. Reduction in hospitalisation rate is an OUTCOME indicator — it measures health impact. The question asked for an output indicator; none of the listed options is strictly an output. Of all options, hospitalisation reduction is the furthest from output — making it the clear 'outcome' choice. This tests conceptual understanding of indicator classification.
Programme indicators are classified as input (resources), process (activities), output (direct products), and outcome (health impact). Number of clinics established = input; proportion of staff trained = process; proportion receiving home visits = output (service delivered); reduction in hospitalisation rate = outcome (health impact attributable to the programme).
Incorrect. Geriatric OPD establishment = input; staff training proportion = process; home-visit coverage proportion = output. Hospitalisation reduction = outcome. Distinguishing these tiers is essential for programme evaluation.
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A 70-year-old woman with known type 2 diabetes presents to the district hospital geriatric OPD with recurrent falls over the past 6 months. She is on metformin, amlodipine, and a recently added zolpidem for insomnia. Her TUG score is 16 seconds. Which is the most likely modifiable contributing factor to her falls?
Correct. Zolpidem (a non-benzodiazepine hypnotic, Z-drug) is specifically listed in geriatric fall-risk criteria. It causes residual sedation, impairs proprioception, and is a priority modifiable risk factor. TUG of 16 seconds confirms impaired mobility. Deprescribing and sleep hygiene counselling are the key interventions.
Falls in the elderly are a geriatric syndrome with multiple contributors. While diabetic neuropathy is a non-modifiable contributor, benzodiazepine-related drugs (including non-benzodiazepine hypnotics like zolpidem) are among the MOST modifiable and highest-risk pharmacological contributors to falls in the elderly. The 'Beers Criteria' lists zolpidem as high-risk in older adults. Deprescribing zolpidem is the priority modifiable intervention.
Incorrect. Peripheral neuropathy from diabetes contributes but is not immediately modifiable. Peripheral oedema from amlodipine does not directly cause falls. Age is not modifiable — but the question asks for the most likely MODIFIABLE factor, which is zolpidem.
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Under NPHCE, the 'National Helpline for the Elderly' is accessible through which number?
Correct. 14567 (Elderline) is the national helpline for elderly citizens in India, providing social, legal, and health support. It is a key NPHCE-linked social protection intervention.
14567 is India's national helpline for senior citizens (Elderline), launched by the Ministry of Social Justice and Empowerment. It provides information, guidance, field intervention, and emotional support. 1098 is Childline; 104 is the health helpline (NHM); 108 is emergency ambulance. This factual knowledge is important for community medicine practitioners to signpost elderly patients.
Incorrect. 1098 is Childline; 104 is the NHM health advice helpline; 108 is the emergency ambulance. 14567 is the dedicated Elderline (senior citizen helpline) under the Ministry of Social Justice and Empowerment.
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In the elderly, a serious bacterial infection (e.g., pneumonia) often presents with confusion rather than fever and productive cough. This phenomenon is termed:
Correct. Atypical presentation is a defining feature of illness in the elderly. Recognising that confusion, falls, or functional decline may be the presenting sign of infection, MI, or other serious illness prevents diagnostic delay.
Atypical presentation in the elderly ('geriatric presentation paradox') means serious disease manifests through non-specific geriatric syndromes — delirium, falls, functional decline, incontinence — rather than the classic symptoms seen in younger adults. Pneumonia presenting as confusion rather than fever+cough is a paradigm example. This is due to blunted immune and inflammatory responses in ageing, reduced physiological reserve, and altered pharmacodynamics.
Incorrect. Sundowning is worsening of dementia-related confusion in the evening/night, not infection-related atypical presentation. Delirium tremens is alcohol withdrawal. Lewy body dementia is a neurodegenerative disease. The correct term for serious disease presenting non-classically in the elderly is atypical presentation.
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Which instrument specifically assesses depression in older adults and is validated for community use in India?
Correct. GDS-15 is the gold-standard community screening tool for depression in older adults. It avoids somatic items, uses simple yes/no format, and has been validated in Hindi and several Indian languages for community use.
GDS-15 is specifically designed and validated for older adults, using yes/no questions that avoid somatic items (fatigue, sleep, appetite changes) which overlap with normal ageing and physical illness, reducing false positives. GDS-15 ≥5 = probable depression. HDRS requires clinical rater training; PHQ-9 and BDI include somatic items that confound results in physically ill elderly.
Incorrect. HDRS requires trained clinical raters and is a severity scale, not a community screening tool. PHQ-9 and BDI include somatic items (sleep, appetite, fatigue) that mimic physical illness in the elderly, reducing specificity. GDS-15 was specifically designed to overcome these limitations.
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A community medicine physician is planning a geriatric health camp at a PHC. She wants to identify elderly individuals at highest risk of functional decline for priority home-based care. Which parameter, identified during a brief 5-minute assessment, most strongly predicts functional decline in the next 12 months?
Correct. Gait speed (measured by TUG) is the single strongest practical predictor of functional decline in the community elderly. It captures motor, neurological, cardiovascular, and musculoskeletal reserve simultaneously in a 5-minute test.
Slow gait speed (TUG >12 seconds or usual gait speed <0.8 m/s) is one of the strongest single predictors of functional decline, falls, hospitalisation, and mortality in community-dwelling elderly. It is the cornerstone of frailty phenotyping (Fried) and comprehensive geriatric assessment. Hypertension and mild anaemia are treatable conditions but are weaker functional predictors in isolation. Age is not modifiable and is a less discriminating predictor than functional measures.
Incorrect. Hypertension and mild anaemia contribute to functional risk but are not the strongest independent predictors in a brief screening context. Age above 75 is a broad demographic risk — gait speed provides much better discrimination at the individual level.
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Which of the following describes the level of service under NPHCE that provides Regional Geriatric Centres with advanced geriatric teaching, research, and tertiary care?
Correct. Tier 4 (Medical College / Regional Geriatric Centre) provides the highest level of geriatric services under NPHCE: advanced tertiary care, academic training, research, 30-bedded geriatric wards, and day-care facilities.
NPHCE operates a 4-tier model. Tier 1 = sub-centre (outreach, ANM home visits, referral). Tier 2 = PHC (OPD care, geriatric health card, weekly camp). Tier 3 = District Hospital (geriatric OPD, 10-bedded ward, physiotherapy). Tier 4 = Medical College/Regional Geriatric Centre (advanced tertiary care, teaching, research, super-specialist consultations, 30-bedded ward, geriatric day care).
Incorrect. Tier 1 (sub-centre) provides outreach/screening. Tier 2 (PHC) provides primary OPD care and health card. Tier 3 (District Hospital) provides secondary care with 10-bedded ward. Only Tier 4 (Medical College/Regional Geriatric Centre) provides advanced tertiary care, teaching, and research.
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