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IM25.1-22 | Geriatrics — Practice Quiz
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An 80-year-old woman is brought to the emergency department after she was found confused and agitated at home. Her daughter reports she was well yesterday. On examination, she is disoriented to place and time, with fluctuating alertness. She has a fever of 38.6°C and urinalysis shows pyuria and bacteriuria. Which feature BEST distinguishes this presentation from dementia?
Correct. The defining features of delirium (acute confusional state) are acute onset and fluctuating course, inattention, and disorganised thinking or altered consciousness. Dementia has an insidious onset and a slowly progressive course. The acute onset over hours to days in the context of a precipitant (UTI/fever) is the cardinal distinguishing feature.
Delirium (DSM-5 criteria): acute onset, fluctuating course, inattention, disorganised thinking or altered consciousness. CAM (Confusion Assessment Method): features 1 + 2 + either 3 or 4. Most common precipitants in hospitalised elderly: infection, medications, metabolic disturbance, urinary retention, constipation.
Delirium is distinguished from dementia primarily by its acute onset and fluctuating course. Disorientation, agitation, and memory problems can occur in both. The key is: delirium = acute + fluctuating; dementia = insidious + progressive. Always search for a precipitant (infection, drugs, metabolic disturbance) in acute confusion in the elderly.
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A 75-year-old man with Alzheimer dementia is admitted for assessment of worsening behavioural disturbance. He has been wandering at night, is increasingly suspicious, and had an episode of visual hallucination last week. His wife mentions he had two falls in the past month. Which type of dementia should be reconsidered in this patient?
Correct. Dementia with Lewy bodies (DLB) has three core features: (1) recurrent visual hallucinations (typically well-formed), (2) parkinsonism (falls, shuffling gait), and (3) fluctuating cognition with pronounced variations in attention. Two of the three core features are sufficient for diagnosis. Antipsychotics are contraindicated in DLB — they cause severe neuroleptic sensitivity reactions (rigidity, immobility, sudden deterioration, death).
Dementia with Lewy bodies (DLB): core features = visual hallucinations + parkinsonism + fluctuating cognition. Contraindication: conventional antipsychotics cause severe/fatal neuroleptic sensitivity. Cholinesterase inhibitors (rivastigmine) are first-line. DLB is second most common dementia after Alzheimer.
Lewy body dementia is characterised by three core features: recurrent vivid visual hallucinations, parkinsonism (explaining the falls), and fluctuating cognition. This patient has hallucinations and falls — two core DLB features. Critical: never prescribe conventional antipsychotics (haloperidol, risperidone) in DLB — they cause fatal neuroleptic sensitivity reactions.
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A 72-year-old woman with type 2 diabetes and hypertension presents for a routine geriatric review. She lives alone and manages her own medications. The physician uses the MMSE. Which of the following cognitive functions is DIRECTLY assessed by asking her to spell WORLD backwards?
Correct. On the Mini Mental State Examination (MMSE), the serial 7s subtraction or spelling WORLD backwards specifically tests attention and concentration (5 points). The MMSE total is 30; a score of less than 24 is the conventional cutoff for cognitive impairment. The MoCA (Montreal Cognitive Assessment) is more sensitive for mild cognitive impairment and includes a clock-drawing test for executive function.
MMSE: 30-point scale; cutoff <24 = cognitive impairment. Domains tested: orientation, registration, attention/concentration (serial 7s or WORLD backwards), recall, language (naming, repetition, command following, reading, writing), visuospatial construction. MoCA adds executive function (Trail B, clock drawing, abstraction) — more sensitive for MCI.
Spelling WORLD backwards tests attention and concentration on the MMSE. MMSE components: orientation (10), registration (3), attention/concentration (5), recall (3), language (8), visuospatial (1). Total 30; cutoff for impairment <24. MoCA is more sensitive for mild cognitive impairment.
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A 78-year-old man with known Parkinson disease, osteoarthritis of the knees, and on multiple medications (levodopa, amlodipine, temazepam, and diclofenac) presents after his third fall in two months. He fell on his way to the toilet at 3 am. Which medication is MOST likely contributing to his falls by causing excessive daytime sedation and impaired nocturnal balance?
Correct. Benzodiazepines (including temazepam) are listed on the Beers Criteria and STOPP criteria as potentially inappropriate medications in elderly patients. They increase fall risk by causing sedation, prolonged drowsiness, muscle relaxation, and impaired balance — particularly dangerous when the patient gets up at night. Benzodiazepines should be avoided in all elderly patients; if required for insomnia, non-pharmacological interventions are first-line.
Falls in the elderly: intrinsic (muscle weakness, balance disorders, visual impairment, neurological disease, orthostatic hypotension) + extrinsic (medications, environmental hazards). Beers/STOPP high-risk drugs for falls: benzodiazepines, sedating antihistamines, antipsychotics, tricyclic antidepressants, opioids. TIMED GET-UP-AND-GO test: >12 seconds indicates increased fall risk.
Temazepam (a benzodiazepine) is on both the Beers Criteria and STOPP criteria as a high-risk medication in the elderly. It causes sedation, muscle relaxation, and impaired balance — classic nocturnal fall risk. Levodopa can also cause orthostatic hypotension, but the nocturia-related fall pattern here points to the sedative agent. All benzodiazepines should be avoided in elderly patients.
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A 68-year-old woman with a 20-pack-year smoking history presents with a two-month history of worsening dyspnoea on exertion, productive cough, and one episode of acute exacerbation requiring hospitalisation in the past year. Spirometry shows FEV1/FVC 0.62, FEV1 58% predicted. According to GOLD classification, what stage of COPD does she have?
Correct. GOLD spirometric staging is based on post-bronchodilator FEV1 as a percentage of predicted in patients with confirmed airflow obstruction (FEV1/FVC <0.70): GOLD 1 (Mild) FEV1 ≥80%; GOLD 2 (Moderate) FEV1 50–79%; GOLD 3 (Severe) FEV1 30–49%; GOLD 4 (Very Severe) FEV1 <30%. FEV1 58% falls in the GOLD 2 range. The GOLD ABE assessment adds symptom burden and exacerbation history to guide treatment intensity.
COPD GOLD staging: confirmed by FEV1/FVC <0.70 post-bronchodilator, then FEV1 % predicted determines severity. GOLD 2 = moderate (FEV1 50-79%). In elderly, FVC may be reduced by restrictive disease — use lower limit of normal if unsure. Oxygen target in type-2 respiratory failure: 88-92% (NOT 94-98% — avoid hypercapnic drive suppression).
GOLD spirometric grading: FEV1/FVC <0.70 confirms obstruction, then FEV1 % predicted: GOLD 1 ≥80%, GOLD 2 50-79%, GOLD 3 30-49%, GOLD 4 <30%. FEV1 of 58% = GOLD 2 (Moderate). CT chest is not required for GOLD staging — post-bronchodilator spirometry is the defining investigation.
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A 74-year-old man is referred by his son for geriatric assessment. He has hypertension and ischaemic heart disease and takes 11 medications daily. He is found to have impaired renal function (eGFR 42 mL/min/1.73m2). His current medications include aspirin, atorvastatin, metoprolol, ramipril, furosemide, amlodipine, nitrate, omeprazole, metformin, glibenclamide, and calcium supplementation. Which medication is MOST urgently inappropriate and should be stopped first?
Correct. Glibenclamide (a long-acting sulfonylurea) is listed in the Beers Criteria and STOPP criteria as inappropriate in the elderly because of the high risk of prolonged, severe hypoglycaemia — particularly dangerous in an elderly patient with impaired renal clearance (eGFR 42). The active metabolites of glibenclamide accumulate in renal impairment, dramatically increasing hypoglycaemia risk. Metformin also requires attention (KDIGO recommends caution at eGFR <45 and stopping at eGFR <30), but glibenclamide is the most urgently dangerous.
Polypharmacy (5+ medications) affects 50% of elderly Indians. Beers Criteria and STOPP-START tools identify inappropriate prescriptions. In the elderly, avoid: long-acting sulfonylureas (glibenclamide — hypoglycaemia), benzodiazepines (falls), NSAIDs (GI bleed, renal failure), anticholinergics (confusion, urinary retention). START criteria flag omissions: osteoporosis treatment in fragility fracture, anticoagulation in AF.
Glibenclamide is a long-acting sulfonylurea on the Beers Criteria as inappropriate in the elderly. In a patient with eGFR 42, its active metabolites accumulate, causing prolonged severe hypoglycaemia that can be fatal. This is the most urgent medication to stop. Metformin requires review too (caution <45, stop <30 mL/min), but hypoglycaemia from glibenclamide is the immediate danger.
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A 70-year-old woman with poorly controlled hypertension presents acutely with a sudden severe headache, followed 10 minutes later by right-sided weakness and speech difficulty. On arrival, GCS is 14, BP 210/120 mmHg. CT brain without contrast is done urgently and shows no haemorrhage. She is within the 3-hour window. Which of the following actions is CONTRAINDICATED before thrombolysis?
Correct. Aggressive lowering of blood pressure before thrombolysis is contraindicated in acute ischaemic stroke. In the first 24-48 hours, permissive hypertension (up to 220/120 mmHg) is maintained to preserve collateral perfusion of the ischaemic penumbra. Before rt-PA, the guideline recommendation is to lower BP only if it exceeds 185/110 mmHg (the threshold for thrombolysis eligibility), and only with gentle agents to reach approximately 180/105 — not to normal targets. Aggressive lowering risks extending the infarct.
Acute ischaemic stroke: do NOT lower BP aggressively in the first 24-48 hours (permissive hypertension up to 220/120 mmHg maintains collateral perfusion). Pre-thrombolysis BP threshold: must be <185/110. Time targets: door-to-CT <25 min, door-to-needle <60 min. Blood glucose must be checked — both hypo- and hyperglycaemia mimic stroke and affect thrombolysis decisions.
In acute ischaemic stroke, do NOT aggressively lower blood pressure. The penumbral tissue depends on collateral pressure — aggressive BP reduction extends the infarct. The BP threshold for rt-PA eligibility is <185/110 mmHg; gentle reduction to just below this threshold is acceptable, but targeting <140/90 is contraindicated. Remember: permissive hypertension in the first 24-48 hours of ischaemic stroke.
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An 82-year-old woman is admitted with a hip fracture following a fall from standing height at home. Her DEXA scan (done on a previous admission) showed a T-score of -2.8 at the femoral neck. She takes calcium 500 mg once daily. She is vitamin D deficient. Which statement BEST describes her management for osteoporosis?
Correct. A fragility fracture (from a fall from standing height or less) is diagnostic of osteoporosis regardless of DEXA score, and mandates bone-protective treatment. A T-score of -2.8 additionally confirms osteoporosis (WHO: T-score ≤-2.5). First-line treatment is an anti-resorptive agent — bisphosphonate (alendronate 70 mg weekly, or zoledronic acid 5 mg IV annually in those who cannot tolerate oral bisphosphonates) — combined with calcium 1000-1200 mg/day and vitamin D supplementation. Fracture risk is highest in the first year after a fragility fracture.
Osteoporosis: WHO T-score ≤-2.5; fragility fracture is diagnostic regardless of DEXA. Treatment: anti-resorptive (bisphosphonate first-line) + calcium 1000-1200 mg/day + vitamin D 800-1000 IU/day. Falls prevention integral to fracture prevention. Bisphosphonate contraindicated if eGFR <30 mL/min — use denosumab instead.
A fragility fracture (any fracture from a fall from standing height or less) is osteoporosis until proven otherwise and requires anti-resorptive treatment — not just calcium and vitamin D. First-line: bisphosphonate (alendronate, risedronate, zoledronic acid) + calcium 1000-1200 mg/day + vitamin D. Post-fracture risk is highest in the first 12 months; starting treatment before discharge prevents the next fracture.
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A 69-year-old retired professor presents for a comprehensive geriatric assessment. He lives alone, uses a walking stick due to knee arthritis, and has been feeling down for 6 months. He mentions he rarely leaves home, eats poorly, and feels that life is not worth living. Which validated screening tool is MOST appropriate as the FIRST step to assess his mood?
Correct. The Geriatric Depression Scale (GDS) is specifically designed and validated for screening depression in elderly patients. It uses yes/no responses (avoiding the Likert format that can be confusing for cognitively impaired elderly), avoids somatic symptoms (that may be due to physical illness rather than depression), and has a 15-item short form (GDS-15) suitable for routine clinical use. The PHQ-9 and BDI include somatic items that reduce specificity in elderly populations with multimorbidity.
Geriatric depression: most prevalent psychiatric disorder in elderly, underdiagnosed. Atypical features in elderly: somatic complaints, pseudodementia, loss of interest rather than overt sadness. GDS-15 is the preferred screening tool. Treatment: SSRIs first-line (sertraline/escitalopram preferred over paroxetine which is anticholinergic). Treat suicidal ideation urgently — lifetime risk of suicide completion is highest in elderly males.
The Geriatric Depression Scale (GDS) is the validated tool for screening depression in elderly patients. It uses a simple yes/no format and avoids somatic symptoms that are confounded by physical illness in multimorbid elderly. GDS-15: 0-4 normal, 5-8 mild, 9-11 moderate, 12-15 severe depression. The PHQ-9 and HAM-D are validated but less specific in the elderly due to somatic item overlap.
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An 80-year-old woman presents with acute confusion, falls, and anorexia over 3 days. On examination, she is cachectic with BMI 16 kg/m2. She has glossitis, angular cheilitis, and signs of peripheral neuropathy. She has been living in a government old-age home and subsisting on a rice-based diet with minimal protein or fresh vegetables. Which nutritional deficiency MOST likely explains the peripheral neuropathy in this patient?
Correct. Vitamin B12 (cobalamin) deficiency causes a triad of subacute combined degeneration of the spinal cord (dorsal column and lateral corticospinal tract demyelination causing peripheral neuropathy and proprioception loss), megaloblastic anaemia, and neuropsychiatric manifestations (cognitive impairment, depression, confusion). In an elderly, institutionalised, vegetarian woman on a monotonous rice-based diet, B12 deficiency from dietary insufficiency is the most likely cause. Glossitis and angular cheilitis can be seen with B-vitamin deficiencies.
Nutritional deficiencies in elderly: B12 (neuropathy, megaloblastic anaemia, cognitive decline — vegetarians, atrophic gastritis), thiamine (Wernicke — give IV thiamine before glucose in confused malnourished elderly), vitamin D (osteoporosis, myopathy, falls), iron (anaemia). MNA (Mini Nutritional Assessment) and MUST are validated geriatric nutritional screening tools.
Vitamin B12 deficiency causes peripheral neuropathy (subacute combined degeneration), megaloblastic anaemia, and cognitive changes in the elderly. It is particularly common in elderly vegetarians, institutionalised patients, and those with atrophic gastritis (reduced intrinsic factor). Always check serum B12 in elderly patients with unexplained peripheral neuropathy or cognitive decline. Thiamine deficiency also causes neuropathy but is associated with Wernicke encephalopathy (ophthalmoplegia, ataxia, confusion).
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