LATEST GERIATRIC PSYCHIATRY
CERTIFICATION EXAM OFFERED BY
AMERICAN BOARD OF PSYCHIATRY &
NEUROLOGY | COMPLETE EXAM Q&A WITH
RATIONALES
1. An 82-year-old male with a 30-year history of major
depressive disorder, currently in remission on
sertraline 100 mg daily, presents with new-onset
confusion, lethargy, and myoclonus. Vital signs: BP
150/90, HR 110, temperature 37.5°C. His family
reports he started taking over-the-counter cough
medicine (dextromethorphan) 3 days ago. Which is
the most likely diagnosis?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome
C) Delirium due to urinary tract infection
D) Worsening depression
Correct answer: A
Rationale: The combination of an SSRI (sertraline)
with dextromethorphan (a weak serotonin reuptake
inhibitor) can cause serotonin syndrome, especially
in older adults with reduced metabolism. Myoclonus,
confusion, and autonomic instability are key features.
,2. An 85-year-old female with Alzheimer's dementia
(MMSE 18/30) has been on donepezil 10 mg daily for 2
years. She develops new-onset urinary incontinence,
gait disturbance, and worsening confusion over 2
weeks. Which is the most appropriate next step?
A) Increase donepezil to 23 mg daily
B) Head CT to rule out normal pressure
hydrocephalus (NPH)
C) Start memantine
D) Refer for bladder training
Correct answer: B
Rationale: The triad of cognitive decline, gait
disturbance, and urinary incontinence in an older
adult suggests normal pressure hydrocephalus,
which is potentially reversible with shunting. CT or
MRI is indicated.
3. A 78-year-old male with Parkinson's disease and
depression has been on carbidopa/levodopa and
paroxetine 20 mg daily for 3 months. He now reports
worsening parkinsonism (rigidity, bradykinesia) and
falls. Which is the most appropriate next step?
A) Increase carbidopa/levodopa
,B) Switch paroxetine to bupropion
C) Add amantadine
D) Decrease carbidopa/levodopa
Correct answer: B
Rationale: Paroxetine (a strong CYP2D6 inhibitor) can
increase levodopa levels but also has anticholinergic
effects that worsen parkinsonism. Bupropion has less
anticholinergic effect and does not interact with
CYP2D6 as strongly.
4. A 72-year-old female with vascular dementia and
hypertension is started on memantine for behavioral
symptoms. Which of the following is the most
common adverse effect of memantine in older adults?
A) Constipation
B) Dizziness
C) Weight gain
D) Bradycardia
Correct answer: B
Rationale: Memantine is generally well-tolerated, but
dizziness is the most common adverse effect
(reported in 5-10%). Constipation and weight gain are
more common with cholinesterase inhibitors.
, 5. An 80-year-old male with major depressive
disorder, recurrent, has failed adequate trials of
sertraline, venlafaxine, and bupropion. He has
chronic kidney disease stage 3 (CrCl 40 mL/min).
Which antidepressant is safest and most appropriate
as a next step?
A) Fluoxetine
B) Citalopram
C) Phenelzine
D) Nortriptyline
Correct answer: D
Rationale: Nortriptyline is a secondary amine tricyclic
with less anticholinergic effect and can be used in
renal impairment (hepatic metabolism). Citalopram
carries QTc risk at higher doses. Phenelzine has
dietary restrictions.
6. An 88-year-old female with severe Alzheimer's
dementia is agitated, yelling frequently, and
physically aggressive toward staff. Non-
pharmacologic interventions have failed. She has a
history of falls. Which is the most appropriate first-
line pharmacologic treatment?
A) Haloperidol
B) Quetiapine
CERTIFICATION EXAM OFFERED BY
AMERICAN BOARD OF PSYCHIATRY &
NEUROLOGY | COMPLETE EXAM Q&A WITH
RATIONALES
1. An 82-year-old male with a 30-year history of major
depressive disorder, currently in remission on
sertraline 100 mg daily, presents with new-onset
confusion, lethargy, and myoclonus. Vital signs: BP
150/90, HR 110, temperature 37.5°C. His family
reports he started taking over-the-counter cough
medicine (dextromethorphan) 3 days ago. Which is
the most likely diagnosis?
A) Serotonin syndrome
B) Neuroleptic malignant syndrome
C) Delirium due to urinary tract infection
D) Worsening depression
Correct answer: A
Rationale: The combination of an SSRI (sertraline)
with dextromethorphan (a weak serotonin reuptake
inhibitor) can cause serotonin syndrome, especially
in older adults with reduced metabolism. Myoclonus,
confusion, and autonomic instability are key features.
,2. An 85-year-old female with Alzheimer's dementia
(MMSE 18/30) has been on donepezil 10 mg daily for 2
years. She develops new-onset urinary incontinence,
gait disturbance, and worsening confusion over 2
weeks. Which is the most appropriate next step?
A) Increase donepezil to 23 mg daily
B) Head CT to rule out normal pressure
hydrocephalus (NPH)
C) Start memantine
D) Refer for bladder training
Correct answer: B
Rationale: The triad of cognitive decline, gait
disturbance, and urinary incontinence in an older
adult suggests normal pressure hydrocephalus,
which is potentially reversible with shunting. CT or
MRI is indicated.
3. A 78-year-old male with Parkinson's disease and
depression has been on carbidopa/levodopa and
paroxetine 20 mg daily for 3 months. He now reports
worsening parkinsonism (rigidity, bradykinesia) and
falls. Which is the most appropriate next step?
A) Increase carbidopa/levodopa
,B) Switch paroxetine to bupropion
C) Add amantadine
D) Decrease carbidopa/levodopa
Correct answer: B
Rationale: Paroxetine (a strong CYP2D6 inhibitor) can
increase levodopa levels but also has anticholinergic
effects that worsen parkinsonism. Bupropion has less
anticholinergic effect and does not interact with
CYP2D6 as strongly.
4. A 72-year-old female with vascular dementia and
hypertension is started on memantine for behavioral
symptoms. Which of the following is the most
common adverse effect of memantine in older adults?
A) Constipation
B) Dizziness
C) Weight gain
D) Bradycardia
Correct answer: B
Rationale: Memantine is generally well-tolerated, but
dizziness is the most common adverse effect
(reported in 5-10%). Constipation and weight gain are
more common with cholinesterase inhibitors.
, 5. An 80-year-old male with major depressive
disorder, recurrent, has failed adequate trials of
sertraline, venlafaxine, and bupropion. He has
chronic kidney disease stage 3 (CrCl 40 mL/min).
Which antidepressant is safest and most appropriate
as a next step?
A) Fluoxetine
B) Citalopram
C) Phenelzine
D) Nortriptyline
Correct answer: D
Rationale: Nortriptyline is a secondary amine tricyclic
with less anticholinergic effect and can be used in
renal impairment (hepatic metabolism). Citalopram
carries QTc risk at higher doses. Phenelzine has
dietary restrictions.
6. An 88-year-old female with severe Alzheimer's
dementia is agitated, yelling frequently, and
physically aggressive toward staff. Non-
pharmacologic interventions have failed. She has a
history of falls. Which is the most appropriate first-
line pharmacologic treatment?
A) Haloperidol
B) Quetiapine
