Best of five MCQs for the geriatric medicine

1. An 82-year-old woman with a 3-year history of a vascular dementia was admitted with a 2-week history of worsening confusion. Over this 2-week period she had been wandering the streets at night looking for the children she believed lived in her house. She had also telephoned the police several times reporting the children to be lost and had punched her son when confronted about her changed behaviour. She was being treated with bendroflumethiazide 2.5mg daily for hypertension, aspirin 75mg daily, and rivastigmine 1.5mg BD. She lived alone in a first floor flat in a sheltered housing complex and had carers to help her wash and dress twice daily. No abnormalities were detected on physical examination. Laboratory investigations, including electrocardiogram and urine dipstick, were normal, apart from serum potassium levels of 2.9mmol/L (3.5–4.9). Bendroflumethiazide was therefore stopped. Following review by the consultant in old age psychiatry, she was started on regular haloperidol 2.5mg bd. Her restlessness and wandering worsened to such an extent that she could not sit or lie still, even for few minutes. Haloperidol was stopped, but her condition did not change. What is the most likely cause of her increased motor restlessness? A. Acute psychosis B. Dementia progression C. Drug-induced akathisia D. Hyperactive delirium E. Restless leg syndrome QUESTIONS exam 1 2 EXAM 1 | QUESTIONS 2. A 72-year-old woman saw her general practitioner with a 2-week history of general malaise. She mentioned that over the last 3 years she occasionally leaked urine when coughing, laughing, or lifting things, but had never suffered from urgency of micturition, dysuria, or haematuria. Examination of her abdominal, cardiac, and respiratory systems were normal. There was no lymphadenopathy. She was on no medication. Dipstick testing of her urine was positive for nitrites only. Three days later the following normal test results were seen: full blood count (FBC), urea and electrolytes (U&E), serum calcium, liver and thyroid function. Urine culture showed >100 000 colony-forming units/mL of Escherichia coli. What is the next most appropriate step in her management? A. Advise on pelvic floor exercises B. External vaginal examination C. Nothing more needs to be done D. Refer to the continence adviser E. Treat with antibiotics 3. A 76-year-old woman with mild Parkinson’s disease was admitted from home to a community rehabilitation facility because of reduced mobility secondary to pain over her left hip, 2 days after being knocked over by a boisterous dog. The day after admission she developed a delirium thought to be due to a urinary tract infection (UTI). One week after admission she had developed a grade 2 sacral pressure sore. Her daughter considered the hospital to have been negligent in their assessments of her mother’s risk of developing pressure sores, and requested an independent assessment of the hospital policies and procedures. According to NICE guidelines when should a pressure sore risk assessment have been instigated? A. Every day during the admission B. If the clinical situation changes C. Within 6hr of admission D. Within 8hr of admission E. Within 24hr of admission EXAM 1 | QUESTIONS 3 4. A 69-year-old woman was seen in outpatients. She gave a story of increasing breathlessness on exertion over the past 4 weeks. She used to be able to walk a mile without difficulty. However, now she was becoming breathless after a hundred metres or so. This was associated with some central chest heaviness. The symptoms eased within a few minutes of stopping. She had no significant past medical history, took no medication, and was a lifelong non-smoker. Cardiovascular, respiratory, and abdominal examinations were unremarkable. Her BP was 138/74mmHg lying down and 140/78 standing. A resting electrocardiogram (ECG) confirmed sinus rhythm of 76 beats/min with leftward axis deviation. There were no ST segment changes. With regards to current guidelines, which of the following is the most appropriate next step in her management? A. Coronary angiography B. CT angiogram C. Exercise tolerance test (ETT) D. Medical treatment with a long-acting nitrate E. Trial of inhaled beta-agonist 5. An 86-year-old woman presented to the emergency department with increasing confusion. She had a past medical history of breast cancer, osteoporosis, and hypertension. Current medications consisted of calcium and vitamin D supplements, alendronate 70mg weekly, and lisinopril 2.5mg OD. Cardiovascular, respiratory, and abdominal examination were unremarkable. She scored 22/30 on a mini-mental state examination (MMSE). When asked, she stated that she did not have any pain. FBC and U&E were normal. Corrected serum calcium was 3.1mmol/L (2.2–2.6). She was started on IV fluids. Which of the following is the next most appropriate step in her management? A. Arrange a bone scintigram B. Check her vitamin D level C. Give 90mg pamidronate IV D. Request a computed tomography (CT) of the chest/abdomen/pelvis E. Send a paired serum calcium and parathyroid hormone level 4 EXAM 1 | QUESTIONS 6. A 70-year-old man presented with a fall in the garden after the sudden onset of headache, vomiting, and blurred vision. He had been fasting for religious reasons. Paracetamol and codeine did not help the headache, which he rated as 8/10. He was being monitored yearly in the haematology clinic because of polycythaemia rubra vera, for which he had undergone and finished chemotherapy 5 years earlier. He also had hypertension. His current medication was aspirin 75mg daily and amlodipine 5mg daily. On examination his pulse was 70beats/min, blood pressure (BP) 138/90mmHg and heart sounds were normal. Both pupils reacted sluggishly to light. There was bilateral papilloedema, and proximal and distal weakness in his right leg (4/5). There was no neck rigidity. There were no other neurological abnormalities. ECG showed sinus rhythm, with slight left ventricular hypertrophy, but no ischaemic changes. Liver function, bone profile, and thyroid function were normal. What is the most likely diagnosis? A. Viral meningitis B. Para-sulcal meningioma C. Sub-arachnoid haemorrhage D. Sub-dural haemorrhage E. Venous sinus thrombosis 7. Which of the following statements is false? A. By 2034, 5% of the UK population is expected to be over the age of 85 years B. In 2012 in the UK, life expectancy at birth is less than for those aged 65 years C. Life expectancy for a woman aged 65 years in 2007 was 12 more years D. The female:male ratio amongst over 65s is falling and expected to continue to do so E. The median age of the UK population is increasing Blood results Hb 20.6g/dL (13–18) WCC 10.2 × 109 /L (4–11) Platelets 450 × 109 /L (150–400) Urea 11.4mmol/L (2.5–7.0) Creatinine 136µmol/L (60–110) CRP 7mg/L (<10) Sodium 149mmol/L (137–144) Potassium 5.6mmol/L (3.5–4.9) EXAM 1 | QUESTIONS 5 8. A 71-year-old woman was referred to the rapid access stroke clinic. Her husband reported that 2 days earlier they had walked into the house for lunch after gardening and, although physically functioning normally, she repeatedly asked him where they were, what was happening, and why he was in her house. By the evening she was back to normal with no recollection for this event. She never lost consciousness. There was no history of any previous similar events. She was on no medication. What is the most likely diagnosis? A. Dementia with Lewy bodies B. Fugue state C. Temporal lobe epilepsy D. Transient global amnesia E. Transient ischaemic attack 9. A 72-year-old woman complained of a gradual deterioration in breathing, which was starting to limit her ability to do her shopping and walk her dog. She smoked 15 cigarettes per day from age 15 to 66. She produced a small amount of white phlegm each morning. Chest X-ray (CXR) was normal. Her FEV1 was 60% of expected, improving to 70% with nebulized salbutamol. Which of the following would be the next most appropriate treatment for her? A. A course of oral prednisolone B. Pulmonary rehabilitation C. Regular inhaled muscarinic antagonist D. Regular inhaled corticosteroid E. Regular oral slow release theophylline 6 EXAM 1 | QUESTIONS 10. An 84-year-old man with severe Alzheimer’s dementia was being treated in hospital for a UTI. His inflammatory markers improved and blood tests normalized. He became increasingly agitated and restless. He had been shouting out and disturbing the other patients. He had not been violent, and was not putting himself or others at risk. Prior to this illness he lived in a nursing home where he was dependent for all activities of daily living. He was unable to communicate and did not recognize close family. Examination demonstrated a new grade 1–2 sacral pressure sore, but was otherwise unremarkable. He was not constipated and a bladder scan excluded recurrent urinary retention. What is the most appropriate pharmacological intervention? A. Haloperidol 500micrograms as required per os (PO) or intramuscular (IM) B. Lorazepam 500micrograms as required PO or IM C. Paracetamol 1g QDS PO D. Quetiapine 25mg BD regularly E. Risperidone 500micrograms regularly BD PO 11. A 79-year-old man with type 2 diabetes had been started on ramipril 2.5mg for hypertension 1 month earlier. In addition, he took metformin 500mg BD, gliclazide 40mg BD, aspirin 75mg OD and simvastatin 40mg ON. His repeat bloods showed that his creatinine had increased as shown below: His BP remained slightly elevated at 145/84mmHg. Which of the following is the most appropriate course of action? A. Add amlodipine 5mg OD and review renal tests in 1 week B. Add amlodipine 5mg OD and review in 3 months C. Add spironolactone 25mg OD D. Change ramipril to losartan 50mg OD E. Stop ramipril and initiate amlodipine 5mg OD Initial appointment This appointment Sodium 138mmol/L (137–144) 139mmol/L (137–144) Potassium 4.2mmol/L (3.5–4.9) 4.4mmol/L (3.5–4.9) Urea 6.3mmol/L (2.5–7.0) 6.4mmol/L (2.5–7.0) Creatinine 100µmol/L (60–110) 128µmol/L (60–110) EXAM 1 | QUESTIONS 7 12. A 70-year-old man recovering from a cerebral infarction had painful spasticity of the stroke affected limbs, which was impairing his quality of life. He was unable to tolerate oral medication for his spasticity. What would be the most appropriate drug to try by intrathecal infusion? A. Baclofen B. Botulinum toxin C. Dantrolene D. Diazepam E. Tizanidine 13. Four weeks after suffering a thrombotic partial anterior circulation stroke, a 79-year-old woman was anxious to discuss possible ways to reduce her risk of future stroke. She was independently mobile with a zimmer frame and able to climb stairs, but was fearful she might fall. She had atrial fibrillation and had been on amiodarone for several years with good rate control. She had stable CKD-4 with a creatinine clearance of 28mL/min. She drank 2 glasses of wine each day, did not smoke, and weighed 52kg. She was normotensive and not diabetic. What is the most appropriate advice to give? A. Amiodarone should be changed to dronedarone B. Aspirin has a lower bleeding risk than warfarin and should be recommended C. Rhythm control by catheter ablation should be considered D. She should take dabigatran, rather than warfarin due to its lower bleeding risk E. She should take warfarin and remain on amiodarone 8 EXAM 1 | QUESTIONS 14. An 84-year-old man had angina attacks on a near daily basis when climbing stairs. The episodes settled rapidly with rest and occasional use of his glyceryl trinitrate (GTN) spray. He was taking aspirin 75mg OD, simvastatin 40mg OD and lisinopril 2.5mg OD for secondary prevention of ischaemic heart disease. He had no significant past medical history and no known drug allergies. On examination, he was clinically in sinus rhythm at 70 beats/min with a BP of 130/82mmHg. His chest was clear and abdominal examination unremarkable. Which of the following would be the most appropriate long-acting anti-anginal to introduce? A. Atenolol 100mg OD B. Bisoprolol 2.5mg OD C. Isosorbide mononitrate modified release (M/R) 60mg OD D. Ivabradine 2.5mg BD E. Nicorandil 10mg BD 15. A 78-year-old man with moderate Alzheimer’s was consistently disruptive at meal times in the residential home where he had recently come to live. The staff of the residential home requested that this resident was moved to a specialist dementia unit in another home. At all other times of the day he exhibited no behavioural disturbance and slept well at night. He was on no medication. Physical examination was entirely normal. What would be the most appropriate next step in his management? A. Admit to psychiatric unit for further assessment B. Arrange transfer to a specialist dementia care home C. Discuss his behaviour with his family D. Start a cholinesterase inhibitor E. Start low-dose antipsychotic 16. An 82-year-old woman complained for several months of headaches, fatigue, anorexia, and dry skin. Physical examination was normal apart from dry skin. Her corrected serum calcium was 2.9mmol/L (2.2–2.6). What is the most likely diagnosis? A. Hypervitaminosis A B. Hypervitaminosis B3 C. Hypervitaminosis B6 D. Hypervitaminosis C E. Hypervitaminosis E EXAM 1 | QUESTIONS 9 17. An 89-year-old man was referred to the clinic with problematic incontinence. He was having accidents several times a day and his family were struggling to cope with the washing. They had particular difficulties at night, as his bed could require changing several times. The patient and his daughter felt that the problem was partly lack of warning, but mainly impaired mobility preventing him from getting to the toilet in time. Indeed, he had had several falls trying to do this. He had a past medical history of mild cognitive impairment, postural hypotension, and atrial fibrillation. Examination confirmed a mild postural drop in BP and a smooth, mildly-enlarged prostate, but was otherwise unremarkable. A post-void bladder scan did not show any significant residual volume. A prostate-specific antigen test was normal. Which of the following interventions would be most appropriate? A. Alpha-blocker B. Anti-cholinergic C. Conveen® D. Pad and pants E. Residential care 18. During a multidisciplinary meeting of community staff, to review the case management of frail older people living at home or in a care home, the community matron asked about the potential use of telecare and telehealth in helping her manage her increasing caseload of frail vulnerable older people. What is the most appropriate advice to give her about telecare and telehealth? A. They are most effective in multiple long-term conditions B. They are not capable of monitoring bath floods C. They are unlikely to be of value for care home residents D. They may improve medication concordance E. They will eliminate the need for carers 10 EXAM 1 | QUESTIONS 19. A 74-year-old man presented following a fall. He tripped on a loose paving slab and was unable to keep his balance. He sustained no significant injuries. He last fell 1 month previously when he slipped on a door step. He had been well recently, but has had some increased urinary frequency and mild dysuria. He had a past medical history of diverticulosis and Addison’s disease. Current medications consisted of hydrocortisone 20mg at breakfast, 10mg at lunch, and 10mg at supper, with fludrocortisone 50micrograms OD. On examination he was clinically in sinus rhythm at 60beats/min with a lying BP of 120/80mmHg and a standing BP of 125/82mmHg. There was no evidence of peripheral oedema. Respiratory and abdominal examinations were unremarkable. A urine dip was positive for nitrites and leucocytes. Co-amoxiclav was started for a UTI, in line with local microbiology guidelines. An ECG confirmed normal sinus rhythm Which of the following is the next most appropriate step in his management? A. Arrange a cardiac Holter monitor B. Arrange bone density scanning C. Increase fludrocortisone dose D. Increase hydrocortisone dose E. Initiate bisphosphonate therapy EXAM 1 | QUESTIONS 11 20. A 79-year-old male resident in a specialist dementia care home had recently become bed-ridden and more aggressive towards the staff. For the last 2 days he had been difficult to feed and was very variable in accepting fluids. Ten days earlier he had been admitted to the local hospital after a fall and been found to have a periprosthetic fracture of his right femur, which was deemed stable and not requiring surgical intervention. He had bilateral hip replacements for previous fractures. He had been discharged back to the care home 6 days ago on the following medication: 5micrograms/hr buprenorphine patch (changed weekly) and 9.5mg/24hr rivastigmine patch (changed daily). On physical examination, his BP was 110/76 and pulse 60beats/min sinus rhythm. Examination of the chest and abdomen were normal, but he became aggressive when attempts were made to roll him onto his side to undertake a digital rectal examination and so this was abandoned. He lashed out at the nursing staff when they attempted personal care, but would accept the food and drink they offered. FBC, U&Es, bone profile, and liver function tests (LFTs) were all normal, as were chest and plain abdominal imaging. What is the next best step in his management? A. Add oromorph as required B. Add daily senna and docusate C. Add daily strontium ranelate D. Increase strength buprenorphine patch E. Give intravenous (IV) ibandronate 3-monthly