Old age (MRCP) Flashcards
After a specifi c number of subcultivations in the laboratory, normal human cells undergo irreversible cessation of mitosis and enter a non-dividing state. This phenomenon is known as A. Programmed cell death B. Hayfl ick phenomenon C. Pruning D. G0 phase arrest E. Cellular atrophy
B. The process of ageing can be classifi ed as primary ageing, which accounts for the relatively
constant lifespan observed in a species, and secondary ageing, which explains much of the
unpredictability among individual members of the species. The primary ageing process is most
probably constitutional and is probably wired in the cellular machinery. This was demonstrated
by Hayfl ick and colleagues, who showed that the maximum number of cell divisions that can
occur in normal human cells in culture is approximately 40–60. Many functional capacities of the
cells reduce as the cells approach the Hayfl ick limit. This ‘Hayfl ick phenomenon’ is under genetic
control; it is not limited to laboratory culture methods. Pruning is a developmental phenomenon
by which unnecessary synapses formed during brain development are removed. Apoptosis refers
to programmed cell death.
The Hachinski Ischaemic Score is used to aid clinical differentiation of
Alzheimer’s dementia from vascular dementia. Which of the following
clinical features support a diagnosis of Alzheimer’s dementia rather than
vascular dementia?
A. Stepwise progression
B. Fluctuating course
C. Abrupt onset
D. Early change in personality
E. Nocturnal confusion
D. The Hachinski Ischaemic Score is an easy-to-use clinical tool that aids in the bedside
differentiation of Alzheimer’s dementia from vascular dementia. It has been validated in patients
with pathologically confi rmed dementia. A cut-off score ≤4 supports a diagnosis of Alzheimer’s
dementia while a score ≥7 favours vascular dementia. These cut-off values have a sensitivity of
89% and a specifi city of 89%. Abrupt onset, fl uctuating course, history of stroke, presence of
focal neurological symptoms and signs strongly favour a diagnosis of vascular dementia. Other
supporting features for a diagnosis of vascular dementia include stepwise deterioration, presence
of nocturnal confusion, absence of changes in personality, presence of emotional incontinence,
depression and a history of hypertension
Which of the following statement regarding the assessment of activities of
daily living (ADL) in elderly people is correct?
A. ADL scales are used as outcome measures
B. The Barthel index is a self-rating scale
C. In dementia basic ADL are affected earlier than complex instrumental ADL
D. None of the validated ADL scales depend on the patient’s self-report
E. The choice of ADL scale in a patient depends on the patient’s gender
A. In dementia complex ADL that require use of tools and equipment (instrumental ADLs)
are affected earlier than basic ADL. Although self-report ADL measures are rare, they do exist.
For example, the ADL-Prevention Instrument (ADL-PI) has a self-rated version and an informant
version. Self-ratings are found to be closer to research observer’s ratings, while family members
tend to under-rate the ADL. Data from self-report of functioning predicts mortality better than
informant data. The Barthel Index consists of 10 items that measure a person’s ADL and mobility.
It can be used to determine a baseline level of functioning and also to monitor changes in ADL
over time. It is rated by carers or professionals. Currently, functional capacity measures are
being used increasingly in pharmacological trials of patients with dementias as primary outcome
measures. ADL scales are not gender biased and are commonly used in both sexes.
Schizophrenia-like psychosis is a prominent feature of which of the following dementing illnesses? A. Pick’s disease B. Creutzfeldt–Jakob disease (CJD) C. Vascular dementia D. Huntington’s dementia E. Lewy body dementia
D. Huntington’s disease is inherited in an autosomal dominant fashion. It is a
neurodegenerative disorder related to expansion of a trinucleotide repeat sequence in the short
arm of chromosome 4. Clinical features include a triad of choreic movements, cognitive decline,
and psychiatric syndromes starting in the fourth to fi fth decade. Psychiatric presentation is usually
variable and can precede motor and cognitive changes. Most common psychiatric problems
include change in personality (impulsive, disinhibited, and dissocial) and depression. Paranoid
schizophrenia-like symptoms occur in 6–25% of cases. Such schizophrenia-like presentation is
very rare in other conditions listed.
A 78-year-old man is treated with diazepam by his general practitioner for
disabling anxiety related to a recent bereavement. The half-life of diazepam
is most likely to be increased in this man due to
A. Increase in intestinal absorption
B. Increase in oral bioavailability
C. Increase in plasma protein binding
D. Increase in volume of distribution
E. Decrease in renal elimination
D. Body composition changes with advancing age resulting in alterations in the way drugs
are metabolized and circulated. Muscle mass and body water decline by as much as 25% by age
70 while the body lipid content increases. Body fat constitutes >40% of body weight in elderly
women and >30% in elderly men. As a result, elderly people have a larger volume of distribution
and longer half-life of lipophilic drugs. Lipid-soluble drugs such as diazepam have greater volume
of distribution and half-life with slower clearance in elderly individuals
Which of the following scales can be used to record the behavioural and
psychological features associated with dementia in elderly people?
A. Neuropsychiatric inventory
B. Schedule for clinical assessment in neuropsychiatry
C. Bristol scale
D. Cornell scale
E. Abbreviated mental test
A. The Neuropsychiatric inventory (NPI) can be used to measure behavioural and
psychological features of dementia in elderly people. It was created by Cummings et al. It
evaluates 10–12 neuropsychiatric disturbances common to dementia using frequency, severity
and the carer’s distress as indices. The Bristol scale is used to measure activities of daily living;
the Cornell depression scale is used to assess depression in demented patients. The abbreviated
mental test is a quick and easily administered test that is used as a screening tool for dementia.
Which of the following diagnostic tests has been most widely used to
monitor treatment response in anticholinesterase trials for dementia?
A. Behaviour Pathology in Alzheimer’s Disease rating scale
B. Clock drawing test
C. Alzheimer’s disease assessment scale – cognitive section (ADAS-Cog)
D. Mini Mental State Examination (MMSE)
E. Magnetic resonance imaging (MRI) brain scan
C. The ADAS-Cog is used as the de facto standard primary outcome neuropsychological
measure for dementia trials. It measures several cognitive domains, including memory, language,
and praxis with total scores ranging from 0 to 70. A four-point change on the ADAS-Cog at 6
months after starting antidementia drugs has been used as an arbitrary cut-off point indicating a
clinically important difference. This pharmaceutical cut-off on ADAS-Cog must be interpreted in
the context of overall response when it is translated to clinical practice. MMSE is not as sensitive
to change as ADAS-Cog; hence, it is rarely used as a primary outcome measure in dementia trials.
An MRI brain scan currently has no role in monitoring treatment response
The average annual decline on the MMSE scores for patients with a natural course of Alzheimer’s dementia is A. 1–2 points/year B. 3–4 points/year C. 5–6 points/year D. 7–9 points/year E. 9–11 points/year
B. Alzheimer’s dementia is associated with an annual decline on the MMSE of 3–4 points.
Similarly using the ADAS-Cog scale, the natural disease progression averages a 7-point decline
per year. But the average change on ADAS-Cog when using antidementia drugs is about
2.7 points. Thus cholinesterase inhibitors are considered to delay this progression by 6 months
on average. MMSE is a reasonable tool for monitoring disease progression in a clinical setting, but
the occurrence of functional impairment is more likely to be relevant to the patient and their
carers than MMSE scores. Performance in instrumental activities of daily living such as telephone
use, taking own medication, handling fi nances, and transport correlates well with cognitive
impairment.
Hyponatraemia is a troublesome side-effect of treating depression in elderly
people. All of the following are true with regard to the above except
A. More common in males
B. More frequent when diuretics are co-prescribed
C. Often related to inappropriate ADH secretion
D. Risk increases with increase in age
E. Symptoms overlap with primary depressive features
A. Generally, a high level of suspicion is needed to detect hyponatraemia in a depressed
patient who does not undergo regular blood tests for electrolytes. The symptoms of
hyponatraemia overlap with those of depression, making it hard to diagnose. Hyponatraemia due
to selective serotonin reuptake inhibitors (SSRIs) or other antidepressant use is often linked to
the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Increased age, female
gender and co-prescription of diuretics are notable risk factors. Symptoms usually occur when
the blood serum level falls below 130 mmol/L. These include lethargy, fatigue, muscle cramps, and
headaches.
Presenilin mutations that are associated with early-onset Alzheimer’s
dementia are proposed to affect which of the following enzymes?
A. κ Secretase
B. Tau phosphorylation enzymes
C. α Secretase
D. β Secretase
E. γ Secretase
E. Plaques seen in the brain of patients with Alzheimer’s dementia are insoluble
extracellular deposits composed mainly of Aβ peptides. These Aβ peptides are derived from a
transmembrane protein called B-amyloid precursor protein (APP) through proteolytic processing.
APP is generally cleaved by β-secretase or α-secretase enzymes followed by γ -secretase.
Aβ peptides are generated when APP is cleaved by β-secretase followed by γ -secretase. This
pathway is amyloidogenic and forms the major metabolic pathway of APP in brain tissue; the
non-amyloidogenic α-secretase pathway is the major pathway in other tissues. Presenilins are
necessary for proteolytic activity of γ –secretase. PS/ γ -secretase complex is widely considered
as a potential target for developing therapies against Alzheimer’s disease
Which of the following is an observational tool designed to evaluate the quality of care and well-being of people with dementia in formal care settings? A. Bristol Scale B. Burden Interview C. Caregiver Burden Scale D. Clinical Dementia Rating (CDR) E. Dementia Care Mapping (DCM)
E. DCM is an observational tool designed to evaluate the quality of care and well-being
of people with dementia in formal care settings. It was designed by Kitwood in 1992. DCM is
based on the social–psychological theory of dementia care, which states that much of the decline
in patients with dementia is a direct consequence of the social and environmental situation
experienced. Better social care may result in less suffering than would otherwise be expected
from their neurological state. The Washington University CDR is a global scale developed to
clinically denote the presence of Alzheimer’s dementia and stage its clinical severity using
semi-structured interviews with the patient and informants. The Burden Interview and Caregiver
Burden Scale are used to measure the degree of caregiver strain.
A 67-year-old retired educational psychologist presents with forgetfulness.
All of the following are features seen in mild cognitive impairment (MCI)
except
A. Presence of subjective memory complaint
B. Objective memory impairment for age
C. Preserved general cognitive function
D. Normal functional activities
E. Presence of family history of dementia
E. An array of various terms has been used to describe age-associated cognitive impairment
not amounting to dementia. The most popular term is MCI, of which several types have been
described of late. The amnestic MCI refers to the original description of MCI. Diagnosis of MCI
requires the presence of memory complaint (preferably corroborated by an informant), objective
memory impairment for age, preserved general cognitive function, normal functional activities,
and no dementia. The presence or absence of family history of dementia is not a criterion used
to describe MCI.
Lund–Manchester criteria are used in the diagnosis of which of the following conditions? A. Alzheimer’s dementia B. Vascular dementia C. Lewy body dementia D. Frontotemporal dementia E. Huntington’s dementia
D. The Lund–Manchester criteria are used in the diagnosis of frontotemporal dementia.
The criteria were initially developed in 1994 and were later updated in 1998. The following core
components are required for a diagnosis:
1. insidious onset and gradual progression
2. early decline in social interpersonal conduct
3. early impairment in regulation of personal conduct
4. early emotional blunting
5. early loss of insight
Other supportive diagnostic features include:
A. Behavioural disorder (decline in personal hygiene, mental rigidity and infl exibility, distractibility
and impersistence, hyperorality and dietary change, utilization behaviour)
B. Speech and language disturbances (altered speech output, stereotypy of speech, echolalia,
perseveration, mutism)
C Physical signs (primitive refl exes, incontinence, akinesia, rigidity, tremor)
D. Abnormal investigations (neuropsychological evidence of impaired frontal lobe function,
normal conventional EEG despite clinically evident dementia and predominant frontal and/or
anterior temporal abnormality in neuroimaging)
Males >females
Age 45-65
Positive FHx in 50%
Association between FTD and MND
All of the following are features of visual hallucinations reported in
dementia of Lewy bodies except
A. The images are vivid
B. The images are mostly grey or black and white
C. Animate objects are often seen
D. The images are usually three dimensional
E. They predict better response to cholinesterase inhibitors
B. Visual hallucinations dominate the clinical picture of dementia with Lewy bodies (DLB)
in many patients. Visual hallucinations have a tendency to persist despite treatment in many
patients. In phenomenological quality, the hallucinations of DLB are similar to those reported
in Parkinson’s disease dementia: they are vivid, colourful, three-dimensional, and generally mute
images of animate objects. Visual hallucinations are associated with greater defi cits in cortical
acetylcholine and predict better response to cholinesterase inhibitors
Two patients are admitted to an inpatient unit for elderly people with
movement disturbances. Patient A has a diagnosis of Parkinson’s disease
while patient B is diagnosed with dementia with Lewy bodies. Which of the
following is correct with regard to the extrapyramidal symptoms in these
conditions?
A. Patient A is more likely to have greater postural instability than patient B
B. Patient A is more likely to have greater facial impassivity than patient B
C. Patient A is more likely to have tremors than patient B
D. Both patients will have similar profi les of extrapyramidal features
E. Patient B is more likely to have prominent cerebellar signs
B. Visual hallucinations dominate the clinical picture of dementia with Lewy bodies (DLB)
in many patients. Visual hallucinations have a tendency to persist despite treatment in many
patients. In phenomenological quality, the hallucinations of DLB are similar to those reported
in Parkinson’s disease dementia: they are vivid, colourful, three-dimensional, and generally mute
images of animate objects. Visual hallucinations are associated with greater defi cits in cortical
acetylcholine and predict better response to cholinesterase inhibitors
Which of the following is associated with poor antidepressant response in
geriatric depression?
A. Earlier age of onset
B. Structural white matter abnormalities
C. Enlarged cerebral ventricles
D. Cingulate hyper-metabolism during depression
E. Presence of somatic symptoms
B. Multiple factors have been examined in an attempt to predict the treatment response in
elderly depressed patients. A prospective study examining neurological and neuropsychological
factors showed that a combination of extrapyramidal signs, pyramidal tract signs, and impairment
of motor hand sequencing strongly predicted resistance to 12 weeks of antidepressant
monotherapy, with 89% sensitivity and 95% specifi city. Microstructural white matter abnormalities
may also perpetuate depressive symptoms in older adults by disrupting connectivity with
cortico-striato-limbic networks, which form the basis of mood regulation. Lower fractional
anisotropy in this network predicted poorer treatment response in geriatric depression.
Although enlarged cerebral ventricles have been reported in some studies, this is not examined
as a predictor of treatment response. Earlier age of onset and somatic symptoms suggest better
response to initial antidepressant treatment.
Which of the following present at the time of onset of depression predict greater risk of depressive relapse after treatment discontinuation in elderly patients with depression? A. Depressive cognitions B. Presence of guilt C. Executive dysfunction D. Episodic memory loss E. Psychomotor retardation
C. Executive dysfunction predicts a poor or delayed response to antidepressant therapy
and also a greater risk of relapse after discontinuing treatment. None of the other core
symptoms of depression has been shown to be strong predictors of later relapse.
Secondary depression may be caused by physical illnesses in elderly people.
Which of the following is correct with regard to depression and physical
illness?
A. Primary depression is not diagnosed in the presence of chronic medical illnesses in
elderly people
B. Secondary depression is more common than primary depression in elderly people
C. Subclinical hypothyroidism is more common among depressed than non-depressed
elderly people
D. Depression is two to three times more common in those with chronic medical illnesses
E. Many apparent physical illnesses are found on investigation to be due to somatoform
disorders
D. Late-life depression often occurs in the context of medical health issues; it is two
to three times more common in the medically ill elderly patient. The diagnosis ‘depression
due to a general medical condition’ (more commonly, secondary depression) is used when
depressed mood or anhedonia occur in patients already diagnosed with an illness that is clearly
linked to depression as a physiological consequence. For example, nearly 25% of patients with
myocardial infarction have a major depressive episode. Primary depression can exist alongside
a general medical condition with no direct physiological relationship. In fact, such co-existing
depression and a general medical condition is more common than depression secondary to
medical problems. Depression may also exacerbate the outcome of medical illnesses. Although
hypothyroidism is considered to cause depression traditionally, recent studies show that a TSH
value of 10 μU/L or greater was found in only 0.7% of elderly patients with clinical depression.
Thus the rate of subclinical hypothyroidism in an elderly depressed group may be similar to that
of the elderly population in general.
Psychosis in elderly people may be due to dementia, Parkinson’s disease, or
schizophrenia. Which of the following is correct with respect to the clinical
features of late-onset psychotic syndromes?
A. Hallucinations are more common than delusions in psychosis due to Alzheimer’s disease
B. Visual hallucination is the most common symptom in very late-onset schizophrenia
C. Partition delusions are characteristic of psychosis associated with parkinsonism
D. Negative symptoms are predominant in very late-onset schizophrenia
E. Paranoid delusions are the most common symptoms in late-onset schizophrenia
E. The term late-onset schizophrenia is applied to patients whose fi rst symptom of
schizophrenia-like psychosis begins after the age of 40. For patients whose symptoms begin after
the age of 60, the term very-late-onset schizophrenia-like psychosis (VLOSLP) is used. Paranoid
delusions are the most common symptoms in late-onset schizophrenia, followed by auditory
hallucinations. Partition delusions are often noted in late/very late-onset schizophrenia where the
patient typically believes that people, objects, or radiation can pass through what would normally
constitute a barrier to such passage. Negative symptoms are conspicuously absent in most cases.
In psychosis associated with Alzheimer’s dementia, simple paranoid delusions are more common
than hallucinations. In psychosis associated with Parkinson’s disease, visual hallucinations are more
common than delusions.
Which of the following forms of grief therapy treats unresolved grief as a form of phobic avoidance? A. Guided mourning B. Supportive grief counselling C. Focused group therapy D. Interpersonal psychotherapy E. Debriefi ng
A. Some individuals with abnormal grief reaction may be avoiding reminders of their grief,
leading to unresolved emotions. Addressing these issues by encouragement may not be suffi cient
and a behavioural approach may be needed in some cases. The approach commonly used is
known as guided mourning. This treats unresolved grief in a way similar to other forms of phobic
avoidance by exposure to the avoided situation. Thus guided mourning involves intense reliving of
avoided painful memories and feelings associated with bereavement. During treatment, patients
are exposed to avoided painful memories or situations related to the loss of their loved one –
both in imagination and in real life.
When compared with those with late-onset depression, elderly individuals
with early-onset depression have
A. Less frequent family history of mood disorders
B. Higher prevalence of dementia
C. More sensory impairment
D. Greater enlargement of the lateral ventricles of the brain
E. Less white matter hyperintensities
E. Elderly people with depression may have a relapse or recurrence of a depressive
disorder from adulthood (early onset) or they might have fresh onset late-life depression.
Late-onset major depression includes a large subgroup of patients with neurological problems.
It is possible that milder, unnoticed episodes of depression with early-onset might be a risk factor
for late-life depression by contributing to brain abnormalities. When compared with elderly
individuals with early-onset major depression, patients with late-onset major depression have a
less frequent family history of mood disorders, a higher prevalence of disorders of dementia, a
larger impairment in neuropsychological tests, a higher rate of dementia development on
follow-up, more neurosensory hearing impairment, a greater enlargement in lateral brain
ventricles, and more white matter hyperintensities
The most effective psychological intervention to reduce depression and
emotional burden in caregivers of people with dementia is
A. Psychoeducational intervention
B. Group behavioural management
C. Individual behavioural management
D. Supportive psychotherapy
E. Coping skills enhancement
C. A systematic review of studies looking at improvements in caregiver psychological
health revealed that six or more sessions of individual behavioural management therapy had the
highest quality of evidence. This intervention was effective for up to 32 months after intervention.
There was some evidence supporting individual and group caregiver coping sessions to reduce
depression among caregivers; the benefi ts may last up to 3 months. Educational interventions,
group behavioural management sessions, fewer than six individual behavioural management
sessions, and supportive therapy were not effective interventions for reducing a caregiver’s
symptoms.
