RECALL: Neurocognitive D/O + CL + Forensics + Critical Appraisal + Professionalism

Question 1

what is the clinical picture of Creutzfeld Jakob disease? what would be seen on EEG

Answer 1

Rapidly progressive (within 6 months = major ncd), neurocog deficits, ataxia, myoclonus, startle reflex, chorea, dystonias. EEG periodic characteristic sharp, triphasic, synchronous discharges & tau or 14-3-3 protein in CSF.

Question 2

“105. 54 year old women with sudden onset of dementia symptoms and hallucinations. Rapidly progressive dementia with ataxia and stimulus-sensitive myoclonus. EEG shows generalized background slowing with periodic sharp discharges. Diagnosis?
a. Creutzfeld Jakob Disease
b. Lewy Body Dementia
c. Vascular Dementia
d. Pick’s Disease”

Answer 2

“A) CJD = TRUE

[DSM5]
CJD. Rapidly progressive (within 6 months = major ncd), neurocog deficits, ataxia, myoclonus, startle reflex, chorea, dystonias. EEG periodic characteristic sharp, triphasic, synchronous discharges & tau or 14-3-3 protein in CSF.

A) TRUE
B) FALSE. Ataxia, myoclonus unusual.
C) FALSE. No rapidly progressive, hallucinations unusual.
D) FALSE. FTD, not rapidly progressive, hallucinations unusual.”

Question 3

“109) pt with dementia symptoms, difficulty walking with feeling that feet are stuck to the floor, also having urinary incontinence. What is the initial approach that will confirm your diagnosis?
a) urinalysis
b) CT scan
c) Lumbar Puncture”

Answer 3

“C) LP

**confusing because CT is INITIAL but LP is CONFIRMATORY so would depend on wording of the stem

Initial approach would be CT (screens for NPH). LP is confirmatory, drain some fluid + see if gait improves.

Feet stuck to the floor= magnetic gait (NPH classic example)”

Question 4

what is the only medication approved for BSPD

Answer 4

risperidone (use for aggression)

Question 5

“126. Parkinson’s dementia, moderate. Which medication is best to improve function?
A) Rivastigmine
B) Memantine
“

Answer 5

“A) Rivastigmine - TRUE
In UTD Risvastigmine (cholinesterase inhibitors) are favored over Memantine for PD. Both have mixed findings but rivastigmine slightly better.

Rivastigmine was evaluated in a 24-week, double-blind, placebo-controlled study of 501 patients with mild to moderate PDD and was found to result in moderate improvement in dementia, mean improvement of 2.1 points on the Alzheimer Disease Assessment Scale-Cognitive Subscale (ADAS-cog) score compared with 0.7-point decline in the placebo-treated group [141]. Clinically meaningful improvements were seen in 20 and 14.5 percent in the treatment and placebo groups, respectively, while clinically meaningful worsening was observed in 13 and 23 percent. This suggests that overall, 15 percent of patients benefited from treatment and 15% worsened

A) TRUE - RIVASTIGMINE
B) FALSE –> Memantine has reported efficacy in moderate to severe Alzheimer disease (AD) and in vascular dementia. One 24-week randomized controlled study of 72 patients with either dementia with Lewy bodies (DLB) or PDD found that patients treated with memantine performed better on the primary outcome assessment measure, the clinical global impression of change, but not on other secondary outcome measures [152]. In a more recent, 24-week randomized controlled study, DLB patients, but not PDD patients, were improved on the same outcome measure [153]. Memantine was well tolerated in these trials and in another shorter study of patients with PDD [154]. However, hallucinations and worsened neuropsychiatric symptoms have occasionally been reported with the use of memantine, suggesting some caution with its use in PDD [155-157].”

Question 6

ALS is associated with what other neuropsychiatric syndromes

Answer 6

FTD and pseudobulbar affect are associated with ALS

Question 7

someone presenting with symptoms of NPH is likely to have what previous event in their past medical hx

Answer 7

hemorrhagic stroke

Question 8

describe the MCA stroke syndrome

Answer 8

Aphasia is DOMINANT sided stroke, MCA is most assoc with aphasia.

MCA stroke syndrome
Deficits in movement and sensation (contralateral hemiplegia and hemianesthesia) mostly of face and arm;
Difficulty swallowing (dysphagia);
Impaired speech ability (dysarthria, aphasia);
Impaired vision and partial blindness (hemianopia);

Question 9

what is the ACA stroke syndrome

Answer 9

ACA stroke syndrome
Deficits in movement and sensation (contralateral hemiplegia and hemianesthesia) mostly in leg
Abulia, disinhibition, executive dysfunction

Question 10

what is the PCA stroke syndrome

Answer 10

PCA stroke syndrome
contralateral homonymous hemianopia

Question 11

“26. Demented fellow gets fearful seeing reflection in mirrors and windows. Paranoid that an intruder is coming into the home, gets agitated. Best first step
a. adult day program for social & recreational cognitive stimulation and engagement
b. cover up reflective surfaces with a towel and avoid walking past windows at night
c. PRNs
d. Train wife in reminiscence therapy”

Answer 11

“B) Cover up reflective surfaces with a towel and avoid walking past windows at night = TRUE

Non-pharm strategies first!

A) FALSE. Good idea, but not first step.
B) TRUE
C) FALSE. Not first step.
D) FALSE. Won’t help this.”

Question 12

“3. What is the most common non-motor symptom of Parkinson’s disease?
A) Sleep-wake disturbance
B) Depression
C)
D)”

Answer 12

“A) Sleep-Wake disturbance

UTD:
- Depression < 50%
- Sleep 55-88%
______________
+ Article included says autonomic & sleep most common
“

Question 13

“30. Man presents with cognitive decline, visual hallucinations, parkinsonism. What is your choice of pharmacotherapy?
A) NMDA antagonist
B) SSRI
C)
D) Acetylcholinesterase inhibitor”

Answer 13

“D) AChEi = true

Sounds like Lewy body. 1st line tx is AChEi (also used in mild-mod Alzheimer’s, Parkinson’s dementia, and vascular. NOT for FTD).”

Question 14

“33. A patient who can express himself fluently but he cannot name a pen or pencil, cannot repeat words, what is the most likely form of aphasia:
a. Global
b. Broca’s
c. Wernicke’s
d. Anomic”

Answer 14

“C) Wernicke’s = TRUE

Wernicke’s is intact fluency, impaired comprehension. Naming is impaired in all aphasias.

A) FALSE. All impaired.
B) FALSE. Impaired fluency, intact comprehension.
C) TRUE
D) FALSE. Intact fluency, intact comprehension (only impaired naming).

Note: we are not given info on whether pt can comprehend, so the answer could also be conduction aphasia (if pt is able to comprehend).

Where is Wernicke’s area? dominant hemisphere, superior temporal gyrus (temporal lobe)”

Question 15

where is brocas area

Answer 15

dominant hemisphere, anterior inferior frontal gyrus (frontal lobe)

Question 16

where is wernickes area?

Answer 16

dominant hemisphere, superior temporal gyrus (temporal lobe)”

Question 17

“35. (repeat) What neuroimaging findings is most consistent with Lewy Body dementia?
A) Atrophy of the frontal lobe and cerebellum
B) Generalized cortical atrophy with sparing of the medial temporal lobe
C) Atrophy of the hippocampus, and entorhinal cortex
D) Hummingbird sign”

Answer 17

“B) Relative sparing of medial temporal lobe

A) FALSE. FTD probably
B) TRUE.
C) FALSE. Alzheimer’s
D) FALSE. PSP.

Question 18

what neuroimaging findings would be associated with PSP

Answer 18

hummingbird sign, also known as the penguin sign, refers to the appearance of the brainstem in patients with progressive supranuclear palsy (PSP). (https://radiopaedia.org/articles/hummingbird-sign-midbrain)
“

Question 19

injury to what part of the brain would present predominantely with executive dysfunction

Answer 19

dorsolateral PFC

Question 20

what is the orbitofrontal syndrome

Answer 20

” orbitofrontal syndrome is the most well known and consists of major antisocial behaviors such as disinhibition, emotional lability, and impulsivity. In some cases, changes are severe enough to lead to new onset of criminality” Phineas Gage

Question 21

“59- LBD sx. Visual hallucinations. Parkinsonism. MMSE 23/30 and depressed and apathy. What do you do?
a. Quetapine
b. Memantine
c. ACh inhibitors
d. SSRI”

Answer 21

“C) ACh inhibitors (first-line)

UTD for general treatment of LBD in general, which I guess may help with BPSD (address underlying cause)
- ACh-I may repreent 1st line treatment in DLB, though evidence limited
- Memantine has reported efficacy in mod-severe AD and vascular, but mixed data in DLB
- APs less prefered

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3147175/
- doesn’t rank them

FIVEALIVE:
Quetiapine would be second-line
Memantine second-line for cog impairment

IF YOU ARE TREATING THE DEPRESSION THOUGH:
- SSRIs first line (per CCSMH, CCDDT4)
—-
A) FALSE – may be chosen for psychosis + LBD – here visual hallucinations are present, it would depend if they are troublesome (then treat) or not (ChEI first) – stem doesn’t suggest psychosis, VH are frequent in LBD
B) FALSE, evidence but select after ChEI
C) TRUE
D) FALSE - would try first-line trt for LBD first, but SSRI would be a close second”

Question 22

“62. What changes on EEG are seen in delirium?

A) Increase alpha waves
B) loss of theta
C) Decreased alpha waves and generalized theta and delta wave activity
D) Increased alpha decreased beta waves
E) generalized spikes
F) loss of beta, generalized alpha “

Answer 22

“C) TRUE-> Reduced alpha waves with generalized theta and delta waves. Generalized slowing [DSM5]
- delta waves also seen in deep sleep

A) FALSE-> This is simply awake state.
B) FALSE-> Shouldn’t be present in awake patient, is first stage of sleep (N1)
C) TRUE
D) FALSE-> This would be variation of awake state (alpha & beta waves)
E) FALSE
F) FALSE- would also be a variation of awake stage”

Question 23

“66- What is found in Broca’s aphasia?
a. Right inferior frontal area affected
b. Fluent speech
c. Can’t understand
d. Repetition and naming are impaired”

Answer 23

“D) Repetition & naming are impaired

Broca’s aphasia is non-fluent, but CAN understand. Naming and repetition is impaired. Left inferior frontal area affected (language is left/dominant).

A) FALSE. is LEFT inferior frontal
B) FALSE. Non-fluent
C) FALSE. Can understand (““relatively spared””). Can’t = Wernicke
D) TRUE”

Question 24

What is the most consistent finding in the PET neuroimaging literature for AD

Answer 24

“The most consistent finding in the PET literature is the pattern of temporal-parietal glucose hypometabolism in patients with Alzheimer’s type dementia.” [KS] Parietotemporal, posterior cingulate, medial temporal hypometabolism, accompanied by frontal hypometabolism in advanced disease

Question 25

“69. Trails B test tests function of what brain region?
a. Orbitofrontal cortex(OFC)
b. Dorsolateral prefrontal cortex (DLPFC)
c. Temporal
d. Peri-hippocampal”

Answer 25

“B) DLPFC = TRUE

Trails B tests executive function, cognitive flexibility (DLPFC). Execute fxn = abstraction & concept formation, planning, response inhibition, cognitive flexibility and some working memory (mostlt prefrontal with some frontal/ subcortical circuits).

DLPFC dysfxn = executive cognitive impairment with decreased working memory/ problem solving

A) FALSE. OFC is for impulsivity, disinhibition, dampening of the experience of emotion, irritability & lability, poor judgment & decision making -> esp. for social behaviors.
B) TRUE
C) FALSE. Auditory, language, visual, etc.
D) FALSE. Memory.

”

Question 26

“7. Elderly man with Alzheimer’s living in LTC. He is constantly wandering into other residents’ rooms and has even left the facility several times unintentionally. What is the best intervention?
A) Set up barriers to room and camouflage the exits.
B) Lap restraints, in chair in common area
C) Snoezelen room
D) Give risperidone”

Answer 26

“Repeat of 2019 but easier because ““engage in walking program/exercise”” is not an option.

A) Set up barriers to room and camoflauge the exits = true

CCSMH LTC 2006:
- certain behaviours unlikely to respond to meds - wandering, exit-seeking, excessive noisiness [p.36]
- structured recrational activities should be considered when goal is to engage the resident… can be designed ot meet physicla and social needs and reduce wandering [p. 34]

A) TRUE. least intrusive/resource intensive… although is barriers to ROOMS too invasive/aggressive wording?
B) FALSE. Restraints aren’t first choice.
C) FALSE. Fancy, but seems too general. [https://www.umh.org/assisted-independent-living-blog/bid/292480/the-benefits-of-a-snoezelen-room-for-alzheimer-s-care]
D) FALSE. CCSMH p37 ““In view of the above warnings many experts in the field believe that the use of antipsychotics in individuals with dementia should be reserved for residents with severe agitation or psychosis, where severity is evaluated on the basis of the degree of danger, suffering or excess disability (Weintraub & Katz, 2005). Clinicians should aim for the lowest possible effective dosage.”””

Question 27

what does the boston naming test evaluate

Answer 27

assessed word retrieval in aphasia/alzheimers

Question 28

“79. Which is the most specific test of executive function?
A) Boston naming test
B) Trails B
C) WAIS
D)”

Answer 28

“B) TRUE- Trails B

"”Trails B generally tests both attention/psychomotor speed as well as executive functioning””

A) FALSE - Assesses word retrieval in aphasia/alzheimer
B) TRUE
C) FALSE - Assesses intelligence ““most advance measure of cognitive abilities”””

Question 29

“96. Regarding mild cognitive impairment:
a. 12% convert to dementia each year
b. Prevalence of 25% in patients over 65
c. It can only be diagnosed with neuropsychological testing
d. Cholinesterase inhibitors are recommended treatment”

Answer 29

“A) 12% convert to dementia each year = TRUE

Not entirely, but probably misremembered.

A) TRUE. 10-15% convert per year in specialy clinics. 5-10% overall [Geripsych Review]
B) FALSE. 10-20% in age >65 [Geripsych Review]
C) FALSE. Neuropsychological testing PREFERRED, but can use any quantifiable clinical assessment [DSM5]
D) FALSE. No evidence for starting ChEI in MCI.”

Question 30

“99. What neuroimaging findings is most consistent with Lewy Body dementia?
A) Atropy of the frontal lobe and cerebellum
B) Generalizd cortical atrophy with sparing of the medial temporal lobe
C) Atropy of the hippocampus, entorhinal cortex and ?
D) Hummingbird sign”

Answer 30

“B) Relative sparing of medial temporal lobe

A) FALSE. FTD probably
B) TRUE.
C) FALSE. Alzheimer’s
D) FALSE. PSP. hummingbird sign, also known as the penguin sign, refers to the appearance of the brainstem in patients with progressive supranuclear palsy (PSP). (https://radiopaedia.org/articles/hummingbird-sign-midbrain)

”

Question 31

what meds do you use in agitation in TBI

Answer 31

in the MCQ in the recalls, it is always valproate + propanolol

more broadly:

Essentially, for life-threatening agitation, CONSIDER IM antipsychotic or IM benzo. For safety-threatening agitation, CONSIDER PO atypicals (typicals have more side effects and worsen cognition).
Otherwise, RECOMMEND propranolol/pindolol especially if post-traumatic amnesia. CONSIDER valproate particularly if seizure d/o, CONSIDER amantadine or methylphenidate if impaired arousal is suspected. CONSIDER sertraline and other SSRI. TCA is 3rd line (no mention of what is 1st and 2nd line).

For completeness, here are the recommendations for mood and anxiety:
MDD: MBCT and CBT. SSRI. Consider methylphenidate to augment partial response to SSRI.
Bipolar: Commonly used meds like Li, anticonvulsants, neuroleptics, but insufficient evidence to support or refute.
Anxiety: CBT. SSRI. Do NOT use benzos long term due to side effect on cognition, arousal, motor coordination, abuse.
Psychosis: Atypicals better than typicals due to EPS.

Question 32

“116. Patient with multiple sclerosis is being treated with interferon and prednisone. She is also on an antidepressant and retinoic acid for acne. Which medication most increases her suicide risk?
A) Interferon
B) Prednisone
C) Antidepressant
D) Retinoic acid”

Answer 32

“Interferon = TRUE

TR2021 - Said ““interferon””. If country is going to put that answer, we should too.
Note though that prednisone and isotrentinoin (not retinoic acid) also have elevated risk of suicide apparently
____________

A) Interferon - Interferon has been to incr suicidality. Not in HDSR but is in review. Is listed here as <5%:
https://www.merck.ca/static/pdf/INTRON_A-PM_E.pdf doesn’t ahve numbers
http://www.bccancer.bc.ca/drug-database-site/Drug%20Index/Interferon_monograph.pdf has <5%

B) Prednisone - In the HDSR paper (2019), pred had an odds ratio of 1.31 for suicidal events. Also mentioned notably in other review (2015)

C) FALSE. Def.

D) Retinoic acid =/= Isotretinoin (accutane), but unclear whether this was a recall error or RC would actually expect us to differentiate. FDA handout for Accutane: warns suicidality specifically; FDA handout for Prednisone speaks about psych sx in broad terms.
This paper says ““no more than background:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463189/

”

Question 33

“152. Man, 35 years old, has seen worms everywhere in his apartment for a few days and has the impression that spiders are walking on his skin.He is slightly confused. What is the most important thing to look for at the evaluation.
a. Medical hx
b. Family hx
c. Personal history
d. Psychiatric hx”

Answer 33

“A) Medical hx

Vague question. Medical history could help with dx of delirium.

hallucinating only for a few days. Confused meaning ?disoriented..
would want medical hx (aka current medical stauts/workup)”

Question 34

“24- Delirium. NMS vs anticholinergic toxicity(most likely toward NMS):
a. Hyperthermia
b. Diaphoresis
c. Tachycardia
d. Autonomic instabilities”

Answer 34

“B) Diaphoresis (more likely in NMS) – would be the only discriminating sx in the list. Dry in anticholinergic.

A. HyperT ——————-> (NMS Y // Anti-ACh. Y )
B. Diaphoresis ————-> (NMS Y // Anti-ACh. N)
C. Tachycardia ————-> (NMS Y // Anti-ACh. Y)
D. Autonomic instability-> (NMS Y // Anti-ACh. Y)”

Question 35

“24. Which is not associated with porphyria
a. Precipitated by phenobarbital
b. Increased cholesterol
c. Anxiety
d. Psychosis”

Answer 35

“B) Increased cholesterol

TR2020 said that (This MCQ was in Dr. Preisman’s lecture)

But I’m having trouble finding great resources.
Eg, https://porphyriafoundation.org/for-patients/diet-and-nutrition/nutrition-in-the-acute-porphyrias/ –> specifically mentions low cholesterol diet

But, can find various sources for the others too.

Anticonvulsants worsening porphyria: https://pubmed.ncbi.nlm.nih.gov/7194443/#:~:text=Because%20acute%20attacks%20of%20porphyria,methsuximide%2C%20phensuximide%2C%20and%20trimethadione.

UpToDate mentions neuropsychiatric manifestations that include anxiety, depression

Random papers mention psychosis (though seems more rare)

[UpToDate]
Most anticonvulsants worsen porphyria
Can present with many psychiatric sx
Triad = abdo pain, peripheral neuropathy, mental status changes”

Question 36

“45yoM presents with paresthesias. Patient is stabilized on phenelzine. What deficiency might be the cause of his symptoms?

a) Vitamin B1
b) Vitamin B3
c) Vitamin B6
d) Vitamin B12”

Answer 36

“C) Vitamin B6 = TRUE

Phenelzine = MAOI can reduce B6. -> ““Paresthesias or “electric‐shock‐like” sensations and carpal tunnel syndrome (numbness) reported; may be due to vitamin B6 deficiency [Management: Pyridoxine 50–150 mg/day]””

A) FALSE
B) FALSE
C) TRUE
D) FALSE”

Question 37

“6. Elderly man in ICU with urosepsis. Now hyperactive delirium but needs CT scan. QTc 525. What to give for sedation before an abdominal CT?
A) Haloperidol
B) Aripiprazole
C) Quetiapine
D) lorazepam”

Answer 37

“D) Lorazepam = TRUE

Consensus: VGH CL, TR2021 CL

CANMAT talks about lorazepam. If you need someone to be calm for CT scan, benzo is the go-to. Wouldn’t be the appropriate treatment for DELIRIUM, but reasonable for sedation.

Aripiprazole is best for QTc prolongation, but not ““sedating””.. Others seem to be unacceptably QT prolonging

Table in TR 2020 CL lecture pg26 illustrating QTc prolongation
Aripiprazole: MINUS 1 - MINUS 4
Haloperidol: 7-15
Quetiapine: 6-15
“

Question 38

“64- Change in MSE. Psychiatric vs organic cause. More likely psychiatric:
a. Normal clock drawing
b. Thought disorder
c. Concreteness
d. Non auditory hallucinations. “

Answer 38

“A) Normal clock drawing

Not enough information. Seems like asking delirium vs psychiatric.

A) TRUE
B) Can see in both
C) Weird but can see in both.
D) More likely in delirium/organic”

Question 39

“80) kid having blank like stares in class, unaware of what is going on around him, lasts for ?7 mins, looks like he is chewing something when it happens.
a) absence seizure
b) complex partial
c) focal localized”

Answer 39

“B) Complex partial seizure -TRUE
However, following UTD this appears to be outdated nomenclature – now would be ““focal seizures with impairment of awareness- previously complex partial sz”” VS ““without – previously simple partial sz”” – complex or with impairment of awareness involves regions of both hemispheres

• this is a common generalized epilepsy syndrome = episodes of sudden, profound impairment of consciousness w/o loss of body tone. Often triggered by hyperventilation.

A) FALSE. Absence seizure doesn’t last that long (about 10 seconds) -
B) TRUE. (see above)
C) FALSE. Focal localized (simple partial) has intact awareness. (see above)”

Question 40

“124. Most important factor in transition from youth to adult care?

Answer 40

A) Overlap in services”

Question 41

“2. When can a physician obtain a blood alcohol level from a patient at the request of the police following a driving accident:
a. When pt is dead
b. Police subpoena
c. Police search warrant
d. When pt arrested”

Answer 41

“C) Police search warrant

"”Unless required by law (including a legislative provision, search warrant, or other court order) or given consent by the patient, a physician cannot be required to perform an invasive service on a patient (such as taking blood from a suspected impaired driver for the purpose of confirming his or her blood alcohol content) or to provide any other information or evidence about a patient.”” [CMPA]

"”a subpoena is generally not sufficient authority for you to release records without the patient’s consent before appearing in court”” [CMPA]
“

Question 42

“22. What has been shown to reduce physician burn out, increase capacity to relate to patients etc (2013)
a. Physician assistance program
b. CBT
c. IPT
d. Mindful communication program”

Answer 42

“D) Mindful communication program

Recommended specifically to reduce burnout.

A) FALSE
B) FALSE
C) FALSE
D) TRUE”

Question 43

“26. You are a locum covering for an outpatient psychiatrist, and you are coming to the end of your 6 month assignment. What is the most important thing to do upon transfer of care?
A) Ensure follow up appointment have been made for each patient
B) Discuss transfer of care with the patients
C) Follow up on outstanding investigations
D) Ensure that you have comprehensive documentation. Other version: Give comprehensive information to psychiatrist”

Answer 43

“26. You are a locum covering for an outpatient psychiatrist, and you are coming to the end of your 6 month assignment. What is the most important thing to do upon transfer of care?
A) Ensure follow up appointment have been made for each patient
B) Discuss transfer of care with the patients
C) Follow up on outstanding investigations
D) Ensure that you have comprehensive documentation. Other version: Give comprehensive information to psychiatrist”

Question 44

“38- Who do you report to about a physician with MCI (no longer practicing) who flies a private plane?
a. Transport Canada
b. Transport ministry of every province
c. Transport ministry of their province
d. Royal College”

Answer 44

“A) Transport Canada

Need to contact Regional Aviation Medical Officer (RAMO)

https://www.tc.gc.ca/eng/civilaviation/publications/tp185-4-06-medical-740.htm”

Question 45

“40. A man presents with advanced prostate cancer and is asking for MAID. The nurses tells him that he may not be eligible and he reacts by saying that he will kill himself instead. What is next thing you assess?
A) Suicide risk assessment
B) Depression assessment
C) Assess capacity for MAID”

Answer 45

“A) Suicide risk assessment = TRUE

Safety first

A) TRUE.
B) FALSE – assess safety first and then determine underlying comorbidity
C) FALSE - Need to assess safety first. Then potentially capacity assessment for MAID if requested by MRP given that there is already doubt that he would fit criteria.
““Psychiatrists who assess eligibility for MAiD are
expected to be rigorous in conducting capacity
assessments and identifying symptoms of mental
disorder that are likely to affect decision-making”” – Assesment for depression/ neurocog & psychotic features will be done as part of the capacity assessment

”

Question 46

“46. Who qualifies for MAID according to bill C14
a. End stage CHF and mod to severe depression
b. Recent diagnosis of ALS, not symptomatic but wants to avoid existential concerns of dying
c. Guy who came from France with his family who has French health insurance, with terminal cancer
d. Someone with terminal cancer who requested MAID 10 days prior and is now confused”

Answer 46

“A) End stage CHF and mod to severe depression

Grievous, irremediable. Existing treatments/life quality unacceptable.

A) TRUE
B) FALSE. Just a dx, not sx.
C) FALSE. Need to be eligible for govt-funded healthcare.
D) FALSE. Now confused tho. Capacity an issue.

PHSA:
Who is eligible to receive MAiD?
Persons who meet all of the following criteria:

Are at least 18 years of age, and eligible for publicly-funded health services in Canada.
Voluntarily request MAiD without coercion or influence.
Provide informed consent to receive MAiD (the person must have the mental capability to provide informed consent, including at the time of taking the drug. Capability is determined by one or more of the health care providers involved).
Have a grievous and irremediable medical condition (in other words, a serious illness, disease or disability).
That illness,disease or disability is in an advanced state of decline and irreversible with natural death being reasonably foreseeable. [FORSEEABLE NO LONGER TRUE]
Have intolerable suffering (note that the patient has no obligation to accept unwanted services or treatment).”

Question 47

“72. Lady (30ish) with fibromyalgia and depression, on escitalopram. Also prescribed oxycodone by her family doctor. She informs you she will be running out of oxycodone early and is feeling anxious. What should you do? You are treating her for MDD w/ citalopram
A) Provide oxycodone prescription for a few days
B) Collaborate w/ family doctor about starting buprenorphine
C) Switch from escitalopram to duloxetine for better pain control
D) Clonazepam for anxiety

Other versions say she is crushing her oxys”

Answer 47

“B) Collaborate

Seems like B is best answer, especially if she is crushing her oxys
Why would you not collaborate…
Buprenorphine good for pain. And opioids prob not best for her pain anyway

A) FALSE. Should not write a short opioid script without checking for diverting etc.
B) TRUE
C) FALSE. TCA- Amitryptyline would be first choice instead of SNRI. Although this isn’t ““unreasonable””, duloxetine is an effective alternative to TCA.
D) FALSE. Bad idea. Also mixing opioids and benzos
“

Question 48

“92- Collaborative care. What is true?
a. Co-location was not important.
b. Systematic f/u not important.
c. No need for special preparation.
d. Collaboration alone will not lead to changes in fm md knowledge.”

Answer 48

“A) Co-location was not important = TRUE

A) TRUE. Can do distance (phone, telecon)
B) FALSE. Need follow-up.
C) FALSE. Should meet together before seeing pt.
D) FALSE. Encourage additional education, though FAMMD will learn something”

Question 49

“94) you find yourself really fond of a patient, you make sure you look extra attractive for your sessions and now you are extending them an extra 15 minutes Best thing to do? His symptoms have not improved.
a) consult with a colleague
b) transfer to another psychiatrist
c) disclose your feelings to the patient
d) document how you feel about the patient in the chart”

Answer 49

“A) Consult with a colleague

A) TRUE
B) FALSE. Can’t just transfer everyone you find hot. Bad care for patient.
C) FALSE
D) FALSE”

Question 50

“11. Testamentary capacity requires all of the following except:
a. Knowledge of assets
b. Knowledge of debts
c. Knowledge of natural beneficiaries
d. Statement of who you are bequeathing assets to

different version has:
a. Knowledge of assets
b. Knowledge of debts
c. Knowledge of natural beneficiaries
d. Knowledge of proposed distribution of assets”

Answer 50

“B19’s answer
B) Knowledge of debts (FALSE)

Testamentary capacity (making a will)
1) Understand nature of act of making a will + its consequence
2) Understand extent of one’s assets
3) Appreciate what the beneficiaries will receive
4) Understand the impact of distributing the assets of the estate
5) Free of any disorder of mind/delusions influence decision
[Gosselin lecture, https://www.donnellgroup.ca/resources/estate-litigation-articles/testamentary-capacity-canada.html]

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B:
Toss up between knowledge of debts and knowledge of natural beneficiaries.

[https://macleanfamilylaw.ca/2018/07/23/what-is-bc-testamentary-capacity/]
Particular to BC, testamentary capacity means…
Understand that the Will has the effect of distributing his property at the time of his death;
Be capable of remembering generally what property is subject to distribution by Will;
Be capable of remembering those persons related to him; and
Be capable of expressing an intelligent scheme of distribution.

"”generally what property is subject to distribution”” implies having a knowledge of assets, but also might imply debts. If you die, your debts are first paid off prior to your assets being distributed to your beneficiaries.

However, I think ““knowledge of debts”” is still probably best answer”

Question 51

“111. A man which schizophrenia is undergoing assessment for NCR after commiting a crime. What is the most important in determining NCR?
A) Severity of symptoms
B) Whether he needs treatment
C) Mental state at time of incident D) Presence of a major mental disorder
E) Not knowing the victim”

Answer 51

“C) Mental state at time of incident

Section 16 CCC
““No person is criminally responsible for an act committed or an omission made while suffering from a mental disorder that rendered the person incapable of appreciating the nature and quality of the act or omission or of knowing that it was wrong””

Mental disorder: ““any illness, disorder or abnormal condition which impairs the human mind and its functioning, excluding however, self-induced states caused by alcohol or drugs, as well as transitory mental states such as hysteria or concussion” (R v. Cooper, 1980)”

Question 52

“35- Bill C-14 from 2014. Who does it apply to?
a. Patient NCR
b. Dangerous offenders
c. Committed patients
d. unfit to stand trial”

Answer 52

“A) NCR

Bill C-14:
Amendment to Criminal code in July 2014
– Clarifies “significant risk”
– Dispositions codified as “necessary and appropriate in the circumstances” (same as old “least onerous and least restrictive” standard)
– High risk designation for NCR
* Can only have detention order
* Limited community access
* Extends mandatory hearings to q 36 mo vs current 12
mo

OR2020, slide 38”

Question 53

“35. You are treating a patient who is under the Review Board after being determined NCR for attacking wife. He has schizophrenia and alcohol use disorder. He describes ““hetero-aggressive”” thoughts towards his roommate and explains that he believes his roommate is poisoning him. You are admitting him involuntarily. What is the most important next step?
A) treat the alcohol use disorder
B) blood work for clozapine start
C) Inform the potential victim
D) Contact the Review Board”

Answer 53

“A vs D

There is debate in the group, but we settled on D.

A) Patient potentially at risk of alcohol WD. Duty toward patient is foremost and needs to remain safe under our watch. However ““treat alcohol use d/o”” a bit a of a strong and vague term – if it would be ““assess risk of withdrawal and treat accordingly”” would be the answer for sure. This one seems a bit more longitudinal and less of the most urgent answer. There is nothing else in the stem suggesting patient is withdrawing.

B) Not necessarily the most important next step. Probably need to assess first medication compliance, response to previous trt, etc.

C) Not needed at this point given that patient is removed from the roomate and roomate is not currently at imminent risk. Duty to protect is in place given that patient is in hospital.

D) Seems most appropriate. but we wouldn’t consider this necessarily the ““most important next step”” as patient is cared for in a designated facility currently – if something more urgent - do this thing first. With information provided it would be our choice. “

Question 54

“108. Calculate specificity of a diagnostic test…cannot recall specific #’s 250 patients test negative & do not have dx. Total of 275.
a. 0.91
b. 0.98

Here is an example question with numbers:
400 pts are given a novel depression screening questionnaire. Of the 200 pts who actually have MDD, 40 of them screen positive. Of the 200 pts who do not have MDD, 20 of them screen positive. What is the specificity? “

Answer 54

“See different version.

Answer to example question:
specificity = TN/(FP+TN) = 180/(20+180) = 0.9”

Question 55

“109. Study examining link between SSRIs and fracture risk. 100 on SSRI and 100 on placebo. 10 patients in SSRI group had fracture versus 5 patients in control group with fracture. What is the relative risk?
a. 0.5
b. 1
c. 2
d. 0.05”

Answer 55

“2

(10/100)/(5/100)=2”

Question 56

“117. You are conducting a study to see the prevalence of a factor among a certain disease. 75/100 cases of self harm had trauma. 25/100 non-cases (no self harm) also had trauma. What is the odds ratio?
A) 0.33
B) 0.9
C) 3
D) 9”

Answer 56

“d) 9

BE CAREFUL, need to pay attention to what is outcome and what is exposure. Easy to get confused and put 3.

2x2:
+outcome (SH) - outcome (no SH)
EXPOSURE (trauma) a b
NO EXPOSURE (nil) c d

a = 75
b = 25
c = 25
d = 75

OR
= (a/c) / (b/d)
= ad / cb
= 7575 / 2525
= 9”

Question 57

“76. In clinical trials:
a. A large enough population can demonstrate statistical but not clinical significance
b. Randomization will decrease both systematic and selection bias
c. Efficacy studies have better applicability than effectiveness for real world
d. Parametric data are not valuable statistically and they are not used in meta-analysis”

Answer 57

“A) Large samples may detect small statistically significant differences that may not be clinically relevant = TRUE

A) FALSE. Randomization avoids CONFOUNDING biase, not selection or systemic bias.
B) TRUE
C) FALSE. Effectiveness studies have better applicability for real world.
D) FALSE. Parametric data is normal distribution data (height, weight, levels). Non-parametric data doesn’t follow normal distribution (PANSS, PHQ-9, etc). Both are valuable statistically and used in meta-analysis.”

Question 58

“77) what is true about the cross over study design?
a) it is a repeated measures design
b) more bias with each cross over
c) carry over effects
d) increases confounding factors”

Answer 58

“TR and LR said C is best answer.

shitty question.

A and C = TRUE

A) TRUE - https://blog.minitab.com/blog/adventures-in-statistics-2/repeated-measures-designs-benefits-challenges-and-an-anova-example

B) ? Depends what kind of bias
C) TRUE
D) FALSE. Reduces confounding factors (excluding confounding carry over effects).”