Mitchell, SL. (2015) Advanced Dementia. NEJM 2015; 372:2533-2540
Question 1
What is the MOST common clinical complication in a patient with advanced dementia?
(A) Urinary and faecal incontinence
(B) Physical agression
(C) febrile episodes
(D) eating problems
(E) pneumonia
D: In the CASCADE study, which prospectively followed 323 nursing home residents with advanced dementia for 18 months, the median survival was 1.3 years. The most common clinical complication were eating problems (86%), febrile episodes (53%) and pneumonia (41%)
Question 2
With regards to oro-pharyngeal dysphagia and the institution of tube feeding, what is FALSE
(A) Tube feeding helps meet nutritional requirements and can shorten the time to healing of pressure ulcers
(B) Tube feeding is not associated with increased comfort and positive satisfaction scores
(C) Tube feeding does not provide a benefit in terms of life prolongation
(D) Tube feeding provides no advantage in nutriontal indices
(E) Tube feeding does NOT provide a decreased risk of aspiration
A: tube feeding provides no nutritional advantage in the patient with advanced dementia and does not shorten the time to healing of pressure ulcers.
Question 3
With regards to infections in patents with advanced dementia, what is TRUE
(A) The route of administration of antibiotics in patients with advanced dementia is significantly associated with survival
(B) There is an 80% chance of death in a patient with advanced pneumonia who is hospitalised
(C) Mental state change in a patient with a urine culture growing E. Coli is NOT a strong indication to initiate antibiotic treatment
(D) Infections are the second most frequent cause of hospitalisation, just behind feeding problems
(E) Patients with advanced dementia and pneumonia who were treated with antibiotics DO NOT live longer than those not treated with antibiotics
C: According to NEJM review. Interestingly, the route of antibiotic administration makes minimal difference. The mortality assoicated with hospitalisation for pneumonia in a patient with advanced demential is 50%. Infections are the most common cause of hospitalisations, accounting for 75% of all in patient admissions. Intuitively and according to the CASCADE study, patients treated with antibiotics live longer (273 more days), but this is associated with more symptomatic discomfort.
Question 4
Successful ageing is associated most highly with which of the following factors
(A) self-rated physical health
(B) self-rated mental health
(C) lack of mental illness
(D) strong social support
(E) life satisfaction
A: According to JAGS 2011; 59(11):2077-2083. Interestingly social contract support is most strongly associated with friends support (0.91) compared to family support (0.25).
Question 5
Which of the following mid-life factors is most closely associated with the development of diabetes in later life?
(A) Hypertension
(B) Dyslipidaemia
(C) Smoking
(D) Physical inactivity
(E) Diabetes
E: According to Neurology 2005; 64(2): 277--281. Cox proportional hazards when adjusted for confounders are hypertension = 1.24, diabetes = 1.46, dyslipidaemia = 1.42, smoking = 1.26
Question 6
What is a good estimate for the number of Australians living with dementia?
(A) 100 000
(B) 200 000
(C) 250 000
(D) 500 000
(E) 1 000 000
C: According to the Victorian Geriatric Medicine Training Program
Question 7
With regards to prevalence of dementia in age groups, what is FALSE
(A) 25 - 40 yo, 0.1%
(B) 65 - 74 yo, 1.2%
(C) 75 - 84 yo, 6.0%
(D) 85 - 100, 23.4%
(E) 100 - 105, 95%
E: According to the Victorian Geriatric Medicine Training Program
Question 8:
Which of the following is NOT associated with a comprehensive geriatric assessment?
(A) Increased living at home at 6 months
(B) Decreased living in residential care
(C) Decreased death or functional care
(D) Increased cognition
(E) Decreased risk of conversion of mild cognitive impairment to alzheimers dementia
E: According to Ellis 2011, BMJ. Increased living at home at 6 months (OR 1.25; CI 1.11-1.42), Decreased living in residual care (OR 0.78; CI 0.69—0.88), Decreased death or functional care (OR 0.76, CI 0.64-0.90) and Increased cognition: std mean diff 0.08 (CI 0.01 to 0.15)
Question 9
With regards to the variants of frontotemporal dementia, what is FALSE
(A) Behavioural variant is associated with a tauopathy
(B) Semantic variant is associated with difficulty remembering words, using wrong words, impaired word comprehension and elevated TDP43
(C) Predominant non-fluent aphasia is associated with a tauopathy
(D) Semantic dementia has a component of profound anterograde amnesia
(E) Progressive non-fluent aphasia variant is associated with memory problems limited to verbal memory
D: RPA course 2015
Question 10
What is TRUE regarding the use of acetylcholinesterase inhibitors in the treatment of mild to moderate dementia?
(A) They may cause bradycardia and diarrhoea
(B) They are NOT associated with improvement in neurocognitive performance
(C) They decrease the rate of admissions to residential aged care facilities
(D) They increase quality of life scores
(E) They improve activities of daily living
A: Cholinergic side-effects. All the others are false. (Victorian Geriatric Medicine Training Program)
Question 11
Which of the following is the most effective in reducing the risk of falling in community-dwelling older persons?
(A) Exercise programs
(B) Multifactorial interventions
(C) Vitamin D supplements
(D) Interventions to improve home safety
(E) Reducing medications that increase the risk of falling
A. However in hospitalised or institutionalised individuals, multifactorial interventions is the answer. Furthermore vitamin D supplementation is effective in reducing rate of falls in nursing care facilities
Question 12
Which of the following drugs is most likely to cause falls in older persons
(A) benzodiazepines
(B) antidepressants
(C) antipsychotics
(D) anti-arrhythmics
(E) beta - blockers
B: According to Clin Geriatr Med 2010; 26:583-605
Question 13
Which of the following tests is a validated risk predictor for falling in older adults
(A) The timed up and go test
(B) Barthels index
(C) Addenbrookes
(D) MMSE
(E) RUDAS
A: >10s discriminates fallers from non fallers. Functional reach test is another test that can be used.
Question 14
Which of the following is the GREATEST individual visual risk factor for falling
(A) decreased visual acuity
(B) impaired depth perception
(C) decreased glare sensitivity
(D) decreased dark adaptation
(E) decreased contrast sensitivity
B: According to PEP 2014. All the others are impaired with ageing
Question 15
Which if the following is most highly correlated with institutionalisation following hospitalisation?
(A) Incontinence
(B) Delirium
(C) Age >95
(D) Dementia
(E) Being female
D: Dementia (OR 6.15), Age > 95 (OR 5.58). J Gerontol A Biol Sci Med Sci 2011 66A(12): 1321-1327
Question 16
Which of the following subsets of delirium is associated with worser outcomes?
(A) Frontal
(B) hypoactive
(C) hyperactive
(D) mixed
(E) variant
B. Option A and E are made up. Hypoactive delirium is probably worse because it goes more often unnoticed.
Question 17
What is FALSE about hepatic clearance AND ageing
(A) Decreased hepatic blood flow by 40 - 50%, which is significant for drugs with high extraction ratios
(B) Decreases hepatic mass by 30%
(C) Decreases phase 1 CYP450 oxidative metabolism (e.g. benzodiazepines)
(D) Decreases phase 2 metabolism more than phase 1 metabolism
(E) Leads to a markedly increased rate of lactic acidosis
D. Often Phase 2 hepatic clearance is in tact. RPA lecture 2014. The preferred benzodiazepine in older adults include oxazepam, temazepam and lorazepam because they undergo phase 2 conjugation as their hepatic elimination mechanism, compared to diazepam that is hydrolysed by the CYP 450 enzyme system. Other pharmacokinetic changes include the increased volume of distribution of lipophilic drugs secondary to the increased proportion of fat compared to lean body weight
Question 18
In 2014, the average life expectancy for an Australian male is?
(A) 78
(B) 84
(C) 87
(D) 89
(E) 91
C: For a male it is 84 years old, according to the AIHW.
Question 19
What is TRUE about the impact of an orthogeriatric service in acute hospitals in New South Wales?
(A) It decreases the rates of falls
(B) It increases the rates of polypharmacy
(C) It decreases opioid prescribing rates
(D) It decreases total length of stay
(E) It decreases 30 day mortality in patients admitted with hip fractures
E. Med J Aust 2014; 201 (7): 409-411. According to this paper, a retrospective study in public hospitals throughout new south wales showed a decreased total 30 day mortality associated with the use of an orthogeriatric service, however at the expense of an increased length of stay. The other parameters in the question were not studied.
Question 20
What is TRUE about the prevalence of dementia in the northern territory?
(A) Vascular dementia was much higher in proportion compared to alzheimers dementia in Indigenous populations
(B) Variant CJD was markedly higher amongst indigenous males compared to non indigenous females
(C) Frontotemporal dementia was higher month indigenous men than indigenous females
(D) Alzheimers dementia rates were paradoxically higher in caucasian populations compared to indigenous populations
(E) The prevalence of Dementia is higher amongst Indigenous populations compared to non-indigenous populations
E: MJA 2015
Question 21
What is the highest risk factor for delirium
(A) Depression
(B) Pre-existing cognitive impairment
(C) Hearing impairment
(D) Visual impairment
(E) Polypharmacy
B: PEP notes 2014. All the others are also risk factors
Question 22
Comparing Alzheimers dementia to Lewy Body dementia, what is FALSE
(A) Lewy body dementia is associated with higher care-giver stress
(B) Lewy body dementia has a lower mortality rate
(C) Lewy body dementia is associated with higher morbidity
(D) Lewy body dementia is an alpha-synucleopathy
(E) Lewy body dementia has lower quality of life scores
B: According to Internal Medicine Journal 2014 vol 44 1066
Question 23
With regards to neuroimaging and lewy body dementia, what is TRUE?
(A) Relative sparing of the mesial temporal lobes
(B) Relative sparing of the lateral temporal roles
(C) Widespread cerebral atrophy
(D) Hummingbird sign
(E) Empty delta sign
A: There is less atrophy compared to Alzheimers dementia. There is relative sparting of the mesial temporal lobes. LBD is generally considered a disease of synaptic dysfunction compared to axonal loss. Internal Medicine Journal 2014 vol 44 1066
Question 24
A 84 year old with prominent visual hallucinations, orthostatic hypotension, bradykinesia and rigidity presents with worsening psychiatric symptoms including delusions. What medications should be trialled as first line therapy?
(A) Atypical antipsychotics
(B) Typical antipsychotics
(C) Cholinesterases inhibitors
(D) Anti-depressants
(E) Anti-hypertensives
C: Cholinesterase inhibitors form the mainstay of treatment of xognitive and psychiatric symptoms in treatment of cognitive and psychiatric symptoms in DLB. Benefits have been reported in cognitive fluctuations, psychiatric symptoms, delusions, hallucinations and sleep disturbances. The anticholinesterases such as rivostigmine and donepezil are also used in alzheimers dementia where they help with symptoms of cognitive function, global outcome and activities of daily living but they do not slow progression. Around 40 - 50% of AD patients benefit. For PBS prescription, the MMSE score must be greater than 10 AND there must be a demonstrable increase in QOL or cognitive performance or behavioural symptoms. Internal Medicine Journal 2014 vol 44 1066, PBS.gov.au
Question 25
Heat stroke in elderly adults occurs due to derrangement in what physiological process?
(A) Decreased sweating
(B) Increased peripheral vasoconstriction
(C) Decreased peripheral vasoconstriction
(D) Decreased thirst response
(E) Increased insensible losses
A: Clin Geriatr Med 1993 Aug; 9(3): 621-639
