Mock Geriatrics Module 2

A 74-year-old man is brought in by his wife because of a 10-month history of progressive cognitive decline.

She reports that his level of alertness fluctuates markedly from day to day, and that on several occasions he has described seeing small children playing in the lounge room who are not there.

He acts out his dreams, occasionally striking his wife during sleep.

On examination there is mild bradykinesia and a symmetrical resting tremor that developed over the past few months.

His MMSE is 24/30, with prominent deficits in attention and visuospatial tasks but relatively preserved recall.

His investigations reveal:

Full blood count, electrolytes, renal function, liver function, TSH (0.4–4.0 mIU/L): all normal
B12 (>180 pmol/L) and folate: normal
CT brain: mild generalised atrophy, no acute changes
Delirium screen negative

Which of the following is the most likely diagnosis?

Dementia due to Lewy body disease

Correct Incorrect Correct answer

Alzheimer disease dementia

Correct Incorrect Correct answer

Parkinson disease dementia

Correct Incorrect Correct answer

Vascular dementia

Correct Incorrect Correct answer

Delirium superimposed on dementia

Correct Incorrect Correct answer

An 87-year-old woman is assessed following an 18-month history of slowly progressive memory loss.

Her family report she repeats questions and misplaces items, but her language, executive function and personality are well preserved. She has no history of stroke, hallucinations or parkinsonism.

Her MMSE is 22/30 with a predominant amnestic deficit.

Investigations reveal:

Routine bloods including B12, folate, TSH: normal
MRI brain: marked hippocampal atrophy, notably asymmetric (more prominent on the right); no significant white matter disease or infarcts
Amyloid PET: negative for significant amyloid deposition

Which of the following pathological processes best explains her presentation?

Limbic-predominant age-related TDP-43 encephalopathy

Correct Incorrect Correct answer

Alzheimer disease neuropathological changes (amyloid and tau)

Correct Incorrect Correct answer

Cortical Lewy body pathology (α-synuclein)

Correct Incorrect Correct answer

Cerebral small vessel disease

Correct Incorrect Correct answer

Chronic traumatic encephalopathy

Correct Incorrect Correct answer

A geriatrician is reviewing community-based clinicopathological data to counsel a family about the likely contributors to their 89-year-old relative’s dementia.

She explains that in careful community-based neuropathological studies, most people with dementia have more than one contributing pathology, and that the association between Alzheimer pathology and clinical dementia declines with advancing age.

Based on the attributable-risk analysis from the Rush University clinicopathological studies, which single neuropathological process carries the largest attributable fraction for dementia?

Alzheimer disease neuropathological changes (amyloid and tau)

Correct Incorrect Correct answer

Vascular disease pathology

Correct Incorrect Correct answer

Limbic-predominant age-related TDP-43 encephalopathy neuropathological changes

Correct Incorrect Correct answer

α-Synucleinopathy / Lewy body pathology

Correct Incorrect Correct answer

Chronic traumatic encephalopathy

Correct Incorrect Correct answer

A 79-year-old man with poorly controlled hypertension, type 2 diabetes and prior transient ischaemic attacks presents with cognitive decline described by his wife as occurring in “steps” — periods of stability punctuated by abrupt worsening.

His main difficulties are slowed thinking, poor attention and impaired planning; his memory recall is comparatively preserved.

Examination reveals a mildly wide-based gait and brisk reflexes.

Investigations:

HbA1c 8.9% (target <7.0% / 53 mmol/mol)
LDL cholesterol 3.4 mmol/L
MRI brain: confluent periventricular white matter hyperintensities, multiple lacunes and several cerebral microbleeds; no cortical infarct

Which of the following statements regarding this patient’s most likely diagnosis is correct?

Median survival is shorter than for Alzheimer disease, approximately 3–5 years

Correct Incorrect Correct answer

Memory impairment is characteristically the earliest and most prominent deficit

Correct Incorrect Correct answer

Median survival is typically longer than for Alzheimer disease dementia

Correct Incorrect Correct answer

Pure vascular dementia accounts for the majority of all dementia at autopsy

Correct Incorrect Correct answer

Memantine has a clinically significant benefit on cognition in this condition

Correct Incorrect Correct answer

A 61-year-old man is brought in by his family because of striking personality change over two years.

Previously a fastidious accountant, he has become disinhibited, making inappropriate sexual comments in public, has developed apathy and lost empathy for his grandchildren, and has begun compulsively eating sweet foods.

His family note he seems unconcerned by his behaviour.

On formal testing, memory and visuospatial function are relatively preserved but he performs poorly on tasks of executive function.

Investigations:

Routine bloods, B12, folate, TSH: normal
MRI brain: asymmetric atrophy of the frontal and anterior temporal lobes
FDG-PET: frontotemporal hypometabolism

Which of the following is the most likely diagnosis?

Behavioural variant frontotemporal dementia

Correct Incorrect Correct answer

Alzheimer disease dementia

Correct Incorrect Correct answer

Semantic variant primary progressive aphasia

Correct Incorrect Correct answer

Dementia due to Lewy body disease

Correct Incorrect Correct answer

Pseudodementia due to major depression

Correct Incorrect Correct answer

A 72-year-old woman with mild cognitive impairment due to confirmed Alzheimer pathology (amyloid PET positive) commenced donanemab infusions eight weeks ago.

She presents to the emergency department with acute right-sided weakness and dysphasia. The treating team is considering intravenous thrombolysis for presumed acute ischaemic stroke.

Investigations:

MRI brain: patchy vasogenic oedema in the left parieto-occipital region with several new microhaemorrhages; no large vessel occlusion.

Which of the following is the most appropriate next step regarding this patient’s management?

Withhold thrombolytic and antithrombotic therapy

Correct Incorrect Correct answer

Proceed immediately with intravenous thrombolysis

Correct Incorrect Correct answer

Continue donanemab at the current dose without interruption

Correct Incorrect Correct answer

Commence therapeutic anticoagulation for presumed cardioembolic stroke

Correct Incorrect Correct answer

Start high-dose aspirin and clopidogrel dual antiplatelet therapy

Correct Incorrect Correct answer

A 68-year-old man with mild cognitive impairment attributed to Alzheimer pathology is keen to commence donanemab after reading media reports.

His baseline MMSE is 26/30. Genetic testing reveals he is homozygous for the ApoE ε4 allele.

Baseline MRI shows no significant white matter disease and no prior haemorrhage.

Investigations:

Amyloid PET: positive
MMSE 26/30
ApoE genotype: ε4/ε4 (homozygous)

Which factor in this patient most strongly argues against commencing donanemab?

Homozygosity for ApoE ε4

Correct Incorrect Correct answer

His MMSE of 26/30

Correct Incorrect Correct answer

The positive amyloid PET scan

Correct Incorrect Correct answer

Absence of white matter disease on MRI

Correct Incorrect Correct answer

His age of 68 years

Correct Incorrect Correct answer

An 82-year-old woman with moderate Alzheimer dementia in residential aged care has become increasingly agitated and physically aggressive towards staff over three weeks, striking out during personal care.

Non-pharmacological strategies including person-centred care approaches and environmental modification have been trialled without adequate response, and her behaviour is now causing significant distress and risk to herself and others.

Reversible precipitants including pain, infection, constipation and delirium have been excluded.

Investigations:

Urinalysis, FBC, CRP, electrolytes: normal
No new focal neurology

Which of the following pharmacological agents has the strongest evidence base for this indication and would be most appropriate?

Risperidone

Correct Incorrect Correct answer

Diazepam

Correct Incorrect Correct answer

Donepezil

Correct Incorrect Correct answer

Sertraline

Correct Incorrect Correct answer

Sodium valproate

Correct Incorrect Correct answer

A 78-year-old man with no prior diagnosis of cognitive impairment is admitted following a fractured neck of femur.

Postoperatively he develops an acute, fluctuating confusional state with inattention and altered consciousness, diagnosed as delirium, which resolves over several days.

His daughter asks whether this episode has any long-term implications for his brain health.

Which of the following statements is most accurate regarding the relationship between delirium and long-term cognitive outcomes?

Delirium is associated with accelerated long-term cognitive decline

Correct Incorrect Correct answer

Delirium has no demonstrated effect on subsequent cognitive trajectory

Correct Incorrect Correct answer

Delirium reliably improves long-term cognition once resolved

Correct Incorrect Correct answer

Delirium only affects cognition in patients with pre-existing dementia

Correct Incorrect Correct answer

Delirium is exclusively a consequence, never a contributor, to cognitive decline

Correct Incorrect Correct answer

A 55-year-old man attends for a health review. He is anxious about dementia, as his father developed Alzheimer disease.

He has a 30 pack-year smoking history, poorly controlled hypertension, type 2 diabetes, a BMI of 33 kg/m², untreated bilateral hearing loss, and drinks 30 standard drinks per week.

He asks what he can do to reduce his risk.

Investigations:

Blood pressure 158/96 mmHg
HbA1c 8.2% (target <7.0% / 53 mmol/mol)
LDL cholesterol 4.1 mmol/L
Audiometry: moderate bilateral sensorineural hearing loss

Which of the following interventions targets a recognised modifiable risk factor and would contribute to reducing his future dementia risk?

Correction of hearing loss with hearing aids

Correct Incorrect Correct answer

Routine population screening with amyloid PET

Correct Incorrect Correct answer

Commencing a cholinesterase inhibitor prophylactically

Correct Incorrect Correct answer

Commencing memantine prophylactically

Correct Incorrect Correct answer

Routine cerebrospinal fluid amyloid-β measurement

Correct Incorrect Correct answer

A 58-year-old male company director is brought in by his wife, who reports that over the preceding 18 months he has become increasingly disinhibited, making inappropriate sexual comments to colleagues and losing his job as a result.

He has developed a marked craving for sweet foods, gaining 12 kg, and shows striking apathy toward his family. He is unconcerned about his behaviour.

On examination, higher cognitive testing reveals relatively preserved memory and visuospatial function, but he performs poorly on tasks requiring planning and mental flexibility. Neurological examination is otherwise unremarkable.

Investigations:

MMSE 27/30 (reference ≥27 normal)
Routine bloods including TSH, B12, folate, and syphilis serology: normal
MRI brain: bilateral frontal and anterior temporal lobe atrophy, right greater than left
CSF: normal cell count, protein and glucose

Which of the following is the most likely underlying molecular pathology?

TDP-43 inclusions

Correct Incorrect Correct answer

Beta-amyloid plaques and neurofibrillary tau tangles

Correct Incorrect Correct answer

Alpha-synuclein Lewy bodies

Correct Incorrect Correct answer

Polyglutamine (CAG) repeat expansion product

Correct Incorrect Correct answer

Prion protein (PrPSc) accumulation

Correct Incorrect Correct answer

A 42-year-old woman presents with a 2-year history of progressive short-term memory loss and difficulty managing finances.

Her father developed similar symptoms at age 44 and died at 55; a paternal uncle was similarly affected in his 40s.

On examination she scores poorly on delayed recall and orientation. Neurological examination is normal.

Investigations:

MMSE 21/30
Routine bloods, TSH, B12: normal
MRI brain: bilateral hippocampal and medial temporal atrophy
CSF: reduced amyloid-beta 42, elevated total tau and phosphorylated tau

Which of the following genes, when mutated, is the most common cause of this autosomal dominant condition?

PSEN1 (presenilin 1)

Correct Incorrect Correct answer

APP (amyloid precursor protein)

Correct Incorrect Correct answer

PSEN2 (presenilin 2)

Correct Incorrect Correct answer

APOE ε4

Correct Incorrect Correct answer

MAPT (microtubule-associated protein tau)

Correct Incorrect Correct answer

A 60-year-old man is admitted with a 10-week history of rapidly progressive cognitive decline.

His wife reports memory failure, visual disturbance and, more recently, jerking movements of the limbs and an unsteady gait.

On examination there is myoclonus provoked by startle, cerebellar ataxia and a fluctuating level of alertness.

Investigations:

Routine bloods, TSH, B12, autoimmune encephalitis antibody panel: normal/negative
MRI brain (DWI): cortical ribboning and increased signal in the basal ganglia
EEG: periodic sharp wave complexes
CSF: elevated 14-3-3 protein and positive RT-QuIC assay

Which of the following is the most appropriate next step in management?

Institute infection control precautions and provide supportive palliative care

Correct Incorrect Correct answer

Commence high-dose intravenous methylprednisolone

Correct Incorrect Correct answer

Commence a cholinesterase inhibitor

Correct Incorrect Correct answer

Commence intravenous aciclovir empirically

Correct Incorrect Correct answer

Arrange urgent CT chest/abdomen/pelvis to search for underlying malignancy

Correct Incorrect Correct answer

A 24-year-old woman is brought to hospital with a 3-week history of subacute personality change, memory disturbance and psychosis initially attributed to a primary psychiatric disorder.

Over the following days she develops orofacial dyskinesias, autonomic instability with fluctuating blood pressure, and a generalised seizure.

Investigations:

Routine bloods, TSH, B12: normal
MRI brain: subtle medial temporal T2/FLAIR hyperintensity
EEG: diffuse slowing with an “extreme delta brush” pattern
CSF: lymphocytic pleocytosis (30 x10⁶/L; reference <5), positive anti-NMDA receptor antibodies
Pelvic ultrasound: a 4 cm complex ovarian mass

Which of the following is the most appropriate initial treatment strategy?

First-line immunotherapy (corticosteroids, IVIg or plasma exchange) plus resection of the ovarian teratoma

Correct Incorrect Correct answer

Cholinesterase inhibitor and long-term antipsychotic therapy

Correct Incorrect Correct answer

Whole-brain radiotherapy

Correct Incorrect Correct answer

Lifelong antiepileptic monotherapy alone

Correct Incorrect Correct answer

Rituximab monotherapy with no further intervention

Correct Incorrect Correct answer

A 40-year-old man presents with a 2-year history of involuntary movements, irritability, and difficulty organising tasks at work. His mother developed similar symptoms at 45 and died in a nursing home at 58.

On examination he has chorea affecting the face and limbs, impaired saccadic eye movements, and executive dysfunction on cognitive testing.

Investigations:

Routine bloods, TSH, B12, copper studies: normal
MRI brain: caudate atrophy with enlargement of the frontal horns of the lateral ventricles
Genetic testing: CAG repeat expansion of 44 in the HTT gene

The patient has two asymptomatic adult children who ask about being tested.

Which of the following statements regarding this condition and predictive testing is most accurate?

Larger CAG repeat lengths are associated with earlier age of symptom onset

Correct Incorrect Correct answer

The children have a 25% chance of inheriting the expanded allele

Correct Incorrect Correct answer

Predictive genetic testing should be offered without pre-test genetic counselling to expedite diagnosis

Correct Incorrect Correct answer

Tetrabenazine or antipsychotics can halt disease progression

Correct Incorrect Correct answer

A CAG repeat length of 44 is within the normal range and does not confer disease

Correct Incorrect Correct answer

An 84-year-old woman is admitted with community-acquired pneumonia and develops an acute confusional state on day 2.

She is inattentive, has a fluctuating conscious level and is disoriented.

As part of a research protocol, a lumbar puncture is performed. Her cerebrospinal fluid (CSF) results are:

CSF lactate: 2.4 mmol/L (reference range <2.0)
CSF neuron-specific enolase: 4.9 ng/mL (reference range <12)
CSF S100B: 610 pg/mL

An 18F-FDG PET scan performed during the acute episode is most likely to demonstrate which of the following?

Hypometabolism in the posterior cingulate cortex and thalamus

Correct Incorrect Correct answer

Increased global cerebral glucose metabolism

Correct Incorrect Correct answer

Hypermetabolism in the frontal lobes and anterior cingulate cortex

Correct Incorrect Correct answer

Symmetrical temporo-parietal hypometabolism only

Correct Incorrect Correct answer

Normal cerebral glucose metabolism

Correct Incorrect Correct answer

A 79-year-old man is admitted for elective total hip arthroplasty. On postoperative day 1 the nursing staff report he is quiet, withdrawn and drowsy but rousable.

He answers questions slowly, is unable to recite the months of the year backwards, and his attention fluctuates through the day. His observations are stable. Bloods show:

Sodium 138 mmol/L (135–145)
Urea 6.2 mmol/L (3.0–8.0)
Creatinine 88 µmol/L (60–110)
CRP 45 mg/L (<5)
Haemoglobin 118 g/L (130–180)

Which screening approach is most likely to detect this patient’s condition?

Systematic screening using a validated instrument such as the CAM

Correct Incorrect Correct answer

Mini-Mental State Examination

Correct Incorrect Correct answer

Reliance on clinician personal judgement without a validated tool

Correct Incorrect Correct answer

Glasgow Coma Scale monitoring

Correct Incorrect Correct answer

Depression screening with the Geriatric Depression Scale

Correct Incorrect Correct answer

An 82-year-old woman with a background of Alzheimer’s disease (baseline MMSE 22) is admitted from a nursing home with reduced oral intake.

Over 3 days she has become increasingly agitated, with visual hallucinations, disorientation and a marked worsening of her cognition that fluctuates hourly. Investigations show:

White cell count 14.2 × 10⁹/L (4.0–11.0)
CRP 88 mg/L (<5)
Urinalysis: leucocytes ++, nitrites positive
MMSE now 12

Which of the following best explains her acute clinical deterioration?

Delirium superimposed on dementia

Correct Incorrect Correct answer

Rapid progression of underlying Alzheimer's disease

Correct Incorrect Correct answer

New-onset dementia with Lewy bodies

Correct Incorrect Correct answer

Major depressive disorder with psychotic features

Correct Incorrect Correct answer

Transient ischaemic attack

Correct Incorrect Correct answer

An 88-year-old man is admitted with a community-acquired pneumonia. He has hearing impairment, uses reading glasses, and his baseline cognition is normal. He is at high risk of developing delirium.

His admission bloods are unremarkable apart from a CRP of 92 mg/L (<5). The team wishes to implement an evidence-based strategy to prevent delirium during his admission.

Which of the following interventions has the strongest evidence for preventing delirium in this patient?

A multicomponent non-pharmacological intervention

Correct Incorrect Correct answer

Prophylactic low-dose haloperidol

Correct Incorrect Correct answer

Prophylactic olanzapine

Correct Incorrect Correct answer

Prophylactic benzodiazepines to optimise sleep

Correct Incorrect Correct answer

Cholinesterase inhibitors

Correct Incorrect Correct answer

A 76-year-old woman is admitted with urosepsis and develops hyperactive delirium. She is agitated, pulling at her intravenous lines and attempting to climb out of bed, placing herself at risk of harm.

Non-pharmacological measures including reorientation, family presence and a calm environment have been trialled without success.

Investigations confirm a urinary tract infection, which is being treated, and there is no evidence of hypoxia, urinary retention, constipation or pain.

Which of the following statements regarding the use of antipsychotics in this setting is most accurate?

Antipsychotics should be reserved for severe distress or safety risk where non-drug measures have failed, at the lowest dose for the shortest time

Correct Incorrect Correct answer

Haloperidol reliably shortens the duration of delirium

Correct Incorrect Correct answer

Antipsychotics have been shown to reduce delirium severity compared with placebo

Correct Incorrect Correct answer

Atypical antipsychotics are clearly superior to typical antipsychotics for delirium

Correct Incorrect Correct answer

Antipsychotics reduce mortality in delirium

Correct Incorrect Correct answer

A 71-year-old man is intubated and ventilated in the intensive care unit following an emergency laparotomy for a perforated diverticulum. He is at high risk of delirium.

The intensive care team is selecting a sedative agent with the additional aim of reducing the risk of delirium. His current parameters are stable and he is haemodynamically well.

Which sedative agent is most likely to reduce the incidence of delirium?

Dexmedetomidine

Correct Incorrect Correct answer

Midazolam

Correct Incorrect Correct answer

Propofol

Correct Incorrect Correct answer

Lorazepam

Correct Incorrect Correct answer

Ketamine

Correct Incorrect Correct answer

A 90-year-old woman presents with a fractured neck of femur following a fall. She has mild cognitive impairment but no established dementia. She is in significant pain, and the orthogeriatric team wishes to implement measures to reduce her risk of postoperative delirium while awaiting surgery. Her observations are stable and bloods show a haemoglobin of 108 g/L (115–165) and normal renal function.

Which of the following interventions has demonstrated a reduction in delirium incidence, severity and duration in patients with fractured neck of femur?

Fascia iliaca compartment block

Correct Incorrect Correct answer

Intramuscular pethidine

Correct Incorrect Correct answer

Prophylactic quetiapine

Correct Incorrect Correct answer

Liberal blood transfusion threshold

Correct Incorrect Correct answer

Intrathecal morphine

Correct Incorrect Correct answer

A 78-year-old man undergoes elective major noncardiac surgery. His postoperative course is complicated by delirium on day 1. He has no other identified postoperative medical complications.

The surgical team is counselling him and his family regarding his expected recovery.

In this situation, delirium (even in the absence of other complications) is most strongly associated with which of the following?

Increased length of stay and increased institutional discharge

Correct Incorrect Correct answer

No difference in length of stay or discharge destination

Correct Incorrect Correct answer

Reduced 30-day readmission rate

Correct Incorrect Correct answer

Reduced risk of falls

Correct Incorrect Correct answer

Decreased overall adverse outcomes

Correct Incorrect Correct answer

An 87-year-old man is admitted under geriatric medicine with delirium precipitated by a lower respiratory tract infection. His baseline cognition is normal and he lives at home.

He is enrolled in a trial investigating a novel treatment aimed at addressing the cerebral glucose hypometabolism observed in delirium. He receives intranasal insulin.

His capillary blood glucose remains stable throughout treatment.

Which of the following statements regarding intranasal insulin in this context is most accurate?

It is transported along olfactory nerve fibres into the brain and reduced delirium duration and length of stay

Correct Incorrect Correct answer

It causes hypoglycaemia due to systemic absorption

Correct Incorrect Correct answer

It has been proven to reduce delirium mortality

Correct Incorrect Correct answer

It causes significant nasal mucosal damage and anosmia in most patients

Correct Incorrect Correct answer

Its benefit is mediated primarily through improved subjective sleep

Correct Incorrect Correct answer

A 85-year-old woman is admitted with delirium in the setting of a lower respiratory tract infection. She has no history of dementia. As part of a research study, she undergoes a lumbar puncture.

Her results are compared against a reference group of patients with Alzheimer’s disease.

Her CSF shows:

CSF lactate: 1.87 mmol/L (reference <2.0, but elevated relative to non-delirious controls)
CSF neuron-specific enolase (NSE): 4.84 ng/mL
CSF S100B: 604.8 pg/mL

Her admission Barthel Index has fallen substantially, and her Instrumental Activities of Daily Living (IADL) score has declined during the admission.

Which of the following statements regarding CSF lactate in this patient is most accurate?

CSF lactate correlates with delirium severity and functional decline and is associated with worse outcomes such as death or nursing home placement

Correct Incorrect Correct answer

Elevated CSF lactate reflects increased aerobic cerebral metabolism and predicts a favourable outcome

Correct Incorrect Correct answer

CSF NSE is a more reliable marker of delirium severity than CSF lactate

Correct Incorrect Correct answer

CSF S100B is significantly elevated in delirium compared with Alzheimer's disease and drives the diagnosis

Correct Incorrect Correct answer

Elevated CSF lactate is a normal finding of ageing with no prognostic significance

Correct Incorrect Correct answer

An 82-year-old woman is admitted following a fall. She lives independently and takes amlodipine, temazepam, oxybutynin, and sertraline.

Her observations show a lying blood pressure of 138/78 mmHg and a standing blood pressure of 108/60 mmHg after 3 minutes.

She reports feeling light-headed on standing.

Investigations reveal:

Sodium: 129 mmol/L (135–145)
Potassium: 4.2 mmol/L (3.5–5.2)
Creatinine: 96 µmol/L (45–90)
eGFR: 52 mL/min/1.73m²
Serum osmolality: 268 mOsm/kg (275–295)
Urine osmolality: 420 mOsm/kg
Urine sodium: 58 mmol/L

Which of the following age-related physiological changes most directly explains this patient’s increased susceptibility to adverse drug effects?

Impaired baroreceptor reflex sensitivity and reduced homeostatic reserve

Correct Incorrect Correct answer

Increased hepatic first-pass metabolism

Correct Incorrect Correct answer

Increased total body water leading to greater volume of distribution for lipophilic drugs

Correct Incorrect Correct answer

Increased renal tubular secretion of organic cations

Correct Incorrect Correct answer

Upregulation of hepatic cytochrome P450 enzyme activity

Correct Incorrect Correct answer

A 79-year-old man with Alzheimer disease was commenced on donepezil 5 months ago. Over the past 8 weeks he has developed increasing urinary urgency, frequency and urge incontinence.

His general practitioner has now prescribed oxybutynin. He is also taking perindopril and atorvastatin.

On review he is more confused than at his last visit, with a Standardised Mini-Mental State Examination score having fallen from 22 to 17.

Post-void residual bladder scan shows 40 mL. Urinalysis is negative for nitrites and leucocytes. Investigations reveal:

Creatinine: 88 µmol/L (60–110)
eGFR: 68 mL/min/1.73m²
Sodium: 138 mmol/L (135–145)
CRP: 3 mg/L (<5)

Which of the following best describes the underlying prescribing problem?

A prescribing cascade in which a cholinesterase inhibitor adverse effect was treated with an anticholinergic drug

Correct Incorrect Correct answer

Under-treatment of overactive bladder requiring dose escalation of oxybutynin

Correct Incorrect Correct answer

Progression of Alzheimer disease unrelated to medication

Correct Incorrect Correct answer

Anticholinergic toxicity from perindopril requiring substitution

Correct Incorrect Correct answer

A urinary tract infection precipitating delirium

Correct Incorrect Correct answer

A 74-year-old woman is reviewed after developing a widespread maculopapular rash and derangement of liver function tests. Three weeks earlier she commenced flucloxacillin for cellulitis. She takes no other new medications. Her observations are unremarkable and she is afebrile.

Investigations reveal:

ALT: 210 U/L (<35)
ALP: 380 U/L (30–110)
GGT: 260 U/L (<40)
Bilirubin: 42 µmol/L (<20)
Eosinophils: 0.9 × 10⁹/L (0.0–0.5)

There are no previous published reports she is aware of but her clinician confirms that flucloxacillin is a well-documented cause of this reaction.

The rash and liver derangement began after starting the drug, there is no other identifiable cause, and no rechallenge is planned.

Based on the Naranjo Adverse Drug Reaction Probability Scale, which category of causality is most appropriate?

Probable

Correct Incorrect Correct answer

Definite

Correct Incorrect Correct answer

Possible

Correct Incorrect Correct answer

Doubtful

Correct Incorrect Correct answer

Unassessable

Correct Incorrect Correct answer

An 88-year-old man in residential aged care with advanced dementia, frailty (Clinical Frailty Scale 7) and a limited life expectancy is reviewed.

His regular medications are: aspirin, atorvastatin, metformin, gliclazide MR, omeprazole, temazepam, and paracetamol.

He has had two hypoglycaemic episodes in the past month and two falls.

Investigations reveal:

HbA1c: 6.2% (44 mmol/mol)
Fasting glucose: 4.1 mmol/L (3.0–5.4)
eGFR: 44 mL/min/1.73m²
Sodium: 137 mmol/L (135–145)

Applying a structured deprescribing approach, which medication should be prioritised for cessation first?

Gliclazide MR

Correct Incorrect Correct answer

Paracetamol

Correct Incorrect Correct answer

Omeprazole

Correct Incorrect Correct answer

Atorvastatin

Correct Incorrect Correct answer

Metformin

Correct Incorrect Correct answer

A hospital-based clinical committee is reviewing the evidence for implementing a computerised electronic decision-support tool to reduce potentially inappropriate medications in older inpatients, based on the recent generation of large randomised controlled trials (including OPERAM and MedSafer).

A trainee is asked to summarise what these trials collectively demonstrated regarding clinical outcomes.

Which of the following statements most accurately reflects the current best evidence on the effect of these deprescribing interventions in older adults?

Deprescribing interventions reduce inappropriate medication use and appear safe, but have not consistently improved clinical outcomes such as hospitalisation or mortality

Correct Incorrect Correct answer

Deprescribing interventions consistently reduce all-cause mortality across all randomised controlled trials

Correct Incorrect Correct answer

Deprescribing interventions increase adverse drug withdrawal events and hospitalisations

Correct Incorrect Correct answer

Deprescribing interventions have no effect on the number of inappropriate medications prescribed

Correct Incorrect Correct answer

Deprescribing interventions significantly worsen quality of life in frail older adults

Correct Incorrect Correct answer

Mock Geriatrics Module 2

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