Assessment
Please use same marking scheme as on Falls and bone Health.
One point for each correct answer, minus one point for wrong answers. Don’t know scores zero.
Pass mark 80%
Users that fail should have feedback at the end, where to go and revise.
Assessment Page 1
Start the assessment
Please don’t attempt this section until you are confident that you have fully understood the tutorials.
Points are awarded for correct answers
Points are deducted for incorrect answers
If you are unsure of any answers you may select the ‘don’t know’ option, as scores are neither added nor subtracted. If you don’t achieve a pass score at your first attempt you can try again. If you quit the program before a successful pass the whole of the assessment must be repeated.
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Title
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A 79 year-old man has a 6 month history of a depressive illness. He was started on an SSRI and improved initially and therefore the drug was continued. He has severe osteoarthritis of his left hip and is awaiting a hip replacement. He is taking paracetamol. He had previously been taking a non-steroidal anti-inflammatory drug but this was stopped following a gastro-intestinal bleed. The patient comes to see you saying “I don’t think I can go on like this, I am desperate”. He is actively suicidal.
What should you do?
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NB There should also be a Don’t know box against every question. A tick or cross should appear when the user clicks on true or false
1 Change his antidepressant True incorrect False correct
No. Are you sure that he is depressed?
2 Reassess depressive symptoms True correct False Incorrect
Yes. There is a distinct possibility that he has relapsed back into depression
3 Urgent referral to old age psychiatrist True correct False Incorrect
Yes. He needs assessment and active management of his suicidal risk
4 Reassure him True incorrect False correct
No. This will do nothing for either his depression or his suicidal ideation
5 Change his analgesia True correct False Incorrect
Yes. Controlling pain is a helpful step, but it is not enough on its own
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One of your patients who is suffering from mild dementia has become depressed and you are treating her with a SSRI.
The daughter calls you one morning to say that her mother has suddenly started vomiting and sweating. She is complaining of a headache and is extremely anxious.
What should you do? Click to the next page and choose
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6 Arrange admission to hospital for suspected food poisoning. True incorrect False Correct
No. Although food poisoning is a possibility conservative management at home is the initial treatment of choice.
7 Suspect the discontinuation syndrome and inquire if she is still taking the SSRI True Correct False Incorrect
Yes. Her symptoms are typical and if she has stopped her antidepressant it should be
re-started.
8 Prescribe haloperidol for hypomania True incorrect False Correct
No. Symptoms are not typical for a manic illness
9 Reassure daughter that these symptoms are to be expected in early stages of dementia True Incorrect False Correct
No. Her symptoms are not typical.
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An 87 year old woman is on the rehabilitation ward having been admitted 3 weeks previously “off her legs” when a diagnosis of cerebrovascular disease was made.
A CT scan at that time showed small vessel disease. She is now mobilising poorly. She is off her food and constipated. The nurses think that she is being difficult. She is irritable and refuses to get out of bed. The family say that they could not have her back home as she is.
What should you do? Click to the next page and choose
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10 Assess cognitive function with a mini-mental state examination True Correct False Incorrect
Yes. She may have a dementia which could explain some of her behaviour
11 Assess for depression with the Geriatric Depression Scale or similar True Correct False Incorrect
Yes. Symptoms could all be explained by a depressive illness.
12 Transfer her to a community hospital to await nursing home placement True Incorrect False Correct
No. You have not yet explained her symptoms and patients should not be sent to
intermediate care without a diagnosis. It is too early to assume that she will
need nursing home care.
13 Repeat CT scan True Incorrect False Correct
Unnecessary. You know that she has small vessel disease and her symptoms
do not suggest a subdural haematoma
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A 74 year old man together with his wife comes to see you complaining of mild memory loss. His mini-mental state examination is 26/30. His wife says that he has become increasingly forgetful over the last 6 months and recently drove the wrong way up a one-way street. You suspect a dementia illness. The patient asks if he can continue to drive.
What should you do? Click to the next page and choose
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14 Advise him to stop driving until the situation has been clarified? True Correct False Incorrect
Yes. He needs to be told that his driving may constitute a risk and his memory
problems need to be investigated.
15 Advise him that he has dementia, that he must stop driving and inform the
Driver and Vehicle Licensing Agency True Incorrect False Correct
No. The diagnosis of a dementia illness cannot be made solely on this history.
16 Refer him to an old age psychiatrist for diagnosis True Correct False Incorrect
Yes. He needs expert assessment.
17 Tell the patient that he may continue to drive, but only short local journeys True Incorrect False Correct
No. It is tempting to give this advice, but it is incorrect.
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An 80 year old woman is admitted to hospital with a headache and visual field defect, thought to be due to possible giant cell arteritis (temporal arteritis). Treatment is started with prednisolone 60 mg daily, there is a rapid improvement in her symptoms and the diagnosis is confirmed by temporal artery biopsy.
She is still in hospital two weeks later owing to a chest infection and she starts to complain that the night nurses are talking about her and saying that she is a loose woman. She is very angry, tearful and agitated and is refusing food. She has told her daughter that she thinks she will never get home and will die in hospital. Her C-reactive protein is 35, ESR 58 mm/hour.
What should you do? Click to the next page and choose
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18 Stop her steroids True Incorrect False Correct
No. There is a real danger that she may become blind unless she is given adequate doses
of steroids. Initially, high doses are needed for about 8 weeks.
19 Assess for depression True Correct False Incorrect
Yes. Her symptoms and mental state suggest a psychotic depressive illness. If depression
is confirmed then treatment with an antidepressant is indicated.
20 Prescribe an atypical antipsychotic True Correct False Incorrect
Yes. This would be appropriate in the short term because of the psychotic nature of her condition.
21 Reassure the patient that her symptoms are a side effect of the steroids that will
improve with time and no treatment is needed True Incorrect False Correct
No. Although her symptoms may well be a side effect of the steroids, improvement in her
mental state will not take place without treatment.
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An 83 year-old man was widowed 2 years ago and presents with non-specific complaints of feeling terrible and he wonders how long he can go on like this. He is slightly confused, obviously depressed, can’t sleep and has lost a lot of weight. He has painful osteoarthritis of his knees, essential hypertension and benign prostatic hypertrophy. His daughter lives nearby and is willing to come and stay with him.
What should you do? Click to the next page and choose
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22 Seek an urgent admission to hospital on the grounds that he is suicidal? True Incorrect False Correct
His daughter is able to support him and he should therefore be managed at home.
Although he has elementary suicidal ideas further exploration reveals that he has no
intention of acting on them.
23 Prescribe a tricyclic antidepressant on the grounds that he responded well
to amitriptyline 30 years ago? True Incorrect False Correct
No. His cardiovascular disease, the confusion and the benign prostatic hypertrophy are
all contra-indications to tricyclics.
24 Seek an urgent appointment with a consultant in old age psychiatry? True Incorrect False Correct
No. This is unnecessary if you have access to a community psychiatric nurse to confirm
your diagnosis and support the patient and his daughter while you treat his
depression.
25 Prescribe an antidepressant such as mirtazapine? True Correct False Incorrect
Yes. This is an effective antidepressant, it will help him to sleep and gain weight and
it is unlikely to exacerbate his cardiovascular and prostatic disease.
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A 75 year-old man has a two-year history of mild cognitive impairment. He was widowed 3 years ago. His general practitioner has recently noticed him driving erratically and has informed the Driver and Vehicle Licensing Agency who have suspended his licence pending further inquiry. His niece reports that he has lost weight, his home has become uncharacteristically untidy and he is still driving. He refuses to be referred to a specialist.
What should you do? Click to the next page and choose
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26 Ask for an urgent home visit from a member of the local old age psychiatry team? True Correct False Incorrect
The team will decide who would be the most appropriate to visit, a nurse, dementia liaison worker or a psychiatrist, and will make contact with the patient and the niece.
27 Arrange an immediate Mental Health Act assessment with a view to sectioning him
into hospital? True Incorrect False Correct
Unnecessary at this stage, but if he is unable or unwilling to co-operate it may be
necessary to arrange an admission under the Mental Health Act for assessment.
28 Prescribe an antidepressant in order to cheer him up and get his weight back
on? True Incorrect False Correct
No. In isolation this is unhelpful since it is possible that he is developing a dementia
illness and may not remember to take his tablets.
29 Report him to the Police? True Correct False Incorrect
Yes. He is a danger to himself and others on the road and the police need to be
informed that he continues to drive despite suspension of his licence.
30 Suggest his niece engineers the removal of his car keys if not the car itself? True Correct False Incorrect
Yes. This is desirable from the safety point of view but it may provoke a crisis of anger, aggression, paranoia or depression. His niece, the police and any involved motoring organisation need to be warned of this.
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An 88 year-old woman lives with her 90 year-old husband. Their daughter who lives some distance away telephones to say that her mother has been confused for some years and her father can’t cope.
At the home you find her seriously cognitively impaired (MMSE 5) and with bruises on her arms and legs. Her husband tells you that she gets up at night to go to the lavatory and last night he had a struggle to get her back to bed and she fell over against the bedroom furniture. He says he can cope and he doesn’t want her to go to hospital.
What should you do? Click to the next page and choose
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31 Arrange emergency respite care at a local authority residential home? True Incorrect False Correct
No. Not an appropriate placement. It is likely that she will become even more confused and disturbed and the staff will be unable to cope with her.
32 Prescribe a hypnotic? True Incorrect False Correct
No. This will increase her risk of falling and becoming incontinent and more confused.
33 Accept what the husband says and telephone the daughter to say that your hands
are tied since he doesn’t want anything done? True Incorrect False Correct
No. The patient is clearly at risk and there is always the possibility that her husband is
abusing her. As she lacks capacity it is your duty to step in to ensure her safety.
34 Arrange an emergency CT head? True Incorrect False Correct
No. The long history of cognitive impairment does not suggest a subdural haematoma
and the most likely diagnosis is Alzheimer’s disease. Arranging a CT head at a
later date would be appropriate.
35 Seek an urgent home visit from the local old age psychiatry team? True Correct False Incorrect
Yes. They will investigate and make a diagnosis, mobilise support, prescribe
if necessary and carry out a risk assessment.
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A 72 year-old man with Parkinson’s disease lives in a residential home. He is reported to have some confusion, although he has always been quite lucid when you have seen him in the past.
He complains of seeing black pirates in his room and he has hit a female care assistant when she told him he was imagining it. He now accuses the staff of plotting to get rid of him and won’t let them near him. He is refusing hospital admission.