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Question One
Mary, a 79-year-old patient, is brought to your office by her daughter, who reports that her mother has been exhibiting several concerning symptoms over the past year. Comprehensive questioning reveals that her symptoms are: trouble remembering familiar things, such as telephone numbers commonly dialed; not recognizing some close family members who visit often; moodiness; and difficulty performing writing tasks. Although not definitive, these symptoms are most likely indicative of which type of dementia?
A. Alzheimer’s disease
B. Dementia with Lewy bodies
C. Huntington’s disease
D. Frontotemporal dementia
The correct answer is A.
| Choice | Peer answers |
|---|---|
| A. Alzheimer’s disease | 89% |
| B. Dementia with Lewy bodies | 2% |
| C. Huntington’s disease | 0% |
| D. Frontotemporal dementia | 10% |
Differential diagnosis of dementias can be difficult, as all are characterized by the core symptom of memory impairment. However, it may be possible to distinguish dementias clinically through other presenting symptoms.
A Correct. In addition to memory impairment, Alzheimer’s disease consists of deficits in language (aphasia), motor function (apraxia), recognition (agnosia), or executive functioning, all of which this patient exhibits. Definitive diagnosis, however, is not possible until autopsy.
B Incorrect. Dementia with Lewy bodies is often accompanied by extrapyramidal symptoms, which this patient does not have.
C Incorrect. Huntington’s disease is associated with spasmodic movements and incoordination, which are also absent in this patient.
References
Question Two
A young man who is pre-med and has a family history of Alzheimer’s disease is interested in learning more about the brain regions involved in memory and the development of Alzheimer’s disease. You describe the pathways of acetylcholine, an important neurotransmitter involved in dementia. As part of your explanation, you tell him that major cholinergic projections stem from the _____ to the _____, which are believed to be involved in memory.
A. Basal forebrain; nucleus accumbens
B. Basal forebrain; prefrontal cortex
C. Striatum; hypothalamus
D. Striatum; prefrontal cortex
The correct answer is B.
| Choice | Peer answers |
|---|---|
| A. Basal forebrain; nucleus accumbens | 7% |
| B. Basal forebrain; prefrontal cortex | 59% |
| C. Striatum; hypothalamus | 15% |
| D. Striatum; prefrontal cortex | 16% |
A, C, and D Incorrect.
B Correct. Acetylcholine is an important neurotransmitter, and is thought to be involved in memory. Major acetylcholine neurotransmitter projections originating in the basal forebrain project to the prefrontal cortex, hippocampus, and amygdala.
References
Question Three
A young woman brings her 72-year-old mother for an appointment because she is concerned that her mother may have Alzheimer’s disease. The mother does not feel that anything is wrong, but her daughter states that she has seemed somewhat depressed and forgetful lately. Data have shown that:
The correct answer is D.
| Choice | Peer answers |
|---|---|
| A. Depression is often comorbid with Alzheimer’s disease | 2% |
| B. Depression may increase the risk of developing Alzheimer’s disease | 2% |
| C. Depression may be a prodromal symptom of Alzheimer’s disease | 6% |
| D. All of the above | 88% |
| E. None of the above | 2% |
A Partially correct. Mood symptoms can occur as part of Alzheimer’s disease and in fact are typically the first notable symptom (often manifested as apathy rather than sadness). In addition, depression is a common comorbid illness in patients with Alzheimer’s disease.
B Partially correct. Depression has been hypothesized to be a possible risk factor for Alzheimer’s disease.
C Partially correct. Depression has been hypothesized to be a possible prodromal symptom of Alzheimer’s disease, with some evidence suggesting that it may exacerbate the progression of Alzheimer’s pathology.
D Correct (all of the above).
E Incorrect (none of the above).
References
Question Four
A 68-year-old patient with an early diagnosis of Alzheimer’s disease is put on a cholinesterase inhibitor in hopes of improving his cognitive function. This patient has been a chain smoker for over 40 years and refuses to give up the habit. Which of the following medications would not be appropriate for this patient, given his smoking habit?
A. Donepezil
B. Galantamine
C. Rivastigmine
D. None of these medications should be prescribed to a patient who smokes
E. There are no contraindications due to smoking for these medications
The correct answer is E.
| Choice | Peer answers |
|---|---|
| A. Donepezil | 0% |
| B. Galantamine | 22% |
| C. Rivastigmine | 4% |
| D. None of these medications should be prescribed to a patient who smokes | 4% |
| E. There are no contraindications due to smoking for these medications | 71% |
E Correct. One can potentially choose any cholinesterase inhibitor as a first-line treatment, since specific contraindications due to smoking do not presently appear in the literature.
A Incorrect. Donepezil, a reversible, long-acting selective inhibitor of acetylcholinesterase (AChE), may be a good choice, resulting in mainly transient gastrointestinal side effects.
B Incorrect. Galantamine has a dual mechanism of action: AChE inhibition and positive allosteric modulation (PAM) of nicotinic cholinergic receptors. This may be a good choice for this patient.
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