A 66-year-old man with metastatic carcinoma of the lung is seen by the palliative care team in Kozhikode. His bone pain is now controlled with oral morphine every 4 hours. Which drug should be prescribed regularly with it from the start?

A stimulant laxative with a stool softener

An antiemetic for the whole treatment course

An 84-year-old woman becomes drowsy, withdrawn and inattentive on day 3 after hip fracture fixation; she was fully alert before surgery. She is not agitated. She has received tramadol for pain, has not opened her bowels since admission, and has a catheter in place. What is the most appropriate first step?

Look for and correct precipitating causes

Start haloperidol as a regular dose

A 78-year-old man is brought to the geriatric clinic with new confusion and inability to pass urine for 12 hours. He takes amlodipine, metformin, amitriptyline for sleep, chlorphenamine for an itch and oxybutynin for urgency, all from different doctors. His bladder is palpable. What is the most likely cause of his presentation?

Cumulative anticholinergic burden of his drugs

Ankle oedema from amlodipine causing confusion

A 54-year-old woman's breast biopsy confirms invasive carcinoma. The surgeon has arranged a quiet room, asked her husband to join as she wished, and switched off his phone. Following the SPIKES protocol, what should he do next?

Ask what she already understands about her illness

Explain the TNM staging of breast cancer

Tell her the diagnosis and treatment plan at once

Reassure her that most breast cancers are curable

Geriatrics, palliative care and communication

7 NEET-PG practice questions on Geriatrics, palliative care and communication, part of General Medicine. The first 7 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 66-year-old man with metastatic carcinoma of the lung is seen by the palliative care team in Kozhikode. His bone pain is now controlled with oral morphine every 4 hours. Which drug should be prescribed regularly with it from the start?
1. AA stimulant laxative with a stool softener
2. BAn antiemetic for the whole treatment course
3. CNaloxone in a low dose
4. DA proton pump inhibitor
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Answer: A · A stimulant laxative with a stool softener
Constipation affects nearly every patient on regular opioids, and tolerance to it does not develop, unlike tolerance to nausea and sedation. Opioids act on mu receptors in the gut wall to reduce peristalsis and secretions, so a regular stimulant laxative such as senna or bisacodyl, often with a softener, is started with the first dose. Nausea usually settles within a week, so an antiemetic is given only as needed. Kerala's community palliative care network makes oral morphine widely available for such patients.
- B: Opioid nausea is usually transient, so antiemetics are given when needed, not for the whole course.
- C: Naloxone would reverse the analgesia and is used only for opioid overdose.
- D: Morphine does not cause peptic ulceration, so a PPI is not routinely needed.
Question 2 · Medium
An 84-year-old woman becomes drowsy, withdrawn and inattentive on day 3 after hip fracture fixation; she was fully alert before surgery. She is not agitated. She has received tramadol for pain, has not opened her bowels since admission, and has a catheter in place. What is the most appropriate first step?
1. AStart oral lorazepam at night
2. BArrange urgent CT brain
3. CLook for and correct precipitating causes
4. DStart haloperidol as a regular dose
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Answer: C · Look for and correct precipitating causes
This is hypoactive delirium, the commonest and most often missed form in older patients. The key step is to find and treat the triggers: pain and opioids, constipation, urinary retention or infection, dehydration, electrolyte imbalance, hypoxia, anaemia and drugs such as tramadol. Non-drug measures (reorientation, glasses and hearing aids, sleep, early mobilisation, family presence) are the mainstay. Antipsychotics are kept for severe distress or danger, and benzodiazepines are avoided except in alcohol or benzodiazepine withdrawal.
- A: Benzodiazepines worsen delirium except in alcohol or sedative withdrawal.
- B: CT is for focal signs or a fall with head injury, not the first step here.
- D: Antipsychotics do not treat the cause and are not for quiet, hypoactive delirium.
Question 3 · Medium
A 78-year-old man is brought to the geriatric clinic with new confusion and inability to pass urine for 12 hours. He takes amlodipine, metformin, amitriptyline for sleep, chlorphenamine for an itch and oxybutynin for urgency, all from different doctors. His bladder is palpable. What is the most likely cause of his presentation?
1. AAnkle oedema from amlodipine causing confusion
2. BHypoglycaemia from metformin
3. CCumulative anticholinergic burden of his drugs
4. DNew-onset Alzheimer's disease
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Answer: C · Cumulative anticholinergic burden of his drugs
Amitriptyline, chlorphenamine and oxybutynin all block muscarinic receptors, and their combined anticholinergic burden in an older man causes urinary retention, constipation and acute confusion. This is a classic prescribing cascade from polypharmacy with several prescribers; such drugs are flagged as potentially inappropriate in older adults by the Beers criteria. Management is catheterisation, stopping or replacing the offending drugs and a full medication review (deprescribing). Benzodiazepines and other sedatives should not be used to calm him.
- A: Amlodipine causes ankle oedema but not retention or confusion.
- B: Metformin alone rarely causes hypoglycaemia and does not explain urinary retention.
- D: Dementia develops gradually and does not cause acute retention.
Question 4 · Hard
An 80-year-old man with Parkinson's disease is admitted with pneumonia in Pune. Consider these statements about delirium in older inpatients like him: 1. It begins acutely and fluctuates during the day. 2. Inattention is a core feature. 3. Haloperidol is the preferred drug to control his agitation. 4. The hypoactive form is common and often missed. Which statements are correct?
1. A1 and 2 only
2. B1, 2 and 4 only
3. C1, 2, 3 and 4
4. D1, 2 and 3 only
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Answer: B · 1, 2 and 4 only
Delirium is an acute, fluctuating disturbance of attention and awareness caused by a medical illness (statements 1 and 2). The hypoactive form, with drowsiness and withdrawal, is common in older people and is often mistaken for depression or fatigue (statement 4). Statement 3 is false for him: typical antipsychotics such as haloperidol block dopamine receptors and can cause severe rigidity and worsening of Parkinson's disease; if a drug is unavoidable, low-dose quetiapine is used. In every patient, non-drug measures and treatment of the cause come first.
- A: Omits the hypoactive form (statement 4), which is common and often missed.
- C: Statement 3 is false, so all four cannot be correct.
- D: Includes haloperidol, which worsens Parkinson's disease and is avoided.
Question 5 · Easy
A 54-year-old woman's breast biopsy confirms invasive carcinoma. The surgeon has arranged a quiet room, asked her husband to join as she wished, and switched off his phone. Following the SPIKES protocol, what should he do next?
1. AExplain the TNM staging of breast cancer
2. BAsk what she already understands about her illness
3. CTell her the diagnosis and treatment plan at once
4. DReassure her that most breast cancers are curable
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Answer: B · Ask what she already understands about her illness
SPIKES is a six-step approach to breaking bad news: Setting, Perception, Invitation, Knowledge, Emotions (with empathy) and Strategy and Summary. With the setting arranged, the next step is to learn her Perception: what she knows and expects, so the news can start from her understanding and correct misconceptions. He then asks how much detail she wants before giving the facts in plain language. This forms part of the AETCOM competencies for Indian medical graduates.
- A: Technical staging jargon does not belong to this stage and confuses patients.
- C: Giving the facts before checking her understanding skips the Perception step.
- D: Premature reassurance is false comfort before she knows the news.
Question 6 · Easy
An 82-year-old man is admitted with pneumonia. On day 2 his daughter says he has become muddled since last evening, is better one hour and worse the next, and cannot keep his attention on a conversation. Which bedside tool is designed to detect this condition?
1. AGlasgow Coma Scale
2. BConfusion Assessment Method
3. CMini-Mental State Examination
4. DGeriatric Depression Scale
Answer and explanation in LearnFree account
Question 7 · Hard
A 76-year-old retired judge with metastatic pancreatic cancer has repeated vomiting from gastric outlet obstruction. After a full discussion, he clearly understands the risks and benefits and declines a feeding jejunostomy; he wants comfort care at home. His son, who lives abroad, insists that the doctors place the tube. Mental status examination is normal. What should the treating doctor do?
1. APlace the tube, as the family has requested it
2. BSeek a court order before accepting his refusal
3. CPlace the tube until the son can arrive in person
4. DRespect his informed refusal and plan comfort care
Answer and explanation in LearnFree account

Geriatrics, palliative care and communication

A 66-year-old man with metastatic carcinoma of the lung is seen by the palliative care team in Kozhikode. His bone pain is now controlled with oral morphine every 4 hours. Which drug should be prescribed regularly with it from the start?

A 54-year-old woman's breast biopsy confirms invasive carcinoma. The surgeon has arranged a quiet room, asked her husband to join as she wished, and switched off his phone. Following the SPIKES protocol, what should he do next?

An 82-year-old man is admitted with pneumonia. On day 2 his daughter says he has become muddled since last evening, is better one hour and worse the next, and cannot keep his attention on a conversation. Which bedside tool is designed to detect this condition?