A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 77-year-old Caucasian woman presents to her primary care provider for a general checkup. The patient is with her daughter who brought her to this appointment. The patient states that she is doing well and has some minor joint pain in both hips. She states that sometimes she is sad because her husband recently died. She lives alone and follows a vegan diet. The patient's daughter states that she has noticed her mother struggling with day to day life. It started 2 years ago with her forgetting simple instructions or having difficulty running errands. Now the patient has gotten to the point where she can no longer pay her bills. Sometimes the patient forgets how to get home. The patient has a past medical history of obesity, hypertension, gastroesophageal reflux disease (GERD) controlled with pantoprazole, and diabetes mellitus. Her temperature is 99.5°F (37.5°C), blood pressure is 158/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 98% on room air. Which of the following will most likely help with this patient's presentation?
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A
DonepezilCorrect. Donepezil is a first-line acetylcholinesterase inhibitor for Alzheimer disease and is appropriate for this patient with progressive 2-year cognitive and functional decline.
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B
Fluoxetine and cognitive behavioral therapyIncorrect. Fluoxetine and CBT treat major depressive disorder; her predominant problem is progressive cognitive decline, not primary depression.
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C
Vitamin B12 and discontinue pantoprazoleIncorrect. B12 deficiency is worth evaluating given her vegan diet and PPI use, but the multi-year progressive functional decline pattern is more consistent with Alzheimer dementia.
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D
No intervention neededIncorrect. No intervention would miss the opportunity to delay progression with a cholinesterase inhibitor in a clearly impaired patient.
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E
MemantineIncorrect. Memantine, an NMDA receptor antagonist, is indicated for moderate-to-severe Alzheimer disease; donepezil is the appropriate first-line agent for this patient's level of cognitive decline.
↑ Tap an answer to reveal the reasoning
Answer: A. A 77-year-old woman with progressive cognitive decline over 2 years — starting with forgetting instructions and progressing to inability to manage finances and wayfinding deficits ('forgets how to get home') — has dementia, and the most likely subtype is Alzheimer disease. The insidious, gradual progression over years, prominence of memory and executive dysfunction, and absence of focal neurologic signs all support this diagnosis. Major depressive disorder (pseudo-dementia) and B12 deficiency (especially in the setting of long-term PPI use and vegan diet) are important alternatives but do not best fit the multi-year insidious course of progressive functional decline.
Donepezil, a centrally acting reversible acetylcholinesterase inhibitor, is first-line pharmacotherapy for mild-to-moderate Alzheimer disease. It increases acetylcholine availability in the cortex and hippocampus, partially compensating for the cholinergic deficit caused by basal forebrain neuronal loss. Donepezil can modestly improve cognition and slow functional decline, though it does not modify underlying disease.
Fluoxetine plus CBT addresses major depression, but her presentation is dominated by progressive cognitive decline rather than primary depressive symptoms; she has only situational sadness. B12 deficiency from a vegan diet and chronic PPI use is a plausible contributor that should be checked, but the gradual 2-year functional decline pattern is more consistent with Alzheimer's, and B12 replacement does not reliably reverse established dementia. 'No intervention' would miss the chance to slow her progressive decline.
**Why each option:**
**A.** Correct. Donepezil is a first-line acetylcholinesterase inhibitor for Alzheimer disease and is appropriate for this patient with progressive 2-year cognitive and functional decline.
**B.** Fluoxetine and CBT treat major depressive disorder; her predominant problem is progressive cognitive decline, not primary depression.
**C.** B12 deficiency is worth evaluating given her vegan diet and PPI use, but the multi-year progressive functional decline pattern is more consistent with Alzheimer dementia.
**D.** No intervention would miss the opportunity to delay progression with a cholinesterase inhibitor in a clearly impaired patient.