CCE-CE-068 - GP Exams

CASE INFORMATION

Case ID: CCE-NEURO-028
Case Name: Margaret Thompson
Age: 76
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P70 – Dementia (including Alzheimer’s)

COMPETENCY OUTCOMES

Competency Domain	Competency Element
1. Communication and Consultation Skills	1.1 Establishes rapport with the patient and carer 1.2 Explores the patient’s concerns, ideas, and expectations 1.3 Communicates diagnosis, prognosis, and management in a clear, compassionate manner
2. Clinical Information Gathering and Interpretation	2.1 Takes a structured cognitive history, including functional impact 2.2 Identifies red flags requiring urgent neurological referral
3. Diagnosis, Decision-Making and Reasoning	3.1 Differentiates between types of dementia and other causes of cognitive impairment 3.2 Identifies when further investigations or specialist referral is required
4. Clinical Management and Therapeutic Reasoning	4.1 Provides an evidence-based management plan, including pharmacological and non-pharmacological strategies 4.2 Supports carers and discusses advanced care planning
5. Preventive and Population Health	5.1 Identifies risk factors for dementia and associated complications 5.2 Advises on strategies to optimise cognitive function and safety
6. Professionalism	6.1 Demonstrates empathy and a patient-centred approach
7. General Practice Systems and Regulatory Requirements	7.1 Ensures appropriate documentation and follow-up for dementia care
8. Procedural Skills	8.1 Orders and interprets relevant investigations (e.g., cognitive assessments, blood tests, imaging)
9. Managing Uncertainty	9.1 Recognises when symptoms require urgent intervention versus ongoing monitoring
10. Identifying and Managing the Patient with Significant Illness	10.1 Identifies and appropriately manages complications of dementia (e.g., behavioural changes, wandering, safety risks)

CASE FEATURES

Discussion of support for the patient and family, including advance care planning
Progressive memory loss and cognitive decline affecting daily function
Carer concerns about increasing confusion and forgetfulness
Need for assessment, diagnosis, and ongoing management planning

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face to face.

A family member (Margaret’s daughter) is present to assist with history.

A patient record summary is provided for your information.

Perform the following tasks:

Take an appropriate history.
Outline the differential diagnosis and key investigations required.
Address the patient’s concerns.
Develop a safe and patient-centred management plan.

SCENARIO

Margaret Thompson, a 76-year-old retired teacher, presents with progressive memory loss over the past 12–18 months. Her daughter accompanies her to the appointment, concerned about worsening forgetfulness and confusion.

Her symptoms include:

Repeating questions and misplacing items frequently.
Forgetting recent conversations and appointments.
Difficulty managing finances and cooking, requiring more assistance.
Occasional confusion about the date or location.
Mood changes – more irritable and withdrawn.

PATIENT RECORD SUMMARY

Patient Details

Name: Margaret Thompson
Age: 76
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

No known drug allergies

Medications

Amlodipine 5 mg daily (hypertension)
Atorvastatin 20 mg daily (hyperlipidaemia)

Past History

Hypertension
Hyperlipidaemia
Osteoarthritis

Social History

Lives alone but daughter visits regularly.

Family History

Mother had dementia in her 80s.
No history of stroke or neurological conditions.

Vaccination and Preventative Activities

Up to date with vaccinations.

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

SCRIPT FOR ROLE-PLAYER

Opening Line

(Daughter speaking first) – “Doctor, I’m really worried about Mum. She’s getting forgetful, and it’s getting worse.”

(Margaret, slightly confused but pleasant) – “Oh, I think my memory is fine. My daughter worries too much.”

General Information

Margaret is a 76-year-old retired teacher who is becoming more forgetful over the past 12–18 months.

Has difficulty remembering recent events but recalls childhood memories well.
Sometimes forgets to take medications or pays the same bill twice.
Frequently misplaces items like keys or glasses and later finds them in unusual places.

Her daughter has noticed worsening symptoms and is increasingly concerned about her mother’s safety and ability to live independently.

Specific Information

(To be revealed only when asked)

Background Information

Repeats questions and conversations without realising it.
Still independent with daily tasks but needs more help with finances and cooking.
Recently left the stove on while cooking, which worried her daughter.

Cognitive Symptoms and Memory Issues

(Margaret may say some of these things when asked directly about her memory.)

“I sometimes forget things, but that happens to everyone, right?”
“I lose my glasses a lot, but I eventually find them.”
“I forget people’s names, but I think that’s normal at my age.”
Doesn’t remember the details of recent news or family events.
Forgets appointments or arrives on the wrong day.
Sometimes struggles to follow conversations when there’s a lot of background noise.

(Her daughter may add more details when prompted.)

“She tells me the same story three or four times in the same day.”
“Mum keeps calling me to remind me about something, but she doesn’t realise she already told me.”
“She’s starting to struggle with things she used to do easily, like following a recipe.”

Behavioural and Emotional Changes

(Margaret’s responses if asked about her mood.)

“I get frustrated sometimes when I can’t remember things.”
“I don’t go out as much as I used to, but I just don’t feel like it.”
“Sometimes I feel a little lost when I’m shopping.”

(Her daughter’s perspective.)

“Mum used to be really social, but now she doesn’t want to meet friends as much.”
“She gets irritable when I ask her about her memory.”
“Sometimes she looks confused in familiar places, which never used to happen.”

Functional and Safety Concerns

Can dress, bathe, and feed herself without issues.
Has had minor car accidents – scraped the side of her car against a fence while parking.
Almost left the front door unlocked overnight once.
Forgets to turn off the oven after cooking.
Sometimes struggles with using her phone or TV remote.

(Margaret may downplay some of these issues, while her daughter will provide more detail.)

Concerns About Diagnosis and Future Planning

(Daughter is more direct about her concerns.)

“Is this normal ageing, or is it dementia?”
“What kind of tests does she need?”
“How quickly will this get worse?”
“What can we do to slow it down?”
“Can she still live alone, or does she need more help?”
“Is it safe for her to keep driving?”
“What kind of support services are available?”

(Margaret’s responses will be more hesitant.)

“I think I’m doing fine. I don’t need any tests.”
“I don’t want to stop driving. I’ve been driving for 50 years!”
“Maybe I just need to do some memory exercises.”

Emotional Cues

Margaret is in mild denial about her memory problems.
She may become frustrated if pressed too hard about her difficulties.
She will respond positively to reassurance and a gentle approach.
Her daughter is very concerned and wants clear answers.

(If the candidate is supportive and structured, Margaret will be reassured and cooperative.)
(If the candidate is vague or dismissive, the daughter will push for immediate specialist referral or a driving assessment.)

Questions for the Candidate

Margaret and her daughter may ask:

“Is this normal ageing, or is it dementia?”
“What kind of tests does Mum need?”
“Can dementia be treated or slowed down?”
“Should she still be driving?”
“How do we keep her safe at home?”
“What support services are available?”

Expected Reactions Based on Candidate Performance

If the candidate provides a clear explanation and structured plan:

Margaret will feel reassured that she’s getting help and not being forced into something.
Her daughter will feel supported and have a clear understanding of what to do next.
They may agree to cognitive testing and discuss future planning calmly.

If the candidate is vague or dismissive:

Margaret will continue to downplay her symptoms.
Her daughter may become frustrated and insist on immediate specialist referral.
They may leave the consultation without a clear plan, increasing stress and uncertainty.

Key Takeaways for the Candidate

Take a structured dementia history, focusing on memory, function, and safety risks.
Differentiate between dementia and normal ageing, considering reversible causes.
Provide an evidence-based management plan, including support for both the patient and carer.
Discuss long-term care, driving, and advanced care planning early.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, including cognitive symptoms, functional impact, behavioural changes, and carer concerns.

The competent candidate should:

Obtain a structured cognitive history, including:
- Onset and progression (12–18 months of memory decline).
- Pattern of memory loss (recent events, repetitive questioning, misplacing items).
- Impact on daily living (finances, medication adherence, cooking, driving).
- Behavioural and mood changes (irritability, social withdrawal).
- Functional independence (ability to dress, bathe, drive safely).
Assess for carer concerns, particularly safety issues (stove left on, minor car accidents, wandering tendencies).
Screen for reversible causes:
- Depression, medications, metabolic conditions, B12 deficiency, thyroid dysfunction.
Identify red flags requiring urgent neurological referral:
- Rapid cognitive decline, focal neurological signs, hallucinations, personality changes.

Task 2: Differentiate between types of dementia and identify red flags requiring further investigation.

The competent candidate should:

Consider differential diagnoses:
- Alzheimer’s disease – gradual decline, memory loss first, followed by functional impairment.
- Vascular dementia – stepwise deterioration, history of stroke or cardiovascular risk factors.
- Lewy body dementia – fluctuating cognition, visual hallucinations, Parkinsonian symptoms.
- Frontotemporal dementia – early personality or behavioural changes rather than memory loss.
- Mild cognitive impairment (MCI) – cognitive decline without significant functional impairment.
Order appropriate investigations:
- Cognitive screening tools (e.g., MMSE, MoCA, RUDAS for CALD patients).
- Blood tests (FBC, UECs, LFTs, B12, folate, TSH, HbA1c, cholesterol).
- Imaging if indicated (CT/MRI brain for vascular or structural pathology, tumour, hydrocephalus).

Task 3: Provide a diagnosis and discuss an initial management plan, including investigations and support strategies.

The competent candidate should:

Explain the likely diagnosis:
- Suspected Alzheimer’s dementia based on memory impairment, functional decline, and lack of focal neurological symptoms.
Address safety concerns:
- Driving assessment (OT driving assessment, notification to transport authority if needed).
- Home safety assessment (risk of falls, wandering, kitchen safety).
Discuss available treatment options:
- Cholinesterase inhibitors (donepezil, rivastigmine) may slow progression in early stages.
- Address cardiovascular risk factors to reduce progression (BP, diabetes, cholesterol management).
Introduce support services:
- Dementia Australia, My Aged Care for home support, Centrelink carer support options.
Plan follow-up and monitoring:
- Review cognitive decline every 6–12 months.
- Discuss advance care planning, enduring power of attorney early.

Task 4: Educate the patient and family on dementia progression, safety considerations, and available support services.

The competent candidate should:

Provide reassurance and education:
- Dementia is progressive but can be managed with support and medications.
- Maintain structure and familiar routines to minimise confusion.
Discuss strategies for memory support:
- Use of reminders, calendars, labelled cupboards, medication dosette boxes.
Prepare for future planning:
- Encourage early legal and financial planning while cognition is still intact.
- Discuss future care options (home care, respite care, residential care when required).
Provide emotional support for the family:
- Carer support groups, mental health support for caregivers.

SUMMARY OF A COMPETENT ANSWER

Takes a structured dementia history, assessing memory, function, and behavioural changes.
Differentiates between types of dementia, ruling out reversible causes.
Orders appropriate investigations, including cognitive screening, blood tests, and imaging if indicated.
Develops a clear management plan, addressing safety, medication options, and support services.
Educates family on dementia progression, future planning, and carer support.

PITFALLS

Failing to assess red flags, leading to missed serious conditions like vascular dementia or Lewy body dementia.
Overlooking safety concerns, such as driving risks, wandering, and home hazards.
Not considering reversible causes, such as depression, B12 deficiency, or medication side effects.
Providing vague reassurance without a structured management plan, leaving the family uncertain.
Failing to involve family in long-term care discussions, leading to crisis situations later.

REFERENCES

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient and carer to gather information about symptoms, concerns, and expectations.
1.3 Provides clear and structured explanations about diagnosis, prognosis, and management.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured cognitive history, including functional impact and red flags.
2.2 Identifies indications for cognitive screening, blood tests, and imaging.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between types of dementia and other causes of cognitive impairment.
3.2 Identifies when specialist referral or further investigations are required.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides an evidence-based management plan, including pharmacological and non-pharmacological strategies.
4.2 Supports carers and discusses future planning and home safety.

5. Preventive and Population Health

5.1 Identifies risk factors for dementia and associated complications.
5.2 Advises on cognitive optimisation strategies and home modifications.

6. Professionalism

6.1 Demonstrates empathy and a patient-centred approach.

7. General Practice Systems and Regulatory Requirements

7.1 Ensures appropriate documentation and follow-up for dementia care.

8. Procedural Skills

8.1 Orders and interprets relevant investigations (e.g., blood tests, cognitive assessments, imaging).

9. Managing Uncertainty

9.1 Recognises when symptoms require urgent neurological referral versus monitoring.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies and appropriately manages complications of dementia (e.g., wandering, driving risk).

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD