CCE-CBD-068 - GP Exams

CASE INFORMATION

Case ID: DEM-001
Case Name: Margaret Dawson
Age: 78
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: P70 – Dementia

COMPETENCY OUTCOMES

Competency Domain	Competency Element
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 the impact of illness. 1.4 Communicates effectively in difficult situations, including delivering serious diagnoses.
2. Clinical Information Gathering and Interpretation	2.1 Systematically collects information relevant to cognitive decline. 2.2 Performs cognitive assessments (e.g., MMSE, GPCOG).
3. Diagnosis, Decision-Making and Reasoning	3.1 Generates differential diagnoses for cognitive decline. 3.2 Applies clinical reasoning to reach a diagnosis.
4. Clinical Management and Therapeutic Reasoning	4.1 Develops a management plan that includes pharmacological and non-pharmacological approaches. 4.2 Coordinates with multidisciplinary teams and carers.
5. Preventive and Population Health	5.1 Considers carer support and education. 5.2 Implements strategies to prevent complications such as falls.
6. Professionalism	6.1 Maintains ethical practice regarding autonomy, consent, and driving assessments.
7. General Practice Systems and Regulatory Requirements	7.1 Completes documentation for cognitive impairment plans and advance care directives. 7.2 Refers appropriately to geriatricians and Alzheimer’s Australia services.
9. Managing Uncertainty	9.1 Manages the uncertainty of prognosis and progression in dementia.
10. Identifying and Managing the Patient with Significant Illness	10.1 Recognises when symptoms indicate significant deterioration needing specialist input or residential care.

CASE FEATURES

No personal advance care planning in place.
78-year-old female presenting with progressive memory loss over 12 months.
Family reports increased forgetfulness, repetition, and difficulty with managing medications and finances.
Lives alone, daughter visits twice a week.
No history of delirium, but recent episodes of getting lost in familiar areas.
Hypertension and hyperlipidaemia managed on medication.
MoCA score: 20/30 (deficits in short-term memory and visuospatial tasks).
Safety concerns: still driving, history of minor fender-bender.
No significant mood disorder but appears frustrated and anxious.

CANDIDATE INFORMATION

INSTRUCTIONS

Review the following patient record summary and scenario.

Your examiner will ask you a series of questions based on this information.

You have 15 minutes to complete this case.

The time for each question will be managed by the examiner.

The time allocation for each question is roughly as follows:

Question 1 – 3 minutes
Question 2 – 3 minutes
Question 3 – 3 minutes
Question 4 – 3 minutes
Question 5 – 3 minutes

PATIENT RECORD SUMMARY

Patient Details

Name: Margaret Dawson
Age: 78
Gender: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

Nil known

Medications

Amlodipine 5 mg daily
Atorvastatin 20 mg daily

Past History

Hypertension
Hyperlipidaemia
Osteoarthritis (knees, mild)

Social History

Retired librarian
Lives alone in a unit
Daughter visits twice a week, neighbours occasionally check in
Still drives independently

Family History

Mother had dementia (diagnosed at 82)
Father died of myocardial infarction at 75

Smoking

Never smoked

Alcohol

1-2 standard drinks on weekends

Vaccination and Preventative Activities

Influenza vaccine: up to date
Pneumococcal vaccine: received
Shingles vaccine: declined

SCENARIO

Margaret Dawson is a 78-year-old woman brought in by her daughter due to concerns about worsening memory over the past 12 months. The daughter reports repeated questions, misplacing objects, and occasional missed meals or medications. Margaret admits to feeling “a little forgetful,” but downplays the severity.

She has managed her own finances and medications until recently, but her daughter has found unpaid bills and mismatched medication doses. Margaret was recently found wandering two blocks from home, unsure where she was.

She remains independent but is starting to avoid social events due to embarrassment about forgetting names. Margaret still drives but was recently involved in a minor car accident (low-speed fender bender). She expresses frustration about her memory but remains pleasant and cooperative in consultation.

On cognitive testing (MoCA), Margaret scores 20/30 with deficits in short-term recall, executive function, and visuospatial abilities.

Her physical examination is unremarkable. Neurological exam shows no focal deficits.

EXAMINATION FINDINGS

General Appearance: Neatly dressed, good hygiene, appears frustrated but cooperative
Blood Pressure: 135/78 mmHg
Heart Rate: 72 bpm, regular
BMI: 26 kg/m²
Neurological Exam: No focal findings
Cognitive Assessment: MoCA score 20/30

INVESTIGATION FINDINGS

Blood Results

TSH: Normal
B12 and Folate: Normal
FBC: Normal
UEC: Normal
LFT: Normal

Imaging

CT Brain: Generalised cortical atrophy, more marked in the hippocampus and temporal lobes. No focal lesions or infarcts.

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. How would you explain the diagnosis of Alzheimer’s dementia to Margaret and her daughter?

Prompt: Explain the diagnosis in simple, compassionate terms.
Prompt: Address their concerns about what to expect.
Prompt: Discuss the progressive nature and management options.

Q2. What is your management plan for Margaret?

Prompt: Describe both non-pharmacological and pharmacological strategies.
Prompt: Address safety concerns such as driving and medication management.
Prompt: Discuss referrals and advance care planning.

Q3. How would you assess and support Margaret’s decision-making capacity?

Prompt: Assess capacity regarding healthcare, finances, and living arrangements.
Prompt: Explain the importance of advance care directives.
Prompt: Discuss enduring power of attorney and guardianship if needed.

Q4. What resources and support services would you recommend for Margaret and her daughter?

Prompt: Mention local services like Alzheimer’s Australia, My Aged Care.
Prompt: Discuss carer support and respite care options.
Prompt: Address future planning, including residential care options.

Q5. What are the red flags that would prompt urgent referral to a geriatrician or hospital?

Prompt: Mention carer burnout or loss of home support as reasons for escalation.

Prompt: Describe symptoms that indicate acute deterioration or unsafe living.

Prompt: Discuss behavioural changes such as aggression or wandering at night.

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: How would you explain the diagnosis of Alzheimer’s dementia to Margaret and her daughter?

Explanation and Communication:

Start by establishing rapport and ensuring Margaret and her daughter are comfortable.
Use simple, respectful language, avoiding medical jargon.
Explain that Alzheimer’s dementia is a progressive condition that affects memory, thinking, and daily activities.
Clarify that it is the most common cause of dementia in older adults and is characterised by gradual worsening over time.
Emphasise that while there is no cure, there are treatments and strategies to slow progression and maintain quality of life.
Acknowledge their concerns about safety (e.g., driving), independence, and decision-making.
Provide emotional support, validating feelings of fear or frustration.

Progression and Prognosis:

Explain that symptoms will likely worsen over time, affecting memory, judgement, and communication abilities.
Stress the importance of ongoing monitoring and regular reviews.

Management Overview:

Introduce treatment options, including medications (e.g., cholinesterase inhibitors like donepezil).
Discuss non-pharmacological approaches, like cognitive stimulation and structured routines.
Offer reassurance about support services, including Alzheimer’s Australia.

Q2: What is your management plan for Margaret?

Pharmacological Management:

Consider cholinesterase inhibitors (donepezil) if appropriate, following Australian guidelines.
Review current medications to avoid polypharmacy and potential cognitive impact.

Non-Pharmacological Management:

Encourage routine and environmental modifications to support memory.
Discuss safety, particularly cessation of driving, and conduct a formal fitness to drive assessment.
Implement strategies for medication compliance (e.g., blister packs).

Support and Referrals:

Refer to geriatrician for comprehensive assessment.
Involve My Aged Care for home support and occupational therapy for home safety evaluation.
Provide carer support, including respite services.

Future Planning:

Discuss advance care directives and enduring power of attorney/guardianship.
Address potential need for residential care in the future.

Q3: How would you assess and support Margaret’s decision-making capacity?

Capacity Assessment:

Assess understanding, appreciation, reasoning, and ability to express a choice in decisions regarding:
- Medical care
- Financial management
- Living arrangements

Legal Considerations:

If capacity is lacking, refer for formal assessment (geriatrician, legal advice).
Encourage setting up Enduring Power of Attorney (financial) and Enduring Guardian (health and lifestyle) while capacity remains.

Advance Care Planning:

Discuss Advance Care Directives early, ensuring Margaret’s wishes are documented.

Support:

Involve family and carers in discussions.
Provide written resources and follow-up appointments.

Q4: What resources and support services would you recommend for Margaret and her daughter?

Educational Resources:

Alzheimer’s Australia: education, support groups.
Dementia Australia: online and in-person resources.

Support Services:

My Aged Care: for home support packages.
Carer Gateway: respite services and counselling.
Community-based groups for social engagement and cognitive stimulation.

Practical Support:

Referral to Occupational Therapy for home safety and assistive technology.
Social work involvement for emotional and practical support.

Q5: What are the red flags that would prompt urgent referral to a geriatrician or hospital?

Clinical Red Flags:

Sudden deterioration in cognition or function (suggesting delirium).
Acute behavioural changes, such as aggression or psychosis.
Wandering at night, increasing risk of harm.
Evidence of self-neglect, malnutrition, or dehydration.

Carer Concerns:

Carer burnout, inability to cope.
Loss of home supports, increasing risk of neglect or harm.

Medical Triggers:

Suspicion of stroke, infection, or metabolic imbalance.
Complex comorbidities needing specialist coordination.

SUMMARY OF A COMPETENT ANSWER

Clear, empathetic communication about diagnosis and prognosis.
Comprehensive management plan, including pharmacological and non-pharmacological measures.
Proactive discussion of capacity and future planning.
Identification of support services and carer needs.
Awareness of red flags requiring escalation of care.

PITFALLS

Failing to involve the patient in discussions and decisions.
Using jargon or unclear explanations when discussing the diagnosis.
Overlooking safety concerns, particularly regarding driving.
Delaying advance care planning, risking loss of capacity.
Neglecting carer support, leading to potential burnout.

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 to gather information about their symptoms, ideas, concerns, expectations of healthcare and the full impact of their illness experience on their lives.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Systematically collects and uses information relevant to the case.

3. Diagnosis, Decision-Making and Reasoning

3.1 Generates and prioritises differential diagnoses and uses clinical reasoning.

4. Clinical Management and Therapeutic Reasoning

4.1 Implements evidence-based management plans.

5. Preventive and Population Health

5.1 Considers carer and family support, anticipates complications.

6. Professionalism

6.1 Maintains ethical and patient-centred practice.

7. General Practice Systems and Regulatory Requirements

7.1 Completes documentation and referrals consistent with Australian laws and regulations.

9. Managing Uncertainty

9.1 Manages uncertainty in progression and prognosis.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies need for escalation to specialist or acute care.

Competency at Fellowship Level

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