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Dementia Assessment and Differentials:: PLAB 2 Mock 2nd attempt

Updated: Jul 14

Summary:

This station involves assessing an elderly patient presenting with memory concerns suggestive of early dementia. The candidate is required to perform effective data gathering, cognitive assessment (e.g. MMSE or AMTS), discuss differential diagnoses, and formulate a comprehensive management plan within time constraints.



Key Points


1. Data Gathering and Cognitive Assessment

  • Excellent data gathering demonstrated overall.

  • Explored presenting complaint effectively:

    • Asked about the patient’s understanding of “dementia” to clarify misconceptions.

    • Enquired about memory issues, onset, progression, and frequency.

    • Assessed daily functioning: getting lost, driving, daily activities.

    • Checked cognitive functions: forgetting names, important dates.

  • Conducted MMIC tasks appropriately (orientation, registration, attention, recall, language).


2. Time Management

  • Critical issue noted:

    • Continued data gathering after the two-minute warning bell.

    • The bell serves as a strict warning to stop data gathering immediately and move to management.

    • Spending too long on data gathering sacrifices crucial management marks.


3. Management Approach

  • Management was limited due to time overrun.

  • Key management aspects to cover:

    • Introduction and diagnosis explanation.

    • Medical management and further investigations.

    • Referral to memory clinic for comprehensive assessment.

    • Lifestyle advice to improve cognitive function.

    • Leaflets/pamphlets for patient education.

    • Safety netting: warning signs requiring urgent review.

    • Arranging follow-up appointments.

  • Recommended structure for management discussions:

    1. Introduce the diagnosis or differential.

    2. Discuss necessary investigations to confirm or rule out reversible causes (e.g. B12, TFTs, depression screening).

    3. Referral pathways (memory clinic, geriatrics, neurology if indicated).

    4. Medical management options if diagnosis is confirmed.

    5. Lifestyle modifications (diet, exercise, cognitive stimulation).

    6. Provide educational material.

    7. Safety netting for worsening symptoms.

    8. Arrange follow-up and conclude with shared decision making (e.g. "Which of these would you like to discuss first?").


4. Examination Technique

  • Orientation question improvement:

    • Avoid asking time as it is variable and not reliable for orientation testing.

    • Ask for season, place, or address as these are more constant.


Important Considerations

  • Always stop data gathering immediately upon the two-minute bell.

  • Prioritize management discussion to maximise marks.

  • Avoid asking repetitive questions; consolidate queries efficiently (e.g. combine stroke, cardiovascular history, and neurological symptoms).

  • Clarify the patient’s understanding of medical terms to address misconceptions.

  • Always structure management into medical, referral, lifestyle, educational, safety netting, and follow-up aspects.


Diagnostic Approach

  1. Take a focused history exploring presenting complaint.

  2. Assess cognitive function via validated tools (e.g. AMTS/MMSE).

  3. Evaluate impact on daily functioning.

  4. Rule out reversible causes:

    • Hypothyroidism

    • Vitamin B12 deficiency

    • Depression (pseudodementia)

    • Medication side effects

  5. Formulate differential diagnoses (Alzheimer’s, vascular dementia, Lewy body dementia, depression-related cognitive impairment).


Management

  • Explain findings clearly and empathetically.

  • Arrange blood tests (FBC, U&Es, LFTs, TFTs, B12/folate, glucose).

  • Refer to memory clinic for formal cognitive assessment and care planning.

  • Discuss potential medical treatments based on confirmed diagnosis (e.g. donepezil in Alzheimer’s).

  • Recommend lifestyle changes:

    • Healthy balanced diet (Mediterranean diet benefits cognition)

    • Regular physical activity

    • Cognitive stimulation and social engagement.

  • Provide written information/leaflets on memory loss and dementia support.

  • Safety net:

    • Advise on signs of worsening cognition, behaviour changes, safety concerns (e.g. getting lost or medication mismanagement).

  • Arrange follow-up for review and management evaluation.


Communication Skills

  • Use patient-friendly language avoiding medical jargon.

  • Engage the patient in shared decision-making (e.g. “Which of these would you like to talk about first?”).

  • Avoid stock phrases; remain natural and empathetic.

  • Check understanding throughout explanations.


Ethical Considerations

  • Respect patient autonomy and capacity.

  • Ensure confidentiality while involving carers or family as appropriate.

  • Maintain a professional and empathetic approach in discussing sensitive topics such as dementia.


Additional Resources

  • NICE Guidelines: Dementia: assessment, management and support for people living with dementia and their carers (NG97).

  • GMC Good Medical Practice (Domain 1: Knowledge & Skills, Domain 2: Communication).

  • PLAB 2 Examiner Top Tips for time management and structured consultation.

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