PUID: 42 ||Suspected Dementia Assessment with Mini Mental State Examination (MMSE): A PLAB 2 mock attempt 1

Practice a case with the AI patient 🤖

Summary:

This scenario involves assessing a patient presenting with memory concerns, exploring possible dementia (including Alzheimer’s and frontotemporal dementia), and conducting a rapid Mini Mental State Examination as part of evaluation.

Key Points:

History Taking – Cognitive Assessment Focus

• Begin with open questions to understand:

  • Patient’s presenting complaint and perception of memory loss

  • Specific instances and progression over time

  • Impact on daily activities and independence (e.g. work, driving, social functioning)

• Clarify:

  • Nature of forgetfulness (recent vs remote memory)

  • Examples such as forgetting names of grandchildren or familiar routes

  • Insight into their memory difficulties (patients with dementia often lack insight, especially in frontotemporal dementia)

Differential Diagnosis Considerations

• Alzheimer’s Disease:

  • Common after age 60-65

  • Early symptoms: short-term memory loss, repetitive questioning

• Frontotemporal Dementia:

  • Earlier onset (~50s)

  • Starts with personality changes, disinhibition, emotional blunting, compulsive sweet consumption

  • Speech issues (Broca’s aphasia – difficulty expressing; Wernicke’s aphasia – fluent but nonsensical speech)

• Other causes to rule out:

  • Depression-related pseudodementia

  • Delirium (if acute onset)

  • Vascular dementia risk factors (hypertension, diabetes)

Important Considerations:

• Always safeguard driving ability if cognitive decline is suspected

• Explore risk factors:

  • Family history

  • Vascular risk factors

• Assess for hallucinations or delusions to rule out other psychiatric or neurological causes

• Patients with higher education levels may show later onset due to cognitive reserve

Diagnostic Approach:

1. Open general question:

   • “Can you tell me a bit more about the problems you have been having with your memory?”

2. Focused cognitive screening:

   • Orientation to time and place (e.g. “What is today’s date?” rather than yes/no questions)

   • Recall of recent and remote memory items

   • Daily functional assessment (driving, finances, cooking)

3. MMSE Quick Screening (if station allows):

   • Explain purpose sensitively: “I’d like to do a short test that checks different parts of your thinking, is that okay?”

   • Domains include:

     • Orientation (date, place)

     • Registration and recall

     • Attention and calculation

     • Language

     • Visual-spatial tasks

4. Assess mood and hallucinations:

   • Depression screening questions

   • Psychotic symptom screening (e.g. “Have you heard voices that others cannot hear?”)

Management:

• Investigations:

  • Blood tests: FBC, U&Es, LFTs, thyroid function, B12, folate

  • Cognitive testing: MMSE, MoCA

  • Consider neuroimaging (CT/MRI) if rapid progression or atypical features

• Referral:

  • Memory clinic for formal assessment and support planning

• Lifestyle advice:

  • Brain stimulation activities (crosswords, puzzles)

  • Exercise and cardiovascular risk factor management

• Safety netting:

  • Discuss driving restrictions if appropriate

  • Safety at home (medication management, falls risk)

Communication Skills:

• Avoid yes/no memory questions; request specific factual answers

• Use open questions to gather rich history

• Avoid stock phrases and maintain natural conversation flow

• Show empathy without rehearsed lines

• Confirm understanding throughout

Ethical Considerations:

• Capacity assessment if concerns arise

• Driving safety and duty to inform DVLA if necessary

• Confidentiality balanced with safeguarding public risk

Additional Resources:

• NICE Guidelines on Dementia (NG97)

• GMC Good Medical Practice on consent and safeguarding

• Alzheimer’s Society UK – Diagnostic pathways