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

Practice a case with the AI patient 🤖

Summary:

This station involves performing a cognitive assessment, often a mini mental state examination (MMSE) or similar, to assess for cognitive impairment in a patient presenting with memory issues or confusion. The key is structured assessment, time management, and recognizing when to move on.

Key Points:

🧠 Cognitive Assessment Approach

• Cognitive stations often take time as simulators may respond slowly to simulate impaired memory.

• Start the MMSE at orientation, as it yields early positive findings.

• If orientation is abnormal, you can abandon the full MMSE, document it, and move to management.

• Attempting to complete the entire MMSE despite an early positive finding wastes time and loses management marks.

⏰ Time Management

• Two-minute warning bell: Signals you must stop data gathering and move to management immediately.

• Continuing data gathering after the bell is a grave mistake; management has higher scoring weightage.

• Avoid spending excessive time on minor history questions if diagnosis and red flags are identified.

🔍 Data Gathering Strategy

• Focus data gathering on:

  • Reaching diagnosis

  • Ruling out red flags

  • Assessing psychosocial factors

• Avoid using data gathering to ‘tick boxes’; think of it as building a holistic patient picture.

✅ MMSE Practical Tips

• Orientation questions:

  • Ask date, day, month, year, season, place instead of "What time is it?" as time is non-constant and less memory-reliant.

• Spelling WORLD backward is a cognitive test but recognize deficits early without completing unnecessary sections.

• If positive findings are present in orientation, explain that a full cognitive assessment would be done in memory clinic.

Important Considerations:

• Management carries four marks, so prioritise it over minor history questions.

• Red flags missed in data gathering can be safety netted in management.

• Never continue data gathering after the two-minute bell; examiners expect you to move on.

Diagnostic Approach (Step-by-Step):

1. Introduce yourself, confirm patient identity, gain consent.

2. Begin with orientation questions:

   • Ask for date, day, month, year, season, location (hospital, city).

3. Assess attention and calculation (e.g. WORLD backward) if orientation normal.

4. If early cognitive deficits are identified:

   • Stop MMSE, document positive finding, and state a full assessment would be done in clinic.

5. Rule out red flags (e.g. sudden confusion causes, infection, metabolic causes).

6. Take relevant social history for functional impact.

Management:

• Explain findings and possible causes of cognitive impairment.

• Discuss further investigations:

  • Blood tests (FBC, U&E, LFT, glucose, calcium, TFTs, B12/folate)

  • CT or MRI brain if clinically indicated.

• Refer to:

  • Memory clinic for formal cognitive assessment and management.

• Provide lifestyle advice even if not covered in data gathering:

  • Cognitive stimulation

  • Social engagement

  • Diet, exercise, vascular risk management

• Safety net:

  • Symptoms of worsening confusion, risk to self, or others to seek urgent medical attention.

• Offer support for carers/family if relevant.

Communication Skills:

• Avoid stock phrases; sound natural and patient-centred.

• Avoid phrases like “May I ask a personal question?” for routine alcohol/smoking questions.

• Be empathetic but concise to maintain time efficiency.

• Summarize at the end with clear next steps and safety netting.

Ethical Considerations:

• Respect patient autonomy and confidentiality.

• Avoid overpromising referrals or interventions beyond realistic NHS resources.

• Always consider capacity and consent, especially in cognitive impairment assessments.

Additional Resources:

• NICE Guidelines: Dementia assessment and management

• GMC Good Medical Practice

• PLAB 2 examiner tips on cognitive stations (as per uploaded documents)

• Oxford Handbook of Clinical Medicine: Cognitive assessments