dementia
Doctor Information
Edward Phelps, age 88
PMH
TIA x2
Hypertension
Peripheral vascular disease
Drug History
Clopidogrel 75mg daily
Amlodipine 5mg od
Simvastatin 75mg on
No known allergies
Mr Phelps' wife Vera has booked an appointment without him to discuss some issues
PMH
TIA x2
Hypertension
Peripheral vascular disease
Drug History
Clopidogrel 75mg daily
Amlodipine 5mg od
Simvastatin 75mg on
No known allergies
Mr Phelps' wife Vera has booked an appointment without him to discuss some issues
Patient Information
Edward Phelps age 88
You are Edwards wife Vera
History: you wanted to come and talk about Edward. He just isn’t himself lately and he is driving you mad. He has definitely become more forgetful these last few years, but then so have you, so it must be your ages. Edward however can completely forget where he is and what he is doing. Only last week you went to the supermarket with him as you have done every week for the last 40 years, and next minute you hear your name on the loudspeaker asking you to collect him from customer services. He got completely lost and upset, and a nice lady had brought him to the front.
If asked only: Edward cant look after himself anymore. You have always done the cooking, but he used to put the bins out and clean the toilet, even hoover occasionally. It is now as though he has forgotten how to do these things - he will just stare at the toilet brush and look completely blank. He also gets up at all hours of the night thinking it is morning, and starts to get dressed! You prompt him for his tablets. Sometimes he gets angry and snaps at you for no reason. It has made you quite upset a few times. If you are asked specifically how you are coping, you break down and cry. You don't know how long you can keep looking after him, as its a full time job and you just dont have the energy. He needs watching all day and night, and even needs help with toileting sometimes, as he will just go in his chair. You are quite frail yourself, and you don’t know where to turn.
Your medical problems include:
Heart attack 3 years back
TIA 5 years ago
Hypertension
OA hip and knee
Both your sons live abroad with their families and you don't want to burden them with your troubles. There is no-one else that you can ask for help from.
Ideas: Edward must be sick to be like this, it is just so unlike him.
Concerns: you can't cope with him anymore, you are always angry and upset, and you don't want to feel like this anymore. But he is your husband of 40 years and you will do anything you can to help.
Expectations: you really just want to know what is wrong, and if you can get some help at home with him.
If the doctor explains dementia well, and discusses the process of diagnosis (blood tests, head scan and memory clinic), you will be happy with this, but you still need help in the meantime. Hopefully they can advise you about any services that may be able to help, you would be so grateful. You are happy to bring Edward in but you wont be able to tell him what the appointment is for, otherwise he will refuse to come.
You are Edwards wife Vera
History: you wanted to come and talk about Edward. He just isn’t himself lately and he is driving you mad. He has definitely become more forgetful these last few years, but then so have you, so it must be your ages. Edward however can completely forget where he is and what he is doing. Only last week you went to the supermarket with him as you have done every week for the last 40 years, and next minute you hear your name on the loudspeaker asking you to collect him from customer services. He got completely lost and upset, and a nice lady had brought him to the front.
If asked only: Edward cant look after himself anymore. You have always done the cooking, but he used to put the bins out and clean the toilet, even hoover occasionally. It is now as though he has forgotten how to do these things - he will just stare at the toilet brush and look completely blank. He also gets up at all hours of the night thinking it is morning, and starts to get dressed! You prompt him for his tablets. Sometimes he gets angry and snaps at you for no reason. It has made you quite upset a few times. If you are asked specifically how you are coping, you break down and cry. You don't know how long you can keep looking after him, as its a full time job and you just dont have the energy. He needs watching all day and night, and even needs help with toileting sometimes, as he will just go in his chair. You are quite frail yourself, and you don’t know where to turn.
Your medical problems include:
Heart attack 3 years back
TIA 5 years ago
Hypertension
OA hip and knee
Both your sons live abroad with their families and you don't want to burden them with your troubles. There is no-one else that you can ask for help from.
Ideas: Edward must be sick to be like this, it is just so unlike him.
Concerns: you can't cope with him anymore, you are always angry and upset, and you don't want to feel like this anymore. But he is your husband of 40 years and you will do anything you can to help.
Expectations: you really just want to know what is wrong, and if you can get some help at home with him.
If the doctor explains dementia well, and discusses the process of diagnosis (blood tests, head scan and memory clinic), you will be happy with this, but you still need help in the meantime. Hopefully they can advise you about any services that may be able to help, you would be so grateful. You are happy to bring Edward in but you wont be able to tell him what the appointment is for, otherwise he will refuse to come.
Examination Findings
Not required in this scenario
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination and investigation Identifies abnormal findings or results and/or recognises their implications Data gathering does appears to be guided by the probabilities of disease Gathers data about both husband and wife. Enquires deeply into social aspect Uses an incremental approach using time and accepting uncertainty |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Fails to enquire about social aspects, and fails to ask about the wife's medical issues. |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis Develops a management plan that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Simultaneously manages multiple health problems, both acute & chronic Encourages improvement, rehabilitation, and, where appropriate, recovery. Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Unable to construct a problem list and prioritise |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s (the wife in this case) agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient to develop a shared management plan or clarify the roles of doctor and patient Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Does not allow own views/values to inappropriately influence dialogue Shows commitment to equality for all |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Fails to empower patient Inappropriately influences patient interaction through own views/values Quick to judge |
Management
Explanation: As people get older they tend to become more forgetful. Dementia is one cause of memory problems, that affects the brain. As well as memory problems, it can also affect personality, ability to talk or communicate well, and even ability to look after themselves day to day. Dementia cannot be reversed, but people progress at different speeds, and for many, the main treatment is giving them support and help to cope. For some, medication can be used as well.
There are several challenges to this case. The first is that the patient himself is unaware of the consultation and not actually present. You need to think about confidentiality - he may well have dementia but you cannot discuss anything from his record with his wife. Thankfully, she does not really ask about his records or consultations. If she wants to give you information about him, that is perfectly fine, and you can ask all the questions you want to her without breaching confidentiality. This poses the second issue - you have to make an assessment based on her information. Granted you need to see and assess him in person at some point, but in cases where memory loss is prominent, a collateral history from a family matter is arguably more useful. Think about daily activities to guide you with questioning - can he dress himself, get breakfast, make tea, do household chores. What sort of things does he forget? He is ever unsafe - e.g. leaving the hob on or forgetting to lock the door. It is useful to ask about his mood, as this is another feature that can be prominent in people with memory impairment.
You technically have two patients to think about - one is Mr Phelps, but the other is the one sitting in front of you. Is she the sole carer? Does anyone help or support her? How is she coping? Carers can often suffer from mood problems and psychological distress. At the moment you can only ask about things, but perhaps if would be reassuring for Mrs Phelps to know that there are lots of things that be done to help. For Edward, he can be assessed for home care, and the house can be adapted to make things easier (for example stair lift, shower rail etc). There is a memory clinic to see a specialist, as some people can benefit from medication. For her, there are many resources and organisations (Age UK, Alzheimer’s society etc) to provide support and education about dementia, and as a carer she may be entitled to financial help as well. Carer support is something that the RCGP have put a lot of emphasis on, so it may be good to offer her an appointment to look at her own health.
To take the consultation further, you need to see Edward. If there are any major issues with bringing him in, he could be seen on a home visit. Use a simple screening tool such as 6-CIT/AMTS to assess his memory. All patients with suspected memory impairment should be seen by memory services - the requirements may be different in your area, but NICE recommends a full blood screen, ECG, and CT head prior to diagnosis.
There are several challenges to this case. The first is that the patient himself is unaware of the consultation and not actually present. You need to think about confidentiality - he may well have dementia but you cannot discuss anything from his record with his wife. Thankfully, she does not really ask about his records or consultations. If she wants to give you information about him, that is perfectly fine, and you can ask all the questions you want to her without breaching confidentiality. This poses the second issue - you have to make an assessment based on her information. Granted you need to see and assess him in person at some point, but in cases where memory loss is prominent, a collateral history from a family matter is arguably more useful. Think about daily activities to guide you with questioning - can he dress himself, get breakfast, make tea, do household chores. What sort of things does he forget? He is ever unsafe - e.g. leaving the hob on or forgetting to lock the door. It is useful to ask about his mood, as this is another feature that can be prominent in people with memory impairment.
You technically have two patients to think about - one is Mr Phelps, but the other is the one sitting in front of you. Is she the sole carer? Does anyone help or support her? How is she coping? Carers can often suffer from mood problems and psychological distress. At the moment you can only ask about things, but perhaps if would be reassuring for Mrs Phelps to know that there are lots of things that be done to help. For Edward, he can be assessed for home care, and the house can be adapted to make things easier (for example stair lift, shower rail etc). There is a memory clinic to see a specialist, as some people can benefit from medication. For her, there are many resources and organisations (Age UK, Alzheimer’s society etc) to provide support and education about dementia, and as a carer she may be entitled to financial help as well. Carer support is something that the RCGP have put a lot of emphasis on, so it may be good to offer her an appointment to look at her own health.
To take the consultation further, you need to see Edward. If there are any major issues with bringing him in, he could be seen on a home visit. Use a simple screening tool such as 6-CIT/AMTS to assess his memory. All patients with suspected memory impairment should be seen by memory services - the requirements may be different in your area, but NICE recommends a full blood screen, ECG, and CT head prior to diagnosis.
