Psych CASC / OSCE · Old age psychiatry — Alzheimer disease
Explain Alzheimer disease diagnosis and treatment plan to patient and spouse — CASC communication station
MRCPsych/FRANZCP-style communication station: explain AD diagnosis, care plan, donepezil start with monitoring, BPSD non-drug first approach, and check understanding.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar in the memory clinic / old-age outpatient setting. [1]
Candidate instructions. Explain probable Alzheimer disease in plain language; address fear that "nothing can be done"; outline blood tests and brain scan purpose without overselling optional research biomarkers; explain starting donepezil with realistic benefits and side-effects; cover driving and safety; explain that behavioural changes are common and usually managed without strong sedatives first; check understanding. Examiner plays the patient; a second role-player may be the spouse. [1][2]
Candidate scenario
Your patient meets clinical criteria for probable mild Alzheimer disease dementia: two years of progressive memory loss, word-finding difficulty, and new need for help with bills and medications; basic self-care intact. Routine bloods are unremarkable; structural imaging excluded a large treatable mass. ECG is acceptable. You plan donepezil 5 mg orally once daily for at least 4 weeks, then 10 mg daily if tolerated, carer education, and community supports. The wife asks about a "blood test that diagnoses Alzheimer 100%" and whether he will need "sleeping tablets or antipsychotics soon." [1][2]
Marking domains
- Empathy, structure, shared agenda with patient and spouse
- Accurate plain-language explanation of probable AD and progressive but supportable course
- Realistic explanation of donepezil (not a cure; modest average benefit; common side-effects; review plan)
- Safety: driving discussion, home safety, follow-up
- BPSD framed as common; non-drug first; antipsychotics not routine first step
- Checks understanding / teach-back [2][3][5]
Reveal assessor key
Open and agenda-set. Greet both; ask main worries (cure, blood test, sedation, driving, "how long"). Name time available. [1]
Explain diagnosis. "The pattern of gradual memory and thinking problems that now affect managing money and medicines, without another better explanation on our tests, fits what we call Alzheimer disease dementia — most likely the probable clinical form. It is a brain disease that progresses over years. We cannot reverse the underlying process with current standard tablets, but we can support independence, treat symptoms, plan safety, and help you both cope."[1][5]
Explain tests. "Blood tests looked for treatable contributors like vitamin and thyroid problems. The brain scan looked for other structural causes. Specialist tests such as certain spinal fluid, PET, or newer blood markers can sometimes increase certainty of Alzheimer brain changes, but they are not always needed for a clinical diagnosis and are not a perfect yes/no crystal ball for every person; we use them thoughtfully when they will change decisions."[1]
Explain donepezil. "Donepezil is a cholinesterase inhibitor. It can give a modest average improvement or slow decline in thinking and daily function for some people — it is not a cure and does not work the same for everyone. We start at 5 mg each day for at least four weeks, then increase to 10 mg if side-effects allow. Possible effects include nausea, loose stools, reduced appetite, vivid dreams, and slower heart rate — contact us if fainting, severe vomiting, or weight loss. We review benefit and tolerability after a few months."[2]
Behaviour and safety. "Irritability, sleep change, or suspicion can occur as the illness progresses. We first look for pain, infection, constipation, and environment triggers and use routines and support rather than jumping to strong sedatives. Antipsychotic medicines can increase risk of serious harm including death in people with dementia, so we use them only if there is severe risk and other approaches are not enough, for a short time, with clear review."[3][4]
Driving and supports. Discuss local licensing expectations (often advise not driving until assessed); offer written information, carer supports, future planning. Teach-back: ask them to summarise the plan. Book review. Invite questions. [5]
References
- [1]McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups Alzheimers Dement, 2011.PMID 21514250
- [2]Birks JS, Harvey RJ Donepezil for dementia due to Alzheimer's disease Cochrane Database Syst Rev, 2018.PMID 29923184
- [3]Kales HC, Gitlin LN, Lyketsos CG Assessment and management of behavioral and psychological symptoms of dementia BMJ, 2015.PMID 25731881
- [4]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
- [5]Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission Lancet, 2020.PMID 32738937