Psych CASC / OSCE · Old age psychiatry — neurocognitive disorders
Explain vascular cognitive impairment and risk-factor plan to patient and son — CASC communication station
MRCPsych/FRANZCP-style communication station: explain VCI phenotype, secondary prevention as the main lever, modest drug evidence, safety-net for delirium/new stroke, 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 old-age/memory clinic. [1][4]
Candidate instructions. Explain vascular cognitive impairment in plain language; contrast with typical Alzheimer disease without overwhelming jargon; explain why controlling blood pressure, diabetes, smoking, and preventing further strokes is the main treatment; outline that memory tablets may give only modest benefit if used; safety-net acute confusion or new stroke symptoms; address driving/finances at a high level; check understanding with teach-back. Examiner plays the patient; a second role-player may be the son. [1][2][3]
Candidate scenario
Your patient had two strokes in the last three years and progressive trouble with planning, slowed thinking, and walking. Scans (already done by stroke services) show prior infarcts and small-vessel changes — you will not invent new film findings. He still smokes 10 cigarettes daily. BP today 168/92. The son asks: "Is this Alzheimer disease? Can't we just start the dementia tablet?" You may discuss a possible later trial of donepezil 5 mg orally daily, increasing to 10 mg after at least four weeks if tolerated, only after risk factors are addressed and with local formulary/counselling. [2][3][4]
Marking domains
- Empathy, structure, shared agenda with patient and son
- Accurate plain-language explanation of vascular cognitive impairment and stepwise/subcortical ideas
- Clear prioritisation of vascular risk control and smoking cessation as main levers
- Honest counselling on modest cognitive-drug benefits and monitoring if trialled
- Safety-netting for delirium and recurrent stroke; driving/finances awareness
- Checks understanding / teach-back [1][2][5]
Reveal assessor key
Open and agenda-set. Greet both; ask main worries (Alzheimer label, miracle tablet, fear of nursing home). Name time available. [1]
Explain diagnosis. "This is vascular cognitive impairment — thinking problems caused mainly by blood-vessel disease and strokes in the brain. It can get worse in steps after strokes or more gradually when small vessels are affected. That is different from the classic Alzheimer pattern that often starts with slowly forgetting recent conversations, though some people have both types of brain change together." [1][4]
Explain main treatment. "The most important treatments are preventing further strokes and protecting blood vessels: blood pressure, diabetes, cholesterol, stopping smoking, heart rhythm checks if needed, exercise as able, and the medicines stroke doctors already recommend. Good control of blood pressure has evidence for protecting thinking skills in some high-risk people." [2][4]
Explain tablets. "Medicines like donepezil can give small average improvements in thinking scores for some people with vascular dementia, but they do not reverse strokes or clear vessel damage. If we try one, we start low — for example donepezil 5 mg daily then 10 mg after several weeks — watch for nausea or slow pulse, and review whether it is truly helping. We would not use a tablet instead of stopping smoking or treating blood pressure." [3]
Safety and future. Sudden confusion may be infection or a new stroke — seek urgent medical care. Discuss driving and financial support needs; capacity is decision-specific. [1][5]
Close. Summarise, teach-back, written information, smoking cessation offer, BP follow-up, invite questions. [4]
References
- [1]O'Brien JT, Thomas A Vascular dementia Lancet, 2015.PMID 26595643
- [2]Williamson JD, Pajewski NM, Auchus AP, et al. Effect of Intensive vs Standard Blood Pressure Control on Probable Dementia: A Randomized Clinical Trial JAMA, 2019.PMID 30688979
- [3]Kavirajan H, Schneider LS Efficacy and adverse effects of cholinesterase inhibitors and memantine in vascular dementia: a meta-analysis of randomised controlled trials Lancet Neurol, 2007.PMID 17689146
- [4]Gorelick PB, Scuteri A, Black SE, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association Stroke, 2011.PMID 21778438
- [5]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278