History Taking · Intermediate · Psychiatry

Cognitive Assessment and Memory Concerns

Practise this PLAB 2 history taking station on Suspected Dementia. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in a GP surgery. Mr Rami Gamal, a 78-year-old man, has come to see you with concerns about his memory and thinking, raised by his daughter. Please take a focused cognitive history and conduct a Mini Mental State Examination (MMSE), interpreting the findings and discussing next steps.

Background notes: PMH: Hypertension, Hypercholesterolaemia, Mild arthritis knees and hands

What this station tests

  • Collateral history from the daughter: the patient's account minimises while the daughter reveals functional impairment
  • Gradual progressive pattern suggesting Alzheimer's versus sudden or stepwise (vascular)
  • Screening for reversible causes: depression, hypothyroidism, B12, hypercalcaemia, medications
  • Brief cognitive assessment: AMT, MMSE, or MoCA with documented score
  • Not diagnosing dementia in primary care: referring to memory clinic for formal assessment

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Memory concerns in an elderly patient require the candidate to distinguish dementia from depression, delirium, and normal ageing, while handling the patient's fear and denial sensitively. Mr Gamal is 78, widower, brought by his daughter Farida who has noticed memory decline. He thinks it is normal ageing. Open with: 'Mr Gamal, your daughter has noticed some changes. Can you tell me how things have been from your perspective?'

Core approach

Take a cognitive history from both patient and daughter. His account: 'I forget names sometimes, doesn't everyone at my age?' Minimising. Daughter's account: he has forgotten to pay bills (previously meticulous), got lost driving to the shops (familiar route), left the stove on twice, asks the same questions repeatedly, struggling with TV remote and phone. These are functional impairments, not just name-forgetting.

Timeline: gradual onset over 12 to 18 months, progressive. This gradual progressive pattern suggests Alzheimer's (commonest cause). Sudden onset would suggest vascular dementia or delirium. Stepwise decline suggests vascular dementia.

Screen for reversible causes. Depression (common mimic): has he been low since his wife died 8 years ago? Hypothyroidism, B12 deficiency, hypercalcaemia, medication side effects (anticholinergics, sedatives). Alcohol use. Sensory impairment (hearing, vision) can mimic cognitive decline.

Perform a brief cognitive assessment: AMT (Abbreviated Mental Test) or MMSE or MoCA. Document the score.

Closing and safety netting

Investigations: bloods (FBC, U&E, TFTs, B12/folate, calcium, glucose, LFTs), urine dipstick, ECG. CT head to exclude structural causes (tumour, subdural, hydrocephalus). Referral to memory clinic for formal assessment (detailed neuropsychology, possible MRI).

Communicate sensitively. Do not diagnose dementia today. 'Mr Gamal, the changes your daughter has described go beyond normal ageing. We need to do some tests to understand the cause, because some causes are treatable. I would like to refer you to the memory clinic.' Address his fear: 'Whatever the outcome, there is support available.' Involve Farida: she needs to understand the process and the support available for carers. Driving: if cognitive impairment is confirmed, DVLA notification may be needed. Safety net: if he becomes acutely confused or his behaviour changes suddenly, return urgently. Follow-up after bloods and CT.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for suspected dementia. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Collateral history obtained. Cognitive assessment performed. Reversible causes screened. Timeline and progression established. Functional impact documented.

Costs marks: No collateral history. No cognitive test. Not screening reversible causes.

Domain 2 (Primary focus)

Scores well: Bloods for reversible causes. CT head. Memory clinic referral. Not diagnosing prematurely. DVLA discussed.

Costs marks: No investigation. Diagnosing dementia. No referral. Not mentioning DVLA.

Domain 3 (Primary focus)

Scores well: Communicating with both patient and daughter. Respecting his denial while acting on the concern. Not using the word 'dementia' prematurely. Involving daughter as carer.

Costs marks: Ignoring the daughter. Using 'dementia' bluntly. Dismissing his perspective. Not involving carer.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Accepting 'it's just normal ageing' without collateral history: the daughter's account reveals functional decline that is not normal
  2. Not screening for reversible causes: treatable conditions (hypothyroidism, B12, depression) must be excluded before attributing to dementia
  3. Diagnosing dementia in the first consultation: formal assessment requires specialist neuropsychology

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the suspected dementia history in this PLAB 2 station?

Memory concerns in an elderly patient require the candidate to distinguish dementia from depression, delirium, and normal ageing, while handling the patient's fear and denial sensitively. Mr Gamal is 78, widower, brought by his daughter Farida who has noticed memory decline. He thinks it is normal ageing.

What are examiners marking in this suspected dementia station?

Marks are won for: Collateral history obtained. Cognitive assessment performed. Reversible causes screened. Timeline and progression established. Functional impact documented. Marks are lost for: No collateral history. No cognitive test. Not screening reversible causes.

What is the most common mistake candidates make in this suspected dementia station?

Accepting 'it's just normal ageing' without collateral history: the daughter's account reveals functional decline that is not normal.

How do I prepare for this station if I have not managed suspected dementia in clinical practice?

This station rewards process over personal experience. The skill being assessed: Gradual progressive pattern suggesting Alzheimer's versus sudden or stepwise (vascular). The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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