Breaking Bad News OSCE - Dementia Diagnosis to Family

Case Overview

• Age/Sex: 62-year-old female
• Occupation: Retired primary school teacher
• Setting: Outpatient memory clinic appointment (accompanied by daughter)
• Chief complaint: "I'm here for test results"

Patient Script

Who I Am

I'm 62, recently retired after many years of teaching, and I live alone in my flat; my daughter comes to visit most days.

What Brings Me In

My daughter says I need to come find out what the tests showed because she thinks my memory is getting worse.

My Story

For about a year and a half (18 months) I've been forgetting recent things more often. I often repeat questions within minutes, misplace keys and bills, and had two episodes of getting briefly lost in a familiar neighbourhood about 6 months ago. I find it harder to manage the bank statements and sometimes I can't think of a word in the middle of a sentence. My family says I've become a bit quieter and less interested in my gardening. I still do most things, but it takes me longer and I sometimes need help to balance the chequebook. I had a urine infection a few months ago that needed antibiotics and I had a bad flu last winter — but after those I returned to the same memory problems.

I sleep okay most nights but sometimes wake early. I don't see or hear things that others can't see. I don't fall, and I haven't had any weakness down one side. I drive occasionally but my daughter worries about it.

My Medical Background

• Past medical history: Type 2 diabetes, hypertension, hypercholesterolaemia, osteoarthritis of knees
• Medications: Metformin 1g twice daily, gliclazide 60 mg daily, lisinopril 10 mg daily, atorvastatin 20 mg nightly, amitriptyline 10 mg at night (for nerve pain), occasional ibuprofen for knee pain
• Allergies: None known
• Social: Lives alone, daughter (age 38) visits daily; non-smoker; drinks 1–2 glasses of wine twice a week; retired teacher
• Family history: Mother had "memory problems" in old age; father died of MI at 72

What I Think & Worry About

• I think maybe I'm just getting old and forgetful, but I'm worried I'll have to move out of my flat.
• I'm frightened that this might mean I'll lose my independence or have to stop driving.
• I want to know if there's anything to treat or if this will get worse.

If You Ask Me About Other Symptoms...

• Mood: I feel a bit down sometimes about being slower, but I don't have suicidal thoughts.
• Sleep: I fall asleep easily; wake around 5–6am and get up then.
• Appetite/weight: Appetite is stable; weight about the same in last year.
• Mobility/falls: I have knee pain when walking, no falls recently.
• Urinary: I have occasional urgency and sometimes go at night; I had a urine infection treated with antibiotics 3 months ago.
• Sensory: I have some numbness in my feet (diabetic neuropathy symptoms), and I need a hearing aid occasionally in noisy places.
• Meds/side effects: I sometimes feel a little groggy in the morning — diagnosed as side effect of pain tablets once.

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Clinical Summary

Examination

• General: Alert, cooperative, well-groomed, accompanied by daughter
• Vitals: BP 138/82 mmHg; HR 78 bpm regular; RR 14/min; SpO2 98% on air; Temp 36.7°C
• Cognitive screen: Mini-Mental State Examination (MMSE) 22/30 (orientation 8/10, recall 1/3, attention/calculation 4/5, language 6/8, visuospatial 3/3)
• Neurological: Cranial nerves grossly intact; no focal motor deficits; gait: steady but cautious due to knee osteoarthritis
• Mood/affect: Affect slightly flattened, denies suicidal ideation

Investigations

• FBC: Hb 135 g/L (normal) (no anaemia to explain cognitive change)
• U&E: Na 138 mmol/L; K 4.1 mmol/L; Creatinine 110 µmol/L (eGFR ~52 mL/min) (mild chronic kidney disease)
• LFTs: within reference ranges
• TSH: 2.0 mIU/L (normal) (no hypothyroidism)
• Vitamin B12: 260 pg/mL (lower end of normal) (not clearly deficient)
• HbA1c: 7.8% (62 mmol/mol) (suboptimal diabetic control)
• CRP: 2 mg/L (normal) (no active inflammation)
• Urine dip: Nitrites +, Leukocyte esterase ++ (recent UTI treated; patient not systemically unwell)
• Non-contrast CT head: Generalised cortical atrophy with medial temporal/hippocampal atrophy greater than expected for age; scattered periventricular white matter ischemic change

Diagnosis

• Primary diagnosis: Probable Alzheimer's disease (progressive short-term memory impairment over 18 months, impaired instrumental activities of daily living, hippocampal/medial temporal atrophy on imaging, MMSE 22/30 consistent with mild cognitive impairment progressing to mild dementia)

• Other important considerations / differentials:

  • Mixed Alzheimer’s and vascular cognitive impairment (scattered white matter changes on CT and vascular risk factors such as diabetes and hypertension)
  • Medication-related cognitive impairment (amitriptyline with anticholinergic effects could worsen cognition)
  • Delirium from infection (recent UTI is a red herring — patient is not systemically unwell and symptoms are chronic rather than acute)
  • Depression with cognitive features (pseudodementia) — less likely given progressive course and objective deficits
  • Reversible metabolic causes (hypothyroidism, B12 deficiency) ruled out by normal TSH and non-deficient B12

Management

• Communication: Arrange a family meeting to explain the likely diagnosis sensitively, using clear language, acknowledge uncertainty, and allow time for questions; involve patient and daughter in planning
• Medication review: Stop amitriptyline (anticholinergic) and consider alternative for neuropathic pain (e.g., duloxetine or pregabalin after assessment) to reduce cognitive burden
• Disease-specific therapy: Discuss and consider starting a cholinesterase inhibitor (e.g., donepezil) for symptomatic treatment for mild-to-moderate Alzheimer’s disease after informing of benefits/side effects and ensuring blood pressure/ECG considerations
• Vascular risk modification: Optimize diabetes control, tighten BP control as appropriate, continue statin therapy and smoking abstinence counselling (if relevant)
• Address reversible contributors: No current antibiotic required for UTI if asymptomatic; treat only if symptomatic or evidence of systemic infection
• Safety and planning: Discuss driving suspension until further assessment; assess capacity for finances and driving; advise on home safety and fall prevention
• Support and referral: Refer to local memory clinic/geriatric medicine or neurology for follow-up; occupational therapy for functional assessment; social services/counsellor for carer support and advance care planning
• Practical steps: Provide written information about dementia, benefits of registration with GP memory service, arrange follow-up cognitive assessment in 3 months, advise on legal/financial planning and support groups

Key Learning Points

• Always seek a clear timeline and examples of functional decline: progressive short-term memory loss, impaired instrumental activities and hippocampal atrophy point towards Alzheimer’s disease.

• Review medications and look for reversible contributors (e.g., anticholinergic drugs, infection, metabolic causes) — treat or stop those that may worsen cognition.

• Delivering a diagnosis of dementia requires clear, empathetic communication with both patient and family, assessment of capacity and safety (including driving), and a plan that combines symptomatic treatment, vascular risk modification, and social support.