ℹ️ This is the case information for the doctor.
Name
George Williams
Age
82 years old
Address
12 Hillcrest Avenue
Social history
George is a retired bank manager, living with his wife Margaret in their own home.
He does not smoke, drinks the occasional glass of sherry, never to excess.
Margaret has a diagnosis of Alzheimers dementia made 3 years prior.
Past history
Osteoarthritis left knee - 6 years ago
Osteoarthritis hands -12 years ago
Hearing loss - 7 years ago
Annual flu vaccine, up to date
Investigation results
BP 134/78, no concerns raised - 8 months ago
Medication
Ibuprofen gel 10%
Booking note
Asking for advice about Margaret's care.
ℹ️ This is the information for the person role playing the patient.
Name
George Williams
Age
82 years old
Address
12 Hillcrest Avenue
Social history
George is a retired bank manager, living with his wife Margaret in their own home.
He does not smoke, drinks the occasional glass of sherry, never to excess.
Margaret has a diagnosis of Alzheimers dementia made 3 years prior.
Past history
Osteoarthritis left knee - 6 years ago
Osteoarthritis hands -12 years ago
Hearing loss - 7 years ago
Annual flu vaccine, up to date
Medication
Ibuprofen gel 10%
"Doctor, I… I’m really worried about my wife, Margaret. She keeps wandering off when we go out and I’m exhausted trying to keep her safe all the time. I’m just not coping anymore..."
Margaret was diagnosed with Alzheimer’s disease three years ago. Her memory and reasoning have gradually worsened.
Over the last six months, she has started going out on her own, sometimes wandering away when out shopping together, even leaving the house at odd times if a door is left unlocked.
George finds it difficult to manage these episodes; he is constantly anxious and follows her everywhere to prevent her from getting lost.
He feels exhausted, lonely and “barely holding it together”.
ℹ️ To mark data gathering & diagnosis select from the descriptors below.
Positive descriptors
Negative descriptors
Data gathering was systematic and targeted ensuring patient safety.
Explores George’s main concerns and Margaret’s recent behavioural changes.
Gathers structured information about incidents that have increased risk (e.g. leaving the house alone, getting lost, being found by others).
Data gathering was incomplete, lacking structure and focus.
Fails to clarify the specific risks posed by Margaret’s wandering or does not elicit recent examples.
Jumps between Margaret’s and George’s needs without a clear line of questioning, missing key safety information.
The presence or absence of relevant red flags was established.
Questions about new or worsening symptoms in Margaret to rule out delirium (e.g. infection, pain), psychosis, or neglect.
Checks for recent events raising safeguarding concerns (e.g. Margaret found on the street, risk of harm to herself or others).
Fails to assess key information necessary to determine risk.
Omits questions about reversible causes of deterioration or recent injuries/episodes where Margaret was at risk.
Neglects to ask about hazards in the home or other evidence of neglect or self-neglect.
Information gathered placed the problem in its psychosocial context.
Explores how caring for Margaret affects George’s mental health, daily life, relationships and sense of isolation.
Elicits support network, social activities, and impact on George’s emotional wellbeing.
The social and psychological impact of the problem was not adequately determined.
Ignores carer strain, emotional burden, and loss of social support for George.
Fails to acknowledge or ask about the psychosocial consequences of the caring role.
Relevant information was collected to place the undifferentiated problem in context and an appropriate differential diagnosis generated.
Elicits information on new behaviours, triggers for wandering, changes in physical health, and possible unmet needs.
Explores both Margaret’s presentation and George's increasing inability to cope, generating appropriate differential diagnoses (e.g. delirium, carer breakdown, safeguarding concern).
Inadequate information was collected to determine the likely cause of symptoms.
Misses new triggers for wandering or does not explore if Margaret’s behaviour is due to reversible illness or environmental factors.
Does not consider carer distress or risk of carer breakdown.
Revises hypotheses as necessary in light of additional information.
Responds to new details during consultation (e.g. recent falls, increased confusion) by expanding the assessment and adjusting approaches.
Adjusts focus if, for example, physical decline, safeguarding, or carer burnout becomes more urgent.
Rigid consulting with new information not adequately considered and integrated into the working diagnosis.
Does not adapt assessment in response to red flags or psychosocial clues.
Sticks rigidly to initial questions, missing important emergent issues such as risk to Margaret, or acute carer distress.
Data gathering considered immediate safety, legal, and safeguarding responsibilities.
Specifically asks about Margaret’s capacity to make decisions about her activities; checks if Lasting Power of Attorney exists.
Assesses immediate risk and takes steps for urgent safeguarding or referral if necessary.
Data gathering missed key safety, legal, and safeguarding concerns.
Fails to assess Margaret’s capacity or does not consider the need for information sharing if there is a risk to her or others.
Overlooks safeguarding procedures and legal considerations regarding confidentiality and decision making.
ℹ️ To mark clinical management & medical complexity select from the descriptors below.
Positive descriptors
Negative descriptors
Offers management options that are safe and appropriate:
Ensures Margaret’s immediate safety by discussing home safety (e.g. door alarms, personal alarms, and action plan for what to do if she is missing.
Arranges urgent adult social care assessment for Margaret’s needs and George’s support, whilst considering medical causes of worsening confusion or behaviour.
Fails to provide appropriate and or safe management choices:
Omits to address the urgent risks of wandering or fails to arrange for a social care assessment.
Provides superficial reassurance without a structured action plan for safety or ignores George’s expressed need for help.
Empowers self-care and independence:
Explains local dementia support resources (Alzheimer’s Society, Carers UK, memory cafes) and discusses tools for carer resilience and self-care.
Encourages George to identify supportive friends, take breaks, and use respite if offered.
Management fails to foster self care and patient involvement:
Fails to alert George about dementia resources or neglects the importance of his own health and social needs.
Does not suggest ways for George to maintain independence or improve his coping.
Prescribes safely considering local and national guidance:
Reviews Margaret’s medications for potential contributors to confusion or agitation; avoids inappropriate antipsychotics in line with guidance.
Advises on avoiding over-the-counter medicines that could worsen confusion.
Unsafe prescribing ignoring best practice:
Increases or introduces antipsychotics without discussion or clear indication, contrary to best practice.
Makes medication changes without considering interactions or the effects on cognition.
Refers appropriately being mindful of resource:
Refers Margaret promptly for social services needs assessment and, where appropriate, for care package or specialist memory support.
Offers George a Carer’s Assessment, involving him in referral pathways relevant to carer support.
Contacts relevant voluntary sector agencies/charities, avoids unnecessary hospital referral if safe.
Sends patients for specialist input unnecessarily:
Refers directly for hospital or mental health admission where community support is more appropriate and immediate risks do not meet the threshold.
Misses opportunity to involve support agencies or ignores resource limitations.
Arranges appropriate follow up:
Clearly explains what happens next: social services contact, GP review for both, safety netting for new symptoms or escalation.
Ensures both George and Margaret know who to contact with queries or in case of worsening.
Unclear or inadequate follow up:
Provides vague/disjointed advice such as “call back if worried” without structured safety netting or clarity about timescales.
Neglects to offer or book any form of review or follow-up.
Manages uncertainty, including that experienced by the patient:
Acknowledges prognosis of dementia, explains that behavioural symptoms are variable and may fluctuate.
Provides clear safety-netting and discusses how to access urgent help should risks escalate.
Negative Area Struggles with uncertainty, leading to inconsistent decisions:
Attempts to provide spurious certainty about outcomes or ignores George’s worries about the unpredictable nature of Margaret’s dementia.
Fails to prepare the family for evolving care needs or emergencies.
ℹ️ To mark relating to others select from the descriptors below.
Positive descriptors
Negative descriptors
Tailors management options responsively according to circumstances, priorities and preferences:
Explores and incorporates George’s and Margaret’s preferences (e.g. wish to remain at home, level of independence, acceptable risk) into decisions about care and support.
Adjusts plans if local resources are delayed, such as interim carer support, while awaiting assessments.
Management options fail to adequately consider patient preference and circumstance:
Recommends generic, non-specific dementia care without gauging what kinds of interventions George and Margaret actually want or need.
Pursues a rigid care approach regardless of their circumstances or wishes.
Shows ability to communicate in a person-centred way:
Acknowledges the emotional burden and exhaustion George expresses regarding his caring role for Margaret.
Validates George’s experience of anxiety and worry when Margaret wanders, responding with active listening and empathy.
Communication is doctor-centred and lacks empathy:
Focuses on clinical details about Margaret’s wandering without recognising George’s visible distress.
Ignores or glosses over George’s statements about feeling overwhelmed or anxious.
Explores the patient’s agenda, health beliefs and preferences:
Encourages George to share his concerns, experiences, and hopes for managing Margaret’s risks and maintaining her dignity.
Asks about George’s expectations for support, including feelings about possible respite care or community input.
Fails to recognise the patient’s agenda and impact of the problem:
Fails to ask about George’s own needs or beliefs about dementia care and safety.
Does not consider how increased risk may affect family dynamics or George’s mental health.
Recognises what matters to the patient and works collaboratively to enhance patient care:
Works with George to co-produce a plan for keeping Margaret safe, taking into account Margaret’s wishes if capacity allows.
Invites George’s input into planning, e.g., discussing local support, immediate changes at home, and escalation procedures.
Fails to work with the patient to plan care:
Proposes management without checking if suggestions are workable or acceptable to George and Margaret.
Disregards Margaret’s autonomy orGeorge’s experience in decision-making.
Demonstrates flexibility of communication adapting to the patient and scenario:
Uses clear, simple language toexplain dementia progression, risk of wandering, and local support options.
Adjusts explanations if Georgeappears confused or overwhelmed, ensuring he has time to process information.
Consults rigidly, providing generic explanations and management plans:
Uses jargon or complex explanations, leaving George unsure how to proceed.
Repeats generic information about dementia without adapting to George’s questions or emotional state.
Checks the patient’s understanding of the consultation including any agreed plans:
Summarises the agreed approach with George, checking he understands next steps for safeguarding and carer support.
Confirms George knows how to access urgent help or follow up if circumstances change.
Does not seek to confirm understanding:
Finishes the consultation without checking George has understood what is being proposed.
Does not check whether George feels confident about what happens next.
ℹ️ Insights from the examiner
Some helpful questions to open up the story
“Can you tell me what’s been happening with Margaret?"
"What’s made you most worried lately?”
Asking: “Before today, whats upport have you tried to keep Margaret safe?” reveals the family’s currentcoping and helps target your plans.
Share your clinical thought process aloud:
“I want to work out if there’s anything we can treat that might be making this worse for Margaret—like an infection or problems with her tablets.
At the same time, I want to help you get more support at home so you can take care of yourself too.”
This helps the patient (and examiners) see that you’re reasoning holistically and safely.
“It sounds exhausting, George. I can see you’re really worried about Margaret’s safety.
How have you been coping yourself with all this?”
Examples
“You seem really tired, George—Ican see this is having a big impact on you.”
“It’s understandable if you feel burnt out—being a full-time carer is a huge challenge.”
“What worries you most when Margaret goes missing?”
Goals commonly address: immediate safety, sleep, access to respite, understanding dementia progression.
“Are you looking for more support day-to-day, or perhaps you need a short break from being a carer to get your energy back??”
Maintain logical sequencing:
Start with Margaret’s behaviours, the potential cuases and move naturally to how this affects George and what’s already tried.
Main differentials are:
Explanations should be clear,short, and relevant:
“Alzheimer’s can cause people towander and become confused. Sometimes, things like infections or pain can makethis worse—so I’ll want to check for those.”
Normalising can help feel supported and improve coping
“You’re not alone—lots of carers feel overwhelmed.”
Avoid long, unfocused explanations.
Immediate assessment for infection/pain/delirium
Review of medication (
Urgent referral to Social Services for a Needs Assessment and respite care (shortbreaks, day centres)
Carers Assessment for George (statutory right under Care Act 2014)
Contacting the Alzheimer’s Society for advice and local support (groups, education)
Information and referral to Admiral Nurses (specialist dementia nurses)
Home adaptation (door sensors,locks)
Consider referral to elderly care psychiatry if severe behavioural and psychological symptoms
Local support groups, Carers UK,counselling for George
Reflect Margaret’s risk (wandering triggers, history) and mental capacity about her own safety.
Balance George’s needs (support, rest, his health) alongside Margaret’s autonomy and preferences.
Any wandering incident in a person lacking capacity is a potential safeguarding risk. Refer promptly, explain this to the carer with empathy, and document your reasoning for information sharing.
Assess capacity for each decision (Margaret may have insight for some issues, not others).
If safety risk is present, override confidentiality only as necessary.
Useful reading
Alzheimer’s Association - Advice on wandering
Alzheimer’s society - Carer burnout in dementia
