Dementia — Written Clinical Reasoning

SAQ 1 — Mixed Dementia with BPSD, Polypharmacy, and Carer Strain (20 marks, 30 minutes)

Prompt: Outline your integrated assessment and management plan for this patient, including the diagnostic reasoning, the medication review, the approach to his behavioural symptoms, the discussion of driving and capacity, and the plan to support his wife. Justify each decision with reference to evidence and guideline recommendations. ^[1]

Model Answer

Diagnostic reasoning and problem framing (3 marks): ^[1]

This man has a progressive cognitive decline over 3 years, now with functional impairment and behavioural symptoms — the clinical picture is of a major neurocognitive disorder (dementia), most likely mixed Alzheimer and vascular dementia. The insidious progressive memory and executive decline over years supports Alzheimer pathology; the white matter changes on CT, the hypertension, the ischaemic heart disease, the brisk reflexes and shuffling gait, and the stepwise contribution of his recent hospitalisation all add a vascular component. Pure subtypes are uncommon in a 79-year-old — mixed dementia is the most likely real-world diagnosis. The recent urinary tract infection and the evening confusion raise the question of delirium superimposed on the dementia, but the trajectory of decline over 3 years is the underlying dementia. ^[1]

The problems are: ^[1]

1. Mixed Alzheimer and vascular dementia, moderate stage (MoCA 14, functional impairment in finances and medications).
2. Behavioural and psychological symptoms (BPSD) — evening agitation ("sundowning"), accusatory delusions (theft of the wallet), nocturnal wandering — driving carer strain and safety risk.
3. High anticholinergic and sedative drug burden — oxybutynin (a potent antimuscarinic directly opposing any cholinergic strategy), codeine (an opioid contributing to sedation, constipation, and cognitive impairment).
4. Fall risk — unsteady gait, evening agitation, nocturnal wandering, and the vasodilatory effect of amlodipine all increase fall and fracture risk.
5. Vascular risk factor management — hypertension (on amlodipine), ischaemic heart disease (on aspirin and atorvastatin), and the prevention of further cerebrovascular events.
6. Driving safety and capacity assessment — he was driving until recently and is now clearly unsafe.
7. Carer strain — his wife is exhausted and is the pillar of his community care; her health and wellbeing are central to his.
8. Advanced care planning — power of attorney, guardianship, future care preferences — to be initiated while he retains some capacity. ^[1]

Medication review (4 marks): ^[1]

This is one of the most effective interventions I can make. I will review every drug against its cognitive and functional impact: ^[1]

• Oxybutynin — stop it. It is a potent antimuscarinic anticholinergic with high blood-brain barrier penetration, directly worsening cognition and opposing the mechanism of any cholinesterase inhibitor I might start. For his overactive bladder, I would switch to a non-anticholinergic option (mirabegron, a beta-3 agonist) or manage with timed voiding and bladder training.
• Codeine — stop or minimise. It is an opioid causing sedation, cognitive blunting, and constipation. I would switch to regular paracetamol for his osteoarthritis, consider topical NSAIDs, and reserve a short-acting opioid only for severe pain.
• Amlodipine — review the dose. His evening agitation, his unsteadiness, and his falls raise the possibility of orthostatic hypotension (exacerbated by the vasodilatation). I would check lying and standing blood pressure, and reduce or adjust his antihypertensive to avoid hypotension — the target in dementia with falls is a balance between vascular protection and fall prevention.
• Aspirin and atorvastatin — continue. These address his ischaemic heart disease and secondary vascular prevention; statins have not been shown to worsen cognition and should not be stopped for that reason.
• Start a cholinesterase inhibitor. Donepezil 5 mg at night, increasing to 10 mg after 4 weeks, is first-line for mild to moderate Alzheimer (and has modest benefit in mixed and vascular dementia; Birks 2006, PMID 16437532). I will check a baseline ECG first (donepezil can cause bradycardia and AV block). As the disease progresses to moderate-severe, I would add memantine. ^[1]

Management of the behavioural symptoms (BPSD) (4 marks): ^[1]

I will follow the BPSD escalation ladder: ^[1]

Step 1 — Search for and treat precipitants. The evening agitation ("sundowning") and the recent change in behaviour may be driven by unmet needs: pain (his osteoarthritis), a recurrence of urinary symptoms (retention or infection, especially after stopping oxybutynin), constipation (from codeine), dehydration, sensory deprivation (does he have his glasses and hearing aids?), or intercurrent delirium. I will check a urinalysis, a bladder scan, a rectal examination, and a blood panel. ^[1]

Step 2 — Non-pharmacological measures. A structured evening routine, adequate lighting as dusk falls (to reduce sundowning), familiar objects, a clock and calendar, reassurance and redirection (not argument) around the delusional beliefs, a safe environment for nocturnal wandering (alarms on the door, a clear walkway), and increased daytime activity and light exposure to consolidate the sleep-wake cycle. ^[1]

Step 3 — Pharmacological treatment, targeted and time-limited. For the accusatory delusions and the evening agitation, if non-pharmacological measures and the precipitant search are insufficient and the behaviour is causing distress or risk, I would consider a time-limited trial of risperidone 0.25 mg in the evening, titrated cautiously, reviewed every 2 to 4 weeks, and stopped if ineffective — recognising the increased mortality (Schneider 2005, PMID 16234500) and stroke risk. I would first exclude Lewy body dementia (the fluctuation, hallucinations, and parkinsonism are not the dominant features here, and the shuffling gait and brisk reflexes fit the vascular picture), because an antipsychotic would be absolutely contraindicated if DLB were the diagnosis. An SSRI (citalopram) is an alternative for the agitation, with a lower side-effect burden than antipsychotics. ^[1]

Driving and capacity (3 marks): ^[1]

Driving: He is no longer safe to drive. The MoCA of 14, the impaired orientation, the visuospatial and executive impairment, the recent falls, and the nocturnal wandering all indicate that he lacks the judgement, reaction time, and attention required. In Australia, there is a legal obligation to report his condition to the licensing authority (the requirements differ by state); I would counsel him and his wife honestly, document the advice, and provide a medical certificate. I would frame the conversation compassionately and pair it with a plan for alternative transport (community transport, family) to preserve his autonomy and social engagement. ^[1]

Capacity: Capacity is decision-specific and time-specific. He may retain capacity to express care preferences and to appoint his wife as enduring guardian, but he clearly lacks capacity to manage his finances or to make complex medical decisions. I would assess his capacity using the functional test (understand, retain, weigh, communicate) at the best time of day (usually morning). I would facilitate the appointment of an enduring power of attorney (for financial decisions) and an enduring guardian (for health and lifestyle decisions) while he retains the capacity to participate, and I would initiate an advance care directive documenting his values and preferences. ^[1]

Supporting his wife (3 marks): ^[1]

His wife is exhausted, and carer strain is the commonest reason for institutionalisation. I would offer: ^[1]

• Education about the diagnosis, the trajectory, and the management — demystifying the behaviour and giving her practical strategies (the Validation technique, structured routines, managing the delusional beliefs without arguing).
• Formal carer support — a carer assessment, referral to a dementia support organisation (Dementia Australia in ANZ, Alzheimer's Society in the UK), and a carer support group.
• Respite — in-home respite, day programmes, and eventually residential respite — to give her regular breaks.
• Practical help — a community aged care package (home care package in Australia) for assistance with shopping, cleaning, medications, and personal care.
• Monitoring of her own health — carers have high rates of depression, anxiety, and physical illness; I would screen her with the Zarit Burden Interview or a depression screen and treat actively.
• A safety plan — what to do if he becomes aggressive, if he wanders and is lost (an identification bracelet or GPS tracker), or if she is unable to cope (the number for crisis respite). ^[1]

Prognosis and follow-up (3 marks): ^[1]

I would set realistic expectations: the dementia will progress, the cholinesterase inhibitor will provide a modest stabilisation rather than a reversal, and the goal is to maintain his function, safety, and quality of life and to support his wife for as long as possible. I would arrange regular review (3 to 6 monthly), a cognitive reassessment to track the trajectory, medication review at each visit, and escalation of community support as needs increase. I would discuss the eventual transition to residential care as a future possibility (not an immediate plan), so the family is prepared. The principles of the Lancet Commission (Livingston 2020, PMID 32738937) — addressing vascular risk, sensory correction, social engagement, and carer support — are the framework for the longitudinal management. ^[1]