Abstract
You are working in an older adult community team and have been asked to talk to Miss Eva Selwyn, daughter of Mr Jacob Selwyn, a 68-year-old gentleman who has had some memory difficulties. Mr Selwyn has given his consent.
Practice Stations
Station 5.1: Alzheimer’s Dementia Collateral History
Station 5.2: Alzheimer’s Dementia Explanation
Station 5.3: Vascular Dementia Explanation
Station 5.4: Lewy Body Dementia Explanation
Station 5.5: Frontotemporal Dementia Collateral History
Station 5.6: Behavioural and Psychological Symptoms of Dementia
Station 5.7: Mild Cognitive Impairment Explanation
Station 5.8: Delirium Collateral History
Station 5.9: Capacity Assessment
Station 5.10: Psychotic Depression
Station 5.11: Mania
Station 5.12: Wandering
Station 5.13: Delusional Disorder
Station 5.14: Hoarding
Physical Examinations
Station 5.15: Cognitive Examination
Station 5.16: Parietal Lobe Examination
Station 5.17: Temporal Lobe Examination
Station 5.1 (90 Seconds)
Candidate Instructions
You are working in an older adult community team and have been asked to talk to Miss Eva Selwyn, daughter of Mr Jacob Selwyn, a 68-year-old gentleman who has had some memory difficulties. Mr Selwyn has given his consent.
Please take a collateral history, considering any possible relevant diagnoses.
Actor Instructions
You are Miss Eva Selwyn, the 35-year-old daughter of Mr Jacob Selwyn.
Your father has been increasingly forgetful over the past 12 months. You first became aware of this when he expressed concerns over missing various minor appointments; you initially dismissed this as part of getting older. However, recently he has been forgetting where he is and getting lost in previously familiar places.
He lives with your mother, who is fit and well. She has also noticed that your father has not been ‘quite right’ for some time. She recently told you that he has been struggling to ‘get the right words out’ and no longer takes pride in his appearance – often going unshaven for several days and buttoning up his shirt incorrectly.
Your father used to be an accountant and managed the family’s finances smoothly. Recently, he has been forgetting to pay bills, and you have now stepped in to help. You put this down to his difficulty with paying things online and modern technology, although you are aware this is not very plausible as your father has been using the internet for more than 20 years and ran his own business successfully.
Your father does not take any medications, has no known health conditions, and has not had any recent infections or medical procedures. He does not drink alcohol and does not smoke.
If asked, there has not been a change in his personality, and he has not been rude, been impulsive, or behaved oddly.
If asked, there has been no fluctuation to his symptoms, just a steady decline.
If asked, he has not had any visual hallucinations.
He has never seen a psychiatrist before, and there is no relevant family history that you can think of.
Feedback Domains
Knowledge
The candidate elicits the history of Alzheimer’s disease, including information across all or most of the following domains (which may also provide the candidate with a revision aide!):
Amnesia: The candidate asks whether there have been any short- and long-term memory difficulties – Do they often misplace things, can they remember shopping lists/restaurant orders, and do they remember important birthdays/anniversaries?
Aphasia: Expressive dysphasia – When they speak, is it grammatically incorrect, even though the meaning is intact? Receptive dysphasia – Have they ever clearly heard what you have said, but didn’t understand what you were saying? Lexical anomia – Do they have difficulty finding the right word, even though they know what it means?
Apraxia: Do they have difficulties in washing, dressing, cooking, and shopping?
Attention: Can they follow the storyline of a favourite television show or book?
Agnosia: Are they able to recognise people such as close family? How about those less familiar?
Awareness: Are they able to find their way home when out in the local area? Are they orientated to time, place, and person?
Risk Assessment
The candidate briefly explores all risks disclosed (e.g. wandering outside, which may lead to vulnerability from strangers) and others that may be relevant: Have they ever left the front door open? Are they vulnerable to financial exploitation? Have you noticed any fire risks, such as leaving the gas hob on?
Differential Diagnosis
The candidate screens for risk factors and symptoms of the common dementias, as well as other causes of impaired cognition:
Vascular : any history of stroke/TIAs, ischaemic heart disease, diabetes, smoking, pattern of symptom progression (stepwise or steady)
Lewy Body: visual hallucinations, fluctuating consciousness, falls, parkinsonism
Frontotemporal: personality changes and impulsivity, positive family history of connected conditions (FTD, MND, early-onset dementia, late-onset psychosis)
Depression: mood changes that might indicate the pseudodementia of depression.
Alcohol: any history of alcohol misuse to exclude alcohol-related brain damage
Medication: any current use of medications that may contribute to memory impairment
Station 5.2 (4 Minutes)
Candidate Instructions
You have been given consent to talk to Ms Rachel Brown, whose 78-year-old mother, Mrs Eleanor Brown, was recently reviewed in the older adult community team clinic.
Relevant Investigations
Addenbrooke’s Cognitive Examination1 (ACE-III): 46/100.
Hospital Anxiety and Depression Scale2 (HADS): Anxiety 4/21, Depression 1/21.
MRI Report: ‘There is significant global atrophy considering age of patient, with widening of the sulci and bilateral ventricular enlargement. Bilateral mesial temporal lobe atrophy is noted with marked hippocampal involvement. Pronounced atrophy also noted in the parietal lobes.’
All blood tests were within normal range (full blood count, C-reactive protein, renal function, liver function tests, thyroid function tests, lipid profile, vitamin B12/folate, negative syphilis screen).
Past Medical History
Osteoporosis
Diverticular disease
Medications
Nil allergies
Alendronic acid, 70 mg, once weekly
Colecalciferol with calcium carbonate, 400 units, twice a day
Paracetamol, 1 g, four times a day
Lactulose, 10 ml, twice a day
Mrs Eleanor Brown lives alone in her own three-bedroom house. She does not drink alcohol or use illicit substances. She does not have carers and is independent in all activities of daily living.
Explain the diagnosis and management of Alzheimer’s disease to Mrs Brown’s daughter.
Actor Instructions
You are Ms Rachel Brown, the highly anxious daughter of Mrs Eleanor Brown. Your mother recently had some memory tests and has asked you to talk to the doctor about the results. You have been concerned about your mother’s memory for some time, so when the candidate breaks the news, the diagnosis of Alzheimer’s disease does not come as a shock. You have read a little bit about the disease but became confused with all the other causes of dementia and would like to talk to someone knowledgeable about this.
If the candidate offers a complicated explanation of Alzheimer’s disease, you become overwhelmed and ask them to stop talking so that you can gather your thoughts. If the candidate takes note of this and then re-explains things in a clear manner, you calm down completely.
You are worried that the disease will progress and want to know exactly what you can do to help prevent it. One of your neighbours had memory problems and took a tablet to help. You want to know whether this tablet could be prescribed to help your mother and wonder exactly how it works.
Your mother lives close to you, and you see her regularly; however, you do have a busy job as a social worker and therefore are keen to understand what services might be available to help her should she deteriorate.
Feedback Domains
Knowledge
The candidate is able to clearly and concisely explain that dementia is an umbrella term for conditions that in clear consciousness affect cognition, function, and behaviour. It results in global deterioration and is progressive and irreversible.
The candidate distinguishes this broader term from Alzheimer’s dementia specifically and states that this is the most common subtype of dementia. They explain (in as much or as little detail as the relative wishes) that Alzheimer’s is thought to be caused by the build-up of protein that forms plaques and tangles that disrupt the normal connectivity of the brain, damaging or destroying healthy brain cells and ultimately causing brain volume loss. Age is the biggest known risk factor for Alzheimer’s disease.
Management
Medication
The candidate explains how anti-dementia medications work using non-technical language. They explain that in some types of dementia, including Alzheimer’s, it has been found that levels of a brain chemical called acetylcholine are low. Medications used to treat Alzheimer’s inhibit the breakdown of that chemical, thus increasing levels in the brain.
These medications do not cure Alzheimer’s, but they can slow down progression of the disease and may improve symptoms. Common side effects affect the gastrointestinal system, with symptoms of diarrhoea, nausea, and vomiting. Therefore, medication should be started at a low dose and titrated up accordingly.
Psychological Interventions
There are a variety of creative and evidence-based therapies used in the management of Alzheimer’s dementia and other cognitive impairments. Reminiscence therapy involves the use of aids (e.g. photos, music, or films from the past, or activities like designing rooms in keeping with the era in which they were young) to re-create memories and remind patients of familiar times. In advanced dementia, interventions such as the use of a soft toy for comfort, touch therapy, and aromatherapy have helped to reduce agitation.
Social Management
The candidate briefly discusses other services that could help Mrs Brown. These include carers to help with washing, dressing, and meal preparation; compliance aids for medication, such as a dosette box or blister pack; and assessment at home by an occupational therapist to determine whether adaptations may be needed. Lastly, the candidate adds that the daughter could attend a local dementia carers’ group for further support.
Communication
The candidate ideally presents as confident and calm, and remembers to offer written information since a great deal of information has been covered.
Author’s Note
Alzheimer’s disease is a common condition in older adult psychiatry and therefore one that should be understood thoroughly by all candidates. The key here is to deliver the information in a way that is understandable to a non-medic. Giving a complex explanation using medical jargon is likely to cause increased anxiety in this relative.
This station could be easily adjusted to focus on detailed explanations of the social component of the management plan. Candidates might in that case be required to address potential capacity issues, and whether a lasting power of attorney for health and welfare and/or property and financial affairs would be suitable.
Station 5.3 (4 Minutes)
Candidate Instructions
You are working in an older adult community team and have been asked to speak to the son of Mrs Helen Beckenham, a 78-year-old patient who has recently been assessed by your colleague.
Mrs Beckenham was initially referred by her GP due to concerns about her memory and behaviour. Her husband had noticed that she had become increasingly irritable, and he recently found her wandering in the street, unable to remember where she was going.
The GP requested various investigations, including a full blood count, B12/folate, renal function, liver function, inflammatory markers, thyroid function, bone profile, glucose, and urine dip. All results were within the normal range.
Mrs Beckenham has a past medical history of type II diabetes, hypertension, hypercholesterolaemia, and a previous CVA (with residual right arm weakness).
Your colleague carried out a cognitive test, on which Mrs Beckenham scored 68/100 (ACE-III). On the HADS, her score was 2/21 for depression and 5/21 for anxiety.
An MRI scan was reported as follows: ‘There are extensive periventricular and deep white matter T2/FLAIR hyperintensities. Although non-specific, in the context of previous multiple infarcts this suggests marked chronic small vessel disease. No microhaemorrhages on susceptibility weighted imaging. There is moderate cerebral volume loss with no lobar predominance secondary to ventricular enlargement.’
Mrs Beckenham lives with her husband and is normally fully independent in all activities of daily living. She continues to drive and attends a local pension club twice a week.
Please explain the diagnosis to Mr Sam Beckenham, the patient’s son, and answer any questions he may have about management.
Actor Instructions
You are Mr Sam Beckenham, the eldest son of Mrs Helen Beckenham. Your father recently told you that your mother has dementia, which was a shock as you saw her only three months ago and she appeared very well. You remain sceptical of the diagnosis – your mother remains very independent and still drives to the shops and attends a pension club twice a week. You work as a porter in the local hospital and have heard that infections can cause confusion and wonder if this may in fact be the cause of your mother’s difficulties.
You want to know how the team has come to diagnose dementia and what this means. You have only heard about Alzheimer’s disease in relation to memory problems, and you aren’t clear whether this means the same as dementia. You have never heard of vascular dementia.
You are worried that you may inherit this condition if it is the correct diagnosis.
If the candidate is able to give a clear explanation of how the team came to the diagnosis and you agree, you should then ask what the management options are. You have heard that some people with memory problems are prescribed tablets to help and want to know more about this.
Feedback Domains
Knowledge
The candidate is able to broadly define dementia (see Station 5.2).
The candidate demonstrates knowledge of vascular dementia and explains in understandable language that it is caused by damaged or blocked cerebral blood vessels, causing cerebral atrophy. They describe the progression of vascular dementia as stepwise, with a sometimes sudden onset.
The candidate is able to elicit a brief history of presenting complaint and identifies, together with the use of relevant investigations, that delirium and depression (low score on HADS) are not the cause of these cognitive problems.
The candidate explains when asked that there is no evidence to suggest that vascular dementia is inherited. However, other health conditions that contribute to vascular dementia, such as diabetes or hyperlipidaemia, may be passed from one generation to another.
Management
The candidate uses a biopsychosocial approach with regard to management.
The candidate describes the correct medical treatment (including management of risk factors such as diabetes, hypertension, hyperlipidaemia, and smoking, as well as lifestyle changes to prevent further vascular events). They are able to identify that acetylcholinesterase inhibitors are not appropriate in ‘pure’ vascular dementia as is laid out in this scenario (as opposed to a mixed dementia).
The candidate discusses appropriate psychological interventions, such as advice on how to reduce irritability and aggression using distraction techniques or reminiscence therapy (see Station 5.2 for further information).
The candidate discusses available social supports, including befriending services through charitable organisations, support for carers, and practical help with finances.
Risk Assessment
The candidate identifies the risk of driving and briefly addresses this with the son.
Communication
The candidate avoids use of medical jargon. They use ‘chunking and checking’ (giving small amounts of information and then checking the son’s understanding before moving on) or a similar technique to avoid overwhelming the relative with information. They offer leaflets and/or follow-up appointments at the end of the discussion.
Author’s Note
This is a relatively straightforward station that simply requires practice to ensure that you explain the diagnosis in a clear and concise manner, leaving ample time for questions.
Your knowledge of vascular dementia could just as easily be tested in a scenario where you are asked to obtain a collateral history from the patient following a stroke, with or without residual affective symptoms.
Station 5.4 (4 Minutes)
Candidate Instructions
You are working on an older adult psychiatry ward and have been asked to speak to Mr Sena de Silva’s daughter, Miss Ramya de Silva. She wants to know more about her father’s recent diagnosis.
Mr Sena de Silva is a 75-year-old gentleman who was admitted to the ward two months ago due to increasingly disturbed behaviour and memory problems. He was initially managed on a medical ward, with a working diagnosis of delirium secondary to constipation. However, following medical treatment, it became clear that there was an underlying cognitive disorder. Of note, it was documented in the initial assessment that Mr de Silva was experiencing visual hallucinations of birds flying around the hospital.
A recent ACE-III score was 42/100, and the DaT scan performed last week was reported as follows: ‘Scan demonstrates symmetrically reduced uptake of tracer throughout the striata involving the caudate and putamen. This appearance is consistent with the bilateral loss of the pre-synaptic dopaminergic terminals. This abnormal appearance is consistent with a diagnosis of Lewy Body Dementia; it may also be seen in idiopathic Parkinson’s disease or Parkinson’s Plus.’ On examination, there is no notable movement disorder.
Explain to the patient’s relative the diagnosis and management of Lewy body dementia.
Actor Instructions
You are Miss Ramya de Silva, the daughter of Mr Sena de Silva. You are very close to your father and have found these recent experiences extremely upsetting. You are the youngest of three daughters and have found it stressful having to relay information between the ward and your family.
Your father was initially admitted to a medical ward and treated for severe constipation, and you were told that was the likely cause of his symptoms. However, the doctors later told you that it might be a type of dementia and transferred your father to this ward.
You have noticed that your father has been increasingly forgetful over the past six months. At first you thought it might be simply a part of getting older, but you have become more concerned recently, especially when he got lost walking to your aunt’s house. Since his admission to this hospital, you have been told about various investigations that your father has undergone, including something called a DaT scan. You were told the results supported the diagnosis of Lewy body dementia, something that you have never heard of. You would like to know more about this diagnosis and what this means for your father.
Your father lives with you, your husband, and your two young children. You would like for him to return to live with you but are worried about what might happen once he is discharged from the hospital. Prior to admission, your father told you he kept seeing birds flying around the house, although these were not real. He became so distressed that he started using his walking stick to bat them away. This resulted in your father smashing a window and nearly hitting your younger child.
If the candidate offers a large amount of information without a gap, you appear confused and become overwhelmed.
Feedback Domains
Knowledge
The candidate initially begins with an explanation of dementia (see Station 5.2) and makes it clear that Lewy body is one type of dementia with some different typical symptoms. They may explain that Lewy bodies are deposits of abnormal proteins that enter and cause the death of brain cells, subsequently leading to deterioration of the brain.
The candidate explains that Lewy body dementia characteristically causes problems with memory and movement. Symptoms also often include vivid visual hallucinations and fluctuating confusion (patients can dramatically swing from alert to confused, in a short period of time). Other suggestive features include syncope and frequent falls. Movement problems may appear similar to those of Parkinson’s disease, with patients exhibiting rigidity of joints, slowness of movement, and a tremor. Sleep is often affected, with vivid dreams and difficulty turning over in bed.
Management
The candidate is able to sensitively explain that there is currently no cure for Lewy body dementia; however, symptoms can be alleviated by a variety of methods.
The candidate explains that there are anti-dementia medications that could be prescribed to slow the progression of cognitive decline and improve symptoms. Recommended first-line medication is an acetylcholinesterase inhibitor, and the second-line recommendation is memantine.3 Additionally, medications used to treat Parkinson’s disease can reduce some motor symptoms. It is important to note that antipsychotics are avoided in Lewy body dementia due to potentially fatal neuroleptic sensitivity.
Other interventions that family members can participate in to reduce agitation include encouraging physical activity and a daily routine, reminiscence therapy, and supporting the patient with a diet with increased fibre to avoid constipation (see Station 5.6).
Author’s Note
Due to the overlap of symptoms with Parkinson’s dementia, the diagnosis of Lewy body dementia can be difficult. However, after taking a thorough history and timeline of symptoms, you will be able to establish whether cognitive symptoms started before motor symptoms (indicative of Lewy body dementia) or vice versa (indicative of Parkinson’s dementia).
There are only a few known risk factors for Lewy body dementia, with age more than 65 years being the strongest.
Station 5.5 (90 Seconds)
Candidate Instructions
You are working in liaison psychiatry and have been asked to see Mrs Cynthia Louis-Ward, the wife of 65-year-old Mr Aubrey Louis-Ward. She called the police today due to a violent altercation at home.
Please take a history about the recent changes in behaviour and conduct a risk assessment.
Actor Instructions
Your name is Mrs Cynthia Louis-Ward, and your husband, Aubrey, tried to strangle you this morning. He has never assaulted you before, and you are frightened something terrible is happening to him, as he is ‘no longer the man you married 30 years ago’.
You start by crying and are barely able to answer questions at first. You clutch your neck, which remains painful although another doctor has just given you appropriate pain relief, which should take effect soon.
If the candidate is sympathetic and gentle in manner, then you calm down and gradually start to answer questions at the chosen pace of the candidate.
This morning you prepared your husband’s usual breakfast of toast and tea. As he started spreading jam, you gently reminded him that this would be bad for his blood sugar (he is usually careful with his diabetes). He flew into a rage, shouted obscenities, and then ran toward you. Aubrey grabbed your neck and started to strangle you. You remember your dog barking, and eventually he let go. You ran upstairs and called the police.
This is the first time he has ever assaulted you, but reflecting on things, you are not entirely surprised by his behaviour. You both run a business together, and over the past few years your husband has been increasingly ‘stressed with work’: coming home and shouting at you, sending rude emails to colleagues, and making embarrassing social faux pas, such as making a sexual joke in his speech at your daughter’s wedding last year. Your employees have complained about your husband’s behaviour, and, indeed, one female colleague left after rumours of sexual harassment (you never found out what happened).
Prior to today’s incident, your husband had never been arrested or had any dealings with the police.
The only medical condition your husband has is diet-controlled diabetes. He does not take any medications.
Your husband has never seen a psychiatrist for any mental health difficulties.
If the candidate asks about family history, you recall that your husband’s father had ‘Pick’s disease’. You don’t know what this is and never met his father.
Apart from the changes in personality, there are no other symptoms (e.g. memory loss) that you have noticed.
Your husband used to be a quiet, loving, and mild-mannered man who was considerate and kind toward others.
Feedback Domains
Knowledge
The candidate is able to elicit the slowly progressive symptoms of frontotemporal dementia and asks about the following symptoms:
Personality and behaviour – disinhibition, impulsiveness, apathy, repetitive behaviours, hyperorality, mood changes (labile, depressed, anxious), aggression
Executive dysfunction – inattention, inability to perform complex tasks, behavioural rigidity
Language – slow, hesitant speech; telegraphic speech; word-finding difficulties
Memory – often affected later and to a lesser degree than other dementias
Motor – akinesia, rigidity, balance and coordination difficulties
Additional Relevant History
The candidate screens for common causes of personality change, such as delirium, infections, mood and affective disorders, psychosis, stroke, and other neurological conditions.
They elicit that this has been a change over many years, rather than acute onset. The relatively young age of the patient should prompt an enquiry about family history (which here includes Pick’s disease).
Risk Assessment
The candidate asks directly not only about the risk of today’s events but also about forensic history (here, nil).
The candidate asks about suicidal ideation and self-harm.
The candidate assesses risk associated with the change in personality: Has he previously made threats to harm others? Has he ever acted inappropriately toward others? Has he been sexually disinhibited toward others? If so, toward whom and what happened?
Communication
The candidate picks up on clear cues from the informant: first, that she is in shock and distress (and therefore needs reassurance, a calm atmosphere, and sufficient time). They notice that she is clutching her neck and empathise appropriately. They explain the reason for the interview and the nature of the questions, perhaps making a statement that recognises how difficult the situation has been and explaining that the change in personality may point toward a diagnosis that requires investigation.
Author’s Note
Frontotemporal dementias account for a high proportion of dementias in those aged 45–65 years. Whilst these remain rare, you are likely to come across this in clinical practice. There are a variety of underlying causes, including the build-up of tau protein forming Pick bodies (hence, the earlier name ‘Pick’s disease’), motor neurone disease, genetic mutations (MAPT, GRN, VCP, and C90RF72 genes), and (as with all dementias) aging.
There are different forms of the illness (‘behavioural variant’ and ‘semantic variant,’ among others), but for the purposes of this station, you will only be required to take a general history of the disease.
This is a hard station and the task is deliberately vague. By focusing on the history of personality change and keeping your differential diagnosis broad, you will get hints from the actor as to the diagnosis.
Station 5.6 (4 Minutes)
Candidate Instructions
You work in the older adult community team and have been asked to review Mr Joshua Holbrook, an 83-year-old male.
Mr Holbrook has Alzheimer’s dementia and has been a resident in the care home for one year. In the past month he has been irritable and aggressive, lashing out at patients and staff alike.
Mr Holbrook was assessed by another psychiatrist from your team, who prescribed low-dose risperidone. Initially, Mr Holbrook’s agitated behaviour resolved and he became calmer. However, over the past week he has again become unsettled, and care home staff are requesting that he be given a higher dose.
You are now at the care home. By chance, Mr Holbrook’s brother is also there and has asked to speak to you. He is angry and upset that his brother has been prescribed an antipsychotic and thinks that he is oversedated.
Past Medical History
Alzheimer’s dementia (diagnosed four years ago)
Current Medication
No allergies
Risperidone, 0.5 mg at night
Nursing Notes from Last Night
‘Mr Holbrook was up all night. He was banging his head against his hand, and hit staff when they tried to intervene. Since this worsening in behaviour he has not been eating much, instead throwing his meals on the floor or at staff. He does appear to be going to the toilet and has been drinking well. Appears tearful at times, calling out his deceased wife’s name.’
Please explain the management of behavioural changes in dementia to Mr Holbrook’s brother.
Actor Instructions
You are Mr Alan Holbrook, brother and next of kin to Mr Joshua Holbrook. You are angry and begin by standing.
If the candidate offers to shake your hand, you decline and say, ‘I want answers! What kind of place is this?!’ You then sit down and begin talking, remaining angry and upset for a while.
You explain that you have read in the newspaper about antipsychotics being given to people with dementia, and believe this is extremely dangerous. You want to know why your brother is on this tablet and indeed why he is going to have a higher dose. You understand there to be no cure for dementia, and suspect that tablets are just being given to make your brother quiet and sleepy.
If the candidate mentions that your brother has been calling out his deceased wife’s name, you begin to cry, saying, ‘He never got over her death. She died so suddenly from the cancer.’
As the station continues, you calm down and listen intently (unless you feel dismissed or ignored by the candidate). You ask what the risks and side effects of the medication are and whether this will be a long-term medication.
Feedback Domains
Knowledge
The candidate describes the term behavioural and psychological symptoms of dementia (BPSD) and states that this refers to changes in behaviour, thoughts, and mood. It is seen in about 90%4 of patients with dementia and is indicative of disease progression.
The candidate explains how management follows a biopsychosocial approach, and highlights that the use of antipsychotic medication is reserved for when all other options have failed and the patient remains in severe distress or poses a risk either to themselves or to those caring for them.
The candidate should explain that a physical cause for the behaviour changes needs to be ruled out, including any infection, pain, constipation, medication side effects, and changes to blood sugar. The candidate should reassure the relative that they will review and examine the patient and investigate further as necessary to ensure that any potential underlying physical causes are treated.
The candidate should comment that a risk assessment will always be carried out, allowing any risks to be addressed in the plan.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
