Cases/Older Adults

Aggressive Behaviour in Dementia — Free SCA Practice Case

BPSD – Aggressive Behaviour in Dementia

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Brian Thompson

Age

79 years

Consultation Type

Telephone

Patient Script

For the friend playing the patient role

Background of the case This is a telephone consultation with Patricia Thompson (Brian's wife). You are Patricia. You have Lasting Power of Attorney for Brian's health and welfare decisions and full consent to discuss all medical matters with the clinician. Brian has advanced vascular dementia. He is at home with you but has minimal verbal communication now and cannot participate meaningfully in the consultation.

Opening statement "Doctor, I'm at my wit's end. Brian's behavior has become really aggressive since he came home from hospital and I don't know how much longer I can manage. I need help urgently."

Character overview and emotional arc Patricia is a devoted, resilient 77-year-old woman who has been Brian's sole carer since his dementia diagnosis two years ago. She is articulate, practical, and not prone to drama — so when she says she is struggling, she means it. She has always managed, and asking for help is difficult for her. She is exhausted, frightened by the change in Brian's behaviour, and starting to feel guilty that she may not be able to keep him at home. She is not angry at the healthcare system but is frustrated that the hospital admission did not lead to a clear plan. She wants to be taken seriously and wants someone to actually do something. She does not want Brian to go into a care home, but she is beginning to realise it may come to that if things do not improve. She may become tearful if the candidate shows genuine empathy, but she is not hysterical — she is a woman at the edge of her coping capacity.

Description of Brian's current behaviour Since coming home from hospital two weeks ago, Brian has been markedly worse. Patricia should describe the following if asked, or volunteer the key points early in the consultation:

●Aggression: Brian has become physically aggressive for the first time. He pushed Patricia against the kitchen counter three days ago when she tried to help him get dressed. He has also grabbed her wrist hard enough to leave bruising. Before the hospital admission, he was never physically aggressive — occasionally verbally sharp, but never like this.
●Agitation and restlessness: He paces around the house for hours, particularly in the late afternoon and evening. He tries to leave the house repeatedly. Patricia has had to put extra locks on the doors. He rattles the door handles and becomes very distressed when he cannot get out.
●Sleep disturbance: His sleep pattern has completely broken down. He is up most of the night — wandering, calling out, and occasionally shouting. Patricia estimates she is getting two to three hours of broken sleep per night.
●Verbal aggression: He calls Patricia names he would never have used before. He has accused her of keeping him prisoner and has said he wants to go home (even though he is at home). He sometimes does not seem to recognise her.
●Reduced oral intake: He is eating very little — picking at food and sometimes refusing meals entirely. He is still drinking but less than usual. Patricia thinks he has lost weight, though she has not weighed him.
●Personal care: He is refusing to wash or change clothes. Patricia has not been able to get him into the shower for over a week. He becomes very agitated if she tries to help with personal care.
●Continence: He has started having episodes of urinary incontinence — something that was not happening before the hospital admission. Patricia is managing this with pads but finds it distressing.

Onset and timeline The behaviour change began during the hospital admission itself. Patricia noticed Brian became more confused and distressed in hospital — he did not understand where he was and kept trying to get out of bed. She feels the hospital environment made him worse, not better. Since discharge, the behaviours have continued to escalate rather than settle. The physical aggression started about a week after discharge and has happened three times now.

What Patricia has tried Patricia has tried to maintain Brian's routine as much as possible. She has tried distraction, playing his favourite music, keeping the house calm and quiet, and limiting visitors because they seem to agitate him. She has tried giving him his medications at the same times each day but he is increasingly resistant to taking tablets — she sometimes has to crush them into yoghurt. Nothing she has tried is making a meaningful difference.

ICE — Ideas, Concerns, Expectations

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Ideas: Patricia is not sure what is causing the sudden deterioration but suspects the hospital admission itself made Brian worse — the disruption to his routine, the unfamiliar environment, and being away from home. She has read online that hospital stays can accelerate decline in people with dementia and wonders if that is what has happened. She does not think there is an underlying infection because the hospital checked for that.
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Concerns: Patricia is worried about her own physical safety — the pushing and grabbing have frightened her, and she is scared it will escalate further. She is also terrified that she is failing Brian and that she will be forced to put him in a care home, which she promised him she would never do. She worries about what will happen to him if something happens to her — she has no family nearby and feels very alone in this. She is also concerned about the weight loss and reduced eating.
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Expectations: Patricia wants practical help — not just reassurance. She wants someone to come and assess Brian at home, she wants to know whether there is any medication that could take the edge off the aggression, and she wants more support from community services. She has heard of the crisis team but does not know how to access them. She also wants to know whether this level of decline is permanent or whether Brian might settle back to how he was before.

If Asked — Medical History and Medications

●Donepezil 10mg: "He's been on that since the diagnosis. I think it was helping at first — he seemed a bit more with it — but honestly I can't tell any more. He's been on the higher dose for about a year now."
●Aspirin and Atorvastatin: "Those are for his heart, aren't they? He's been on them for years. He had a small heart attack about five years ago but he recovered well from that."
●Ramipril: "That's the blood pressure one. His blood pressure has always been well controlled — the hospital checked it and said it was fine."
●Metformin: "He's been diabetic for about ten years. It's always been managed with just the tablets. The hospital checked his sugars and they were alright. I do worry though because he's not eating properly — could his sugars drop too low? I hadn't thought about that until now."
●Medication adherence: "Getting tablets into him is a battle now. He clamps his mouth shut or spits them out. I've started crushing them into yoghurt or jam but I'm not even sure he's getting the full dose every time. I haven't missed a day yet but it's getting harder."
●Hospital admission: "They kept him in for three days. They did blood tests, a chest X-ray, checked his urine — everything came back normal. They said there was no infection or anything acute, just that his dementia was progressing. They told me to see the GP and that was it. No follow-up arranged, no referral, nothing. I felt like we were just sent home to get on with it."
●Allergies: "No, no allergies to anything as far as I know."

Social History and Lifestyle Impact

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Home and care situation: Brian and Patricia live in a three-bedroom semi-detached house. It is just the two of them — their son lives in Australia and their daughter is in Edinburgh, so neither can help day-to-day. Patricia is Brian's sole carer. She manages all his personal care, meals, medications, and supervision. Before the hospital admission she was coping, though it was hard. Now she feels she is not coping at all.
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Daily life impact: "I can't leave him alone for even five minutes. I can't go to the shop, I can't have a bath without worrying he'll hurt himself or try to get out. I haven't slept properly in two weeks. I'm 77 myself and I've got arthritis in my knees — physically I'm struggling to manage him when he gets agitated. The other day he pushed me and I nearly fell. If I'd hit my head that would have been both of us on the floor. I used to go to my book club on a Thursday evening — I haven't been in months. I don't see anyone. My whole life is just caring for Brian and it's getting to the point where I'm dreading each day."
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Support currently in place: Patricia has a carer who comes in for 30 minutes three mornings a week to help with washing and dressing, but Brian has been refusing to let the carer near him since the hospital discharge. No other formal support is in place. Patricia has not had a carer's assessment. She is not aware of any local dementia support services beyond the memory clinic, which she last attended about six months ago.
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Financial and practical: Patricia manages all finances. She is not struggling financially but has not looked into any benefits or allowances she might be entitled to. She drives and the house is suitable for Brian's current needs, though she has had to put locks on the front and back doors.

If Asked — Associated Symptoms

●If asked about fever or signs of infection: "No, he doesn't feel hot and he hasn't had a cough or anything like that. The hospital checked for infections and everything was clear."
●If asked about pain: "He can't really tell me if he's in pain. He doesn't seem to be guarding anywhere or crying out when he moves. I haven't noticed him wincing or anything, but I suppose I can't be sure."
●If asked about falls: "He hasn't fallen, no, but he's unsteady on his feet sometimes, especially when he's agitated and pacing. I worry about it constantly."
●If asked about hallucinations or seeing things: "I'm not sure. Sometimes he seems to be looking at something that isn't there, or he'll talk to someone who isn't in the room. It's hard to tell whether he's hallucinating or just confused. That has been happening more since the hospital."
●If asked about delusions or paranoia: "He keeps saying I'm not his wife. He said the other day that I was someone pretending to be Patricia. And he thinks I'm trying to keep him locked up. He gets very distressed about it."
●If asked about bowel habit: "His bowels have been a bit irregular actually — he's been more constipated than usual. I think it's because he's not eating or drinking as much."
●If asked about new medications or changes in hospital: "No, they didn't change any of his medications. He came home on exactly the same things."
●If asked about alcohol: "No, Brian hasn't touched alcohol in years."
●If asked about swallowing difficulties: "He doesn't seem to have trouble swallowing exactly, but he holds food in his mouth sometimes and doesn't chew it properly. I have to remind him to chew and swallow."
●If asked about mood or depression: "I don't think he's depressed exactly — he's not tearful or withdrawn. He's more angry and agitated than anything. But it's hard to know what he's feeling because he can't express it."
●If asked about seizures: "No, nothing like that."
●If asked about headaches: "He can't tell me, but he doesn't seem to be holding his head or anything like that."
●If asked about vision or hearing changes: "His hearing has always been a bit poor — he wears hearing aids but he keeps pulling them out now. I don't think his vision has changed but I can't be certain."
●If asked about leg swelling or breathlessness: "No swelling in his legs. He doesn't seem breathless, even when he's pacing around for hours."
●If asked about skin integrity or pressure areas: "His skin seems alright at the moment. No sores or redness that I've noticed, though getting a proper look is difficult because he won't let me check."

Management discussion and negotiation

Patricia is open to suggestions but has clear views:

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Medication for behaviour: She is willing to consider medication if it would help reduce the aggression and agitation, but she does not want Brian "zombified" or over-sedated. She has heard negative things about antipsychotics in dementia patients and will ask about this if medication is suggested. She needs reassurance about safety and side effects. If the candidate explains the risks and benefits clearly and proportionately, she will agree to a trial.
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Referral to community mental health team / crisis team: She is very keen on this and will be relieved if it is offered. She did not know this was available.
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Increased care package: She would welcome more carer visits and is open to the idea of respite care for short periods, but she feels guilty about it and needs the candidate to normalise this and frame it as supporting both her and Brian.
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Carer's assessment: She has never been offered one and does not know what it involves. She will accept if it is explained clearly.
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Care home / long-term placement: She is not ready to discuss this and will become upset if it is raised too early or insensitively. If the candidate raises it gently and frames it as something to think about for the future rather than an immediate step, she will listen but will say she is not there yet. If it is pushed, she will push back firmly.
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Safeguarding: If the candidate sensitively explores whether Patricia feels safe and acknowledges the risk of harm to her, she will be grateful. She does not see herself as being abused — she understands it is the dementia — but she is frightened. If the candidate mentions a safeguarding referral, Patricia will be anxious about this and will need reassurance that it is about getting support, not about taking Brian away.
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Hospital readmission: Patricia does not want Brian to go back to hospital unless it is absolutely necessary. She believes the hospital made him worse and will resist this unless a compelling clinical reason is given.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

Data Gathering and Diagnosis:

Behavioural History: Systematically explores the nature, frequency, and severity of Brian's aggressive behaviours — including physical aggression (pushing, grabbing), verbal aggression, agitation, pacing, and attempts to leave the house. Establishes timeline of onset (worsened during/since hospital admission) and pattern of escalation. Positive: Asks specifically about the types of aggression (physical vs verbal), frequency, and any injuries sustained by Patricia (e.g. bruising from grabbing, near-fall from pushing). Establishes clear timeline linking deterioration to hospital admission. Negative: Asks only vaguely about behaviour (e.g. "how is he?") without exploring the nature, severity, or timeline of the aggression in any detail.

Triggers and Patterns: Explores situational triggers and temporal patterns — when aggression occurs (e.g. during personal care, in the evening), whether there is a sundowning pattern, and what makes behaviours better or worse. Positive: Identifies that aggression is provoked by attempts to assist with personal care, that agitation worsens in late afternoon/evening (sundowning), and asks about what Patricia has tried to manage it. Negative: Does not explore triggers or timing, treating the aggression as a constant rather than exploring contextual factors that could inform management.

Screening for Reversible Causes: Systematically considers and screens for potentially reversible causes of acute behavioural deterioration superimposed on dementia. Criteria met if candidate explores at least three of the following: pain (including non-verbal pain indicators), constipation, urinary symptoms or infection, hypoglycaemia risk (reduced oral intake on metformin), dehydration, new medication or medication changes, sensory deprivation (hearing aids being removed), environmental disruption from hospitalisation. Positive: Works through a structured screen for reversible causes, recognising that acute-on-chronic deterioration in dementia warrants exclusion of treatable factors even after a recent hospital workup. Considers constipation and hypoglycaemia risk given reduced oral intake. Negative: Accepts the hospital's conclusion that there is no acute cause without independently screening for reversible factors, or screens for only one cause superficially.

Psychotic Symptoms and Misidentification: Explores the presence of hallucinations, delusions, and misidentification phenomena — specifically whether Brian sees things that are not there, talks to people who are not present, or fails to recognise Patricia (Capgras-like misidentification). Positive: Asks directly about visual hallucinations, delusional beliefs (e.g. believing Patricia is an impostor, feeling imprisoned), and misidentification. Recognises these as features of BPSD that inform management decisions. Negative: Does not ask about psychotic symptoms or misidentification at all, or dismisses Patricia's account of Brian talking to people who are not there as simply "confusion."

Functional Assessment and Dementia Progression: Assesses Brian's current level of functioning to establish degree of dementia progression. Criteria met if candidate explores at least three of the following: verbal communication ability, mobility and falls risk, sleep-wake cycle disruption, oral intake and nutritional status, continence, personal care/washing, swallowing difficulties. Positive: Builds a comprehensive picture of Brian's functional decline across multiple domains, noting the degree of change from his pre-admission baseline. Negative: Focuses narrowly on the aggression without assessing broader functional status, missing the extent of overall decline.

Medication Adherence: Explores current medication-taking, including difficulties with adherence, Brian's resistance to taking tablets, and Patricia's strategy of crushing medications into food. Positive: Asks specifically about how Brian is taking his medications, whether he is refusing them, and what Patricia is doing to manage this. Considers whether crushing is appropriate for all his current medications (e.g. donepezil can be crushed, but this should be verified). Negative: Assumes medications are being taken as prescribed without exploring the practical difficulties of medication administration in a patient with advanced dementia.

Carer Assessment and Impact: Explores the physical and emotional toll on Patricia — sleep deprivation, physical safety concerns, social isolation, loss of activities, impact on her own health (arthritis), and whether she feels she is coping. Positive: Asks sensitively about Patricia's own wellbeing, sleep, physical health, and whether she feels safe. Acknowledges her as a patient in her own right and not just an informant. Explores her support network (or lack of one). Negative: Treats Patricia solely as a source of information about Brian without acknowledging or exploring the impact on her own physical and mental health.

Current Support and Care Package: Establishes what support is currently in place — carer visits, frequency, whether Brian is accepting care from others — and whether Patricia has had a carer's assessment or is receiving any other formal or informal support. Positive: Maps the current care package (30-minute carer visits three mornings a week, now being refused), identifies the gap in support, and asks about other services such as memory clinic follow-up or community mental health team involvement. Negative: Does not ask about existing support arrangements, making management recommendations without understanding the current care landscape.

Lasting Power of Attorney and Legal Framework: Confirms that Patricia holds LPA for health and welfare decisions and clarifies the scope of her authority to make decisions about Brian's care and treatment. Positive: Confirms LPA status early in the consultation, establishing the legal basis for the discussion and management planning. Negative: Does not confirm or acknowledge Patricia's LPA status, or proceeds with the consultation without establishing who has authority to make decisions about Brian's care.

Advance Care Planning: Explores whether Brian expressed any wishes about his care, treatment preferences, or end-of-life preferences while he still had capacity, and whether there are any advance decisions in place. Positive: Asks sensitively about Brian's previously expressed wishes, including his feelings about residential care, and acknowledges the difficulty of these conversations. Negative: Does not explore advance care planning or previously expressed wishes at all, missing the opportunity to understand the values framework for decision-making.

Domain 2: Clinical Management and Medical Complexity

Clinical Management and Medical Complexity:

Non-Pharmacological Approaches as First Line: Discusses non-pharmacological strategies for managing BPSD before or alongside any pharmacological intervention, in line with NICE NG97 which recommends non-drug approaches as first-line management. Criteria met if candidate suggests at least two of the following or similar evidence-based approaches: maintaining a calm and consistent approach during care tasks, reducing environmental stimulation (noise, clutter, number of people), breaking personal care tasks into smaller steps with gentle prompting, distraction and redirection techniques, ensuring adequate lighting (especially in evening to reduce sundowning), music therapy or familiar sensory stimulation, maintaining a predictable daily routine, using familiar carers where possible, avoiding confrontation or correction of delusional beliefs. Positive: Offers specific, practical non-pharmacological strategies tailored to Brian's presentation (e.g. addressing sundowning with lighting and routine, reducing provocation during personal care, not contradicting his misidentification beliefs). Frames these as first-line management. Negative: Jumps straight to medication without discussing non-pharmacological approaches, or offers only vague advice such as "try to keep things calm" without providing specific, actionable strategies.

Pharmacological Management of BPSD — Antipsychotic Use: Discusses the potential role of a low-dose antipsychotic (risperidone is the only antipsychotic licensed for short-term management of persistent aggression in moderate-to-severe Alzheimer's dementia in the UK per NICE NG97, though it is used off-label in vascular dementia) for severe, persistent aggression where there is risk of harm to self or others. Explains that this should be short-term, at the lowest effective dose, with regular review. Addresses Patricia's specific concern about Brian being "zombified." Positive: Discusses risperidone (or an appropriate antipsychotic) with appropriate caveats — short-term use, low starting dose (e.g. 250mcg twice daily), regular review (every 6 weeks with attempt to withdraw at 12 weeks per NICE NG97), and specific risks including increased stroke risk and mortality in elderly patients with dementia. Addresses Patricia's fears about sedation proportionately and acknowledges the difficult risk-benefit balance. Notes that prescribing may be best initiated by the specialist team. Negative: Prescribes an antipsychotic without discussing risks, particularly stroke risk and excess mortality in dementia patients. Or dismisses the possibility of medication entirely despite significant risk of physical harm, leaving Patricia without a clear management plan for the aggression.

Medication Review and Safety: Reviews Brian's current medication list in the context of his clinical deterioration, identifying potential medication-related issues. Key considerations: hypoglycaemia risk with metformin given significantly reduced oral intake; whether donepezil is still providing benefit or could be contributing to agitation; appropriateness of continuing all medications given his advanced dementia and quality-of-life priorities; practical issues of medication administration (crushing, refusal). Positive: Identifies the hypoglycaemia risk from continuing metformin with poor oral intake and considers dose reduction or temporary suspension. Reviews whether donepezil remains beneficial at this stage of disease. Considers the practical challenges of medication administration and discusses options (e.g. liquid formulations, prioritising essential medications). Negative: Does not review Brian's existing medications in light of his changed clinical status, missing the hypoglycaemia risk from metformin with reduced oral intake or failing to consider whether all current medications remain appropriate.

Referral to Old Age Psychiatry / Community Mental Health Team: Arranges referral to the community mental health team (CMHT) or old age psychiatry service for specialist assessment of BPSD and medication initiation. Considers urgency — whether a crisis team referral is appropriate given the level of risk and Patricia's distress. Positive: Offers referral to the CMHT or old age psychiatry service and, given the severity and risk, explores whether a crisis team or urgent community assessment can be arranged. Explains what the referral involves, who will come, and what they can offer (specialist behavioural assessment, medication initiation, care coordination). Acknowledges that this is different from the memory clinic. Negative: Does not offer specialist referral, attempting to manage severe BPSD entirely in primary care without specialist input. Or offers a routine referral without recognising the urgency of the situation.

Carer's Assessment and Support: Offers Patricia a formal carer's assessment, which she has never received. Explains what this involves and what support it could unlock (respite care, additional practical support, psychological support for carers). Positive: Proactively offers a carer's assessment, explaining that Patricia is entitled to this as a carer and that it can provide access to additional support including respite care. Normalises the need for support and frames it as essential for sustaining her ability to care for Brian. Negative: Does not mention or offer a carer's assessment, missing the opportunity to address Patricia's unmet support needs through a formal pathway.

Increased Care Package and Respite: Discusses the need for an enhanced care package — more frequent and longer carer visits, specialist dementia carers, and the option of respite care (either day care or short residential respite) to give Patricia a break. Positive: Discusses specific options for increasing support: more carer visits, specialist dementia care workers who may be better accepted by Brian, day centre attendance if appropriate, and short-term respite care. Frames respite as supporting Patricia's capacity to continue caring, not as failure or abandonment. Negative: Tells Patricia she needs more help without offering specific pathways to access it, or does not address the practical gap left by Brian's refusal of the current carer.

Safeguarding Considerations: Recognises and addresses the safeguarding dimension — Patricia has sustained bruising and is at risk of further physical harm. Discusses this sensitively, framing safeguarding as a route to support rather than a punitive measure. Positive: Names the safeguarding concern directly but sensitively — acknowledges that Brian's behaviour is a result of his dementia and not intentional, while clearly stating that Patricia's safety matters and that a safeguarding referral is about ensuring both of them get appropriate support. Reassures Patricia that this is not about "taking Brian away." Negative: Either does not recognise the safeguarding implications of the physical aggression and bruising, or raises safeguarding in a way that alarms Patricia without adequate explanation or reassurance.

Safety-Netting and Red Flags: Provides clear safety-netting advice — what Patricia should do if Brian's aggression escalates acutely, if she feels unsafe, or if Brian develops new symptoms (fever, acute confusion beyond baseline, falls, seizures, refusal of all fluids). Positive: Gives specific safety-netting instructions: call 999 if she feels in immediate danger, contact the GP urgently or attend A&E if Brian develops fever/acute deterioration/falls/seizures/complete refusal of fluids. Discusses a practical safety plan for managing acute aggression episodes (e.g. leaving the room, calling for help). Negative: Does not provide any safety-netting advice, leaving Patricia without a clear plan for what to do in an acute crisis or emergency.

Follow-Up and Continuity of Care: Arranges a specific, close follow-up plan — not an open-ended "come back if things don't improve." Includes timescale for review, what will be monitored, and who is responsible for coordinating care. Positive: Arranges a specific follow-up (e.g. telephone review within one week), explains what will be monitored (response to any medication started, carer coping, oral intake, safety), and confirms who is coordinating the various referrals. Ensures Patricia knows she has a named point of contact. Negative: Ends the consultation without a clear follow-up plan, or offers only vague advice to "call back if things get worse" without a proactive review arrangement.

Sensitive Discussion of Future Care Options: Acknowledges that residential care may need to be considered if the situation does not improve, while respecting Patricia's promise to Brian and her emotional resistance to this. Frames it as one option among several, not as an imminent or inevitable step. Positive: Raises future care options gently and at an appropriate point in the consultation (not too early), acknowledging the promise Patricia made to Brian and validating how difficult this is. Frames it as something to keep in mind rather than pushing for a decision now. Normalises that circumstances change and that considering care home placement is not a betrayal. Negative: Either avoids mentioning residential care entirely (leaving Patricia to face this alone later) or pushes the topic too early or insensitively, causing Patricia distress and damaging the therapeutic relationship.

Holistic and Multi-Morbidity Considerations: Addresses the intersection of Brian's multiple conditions — vascular dementia, ischaemic heart disease, type 2 diabetes, hypertension — in the context of management decisions. Considers the overall goals of care at this stage of Brian's illness and whether the focus should shift towards comfort and quality of life. Positive: Considers how Brian's comorbidities affect management (e.g. cardiovascular risk from antipsychotics in a patient with IHD, diabetes management with poor oral intake) and begins to frame goals of care around quality of life and comfort rather than aggressive management of all conditions. Negative: Manages the BPSD in isolation without considering Brian's other medical conditions or the broader goals of care at this stage of his illness.

Domain 3: Relating to Others

Relating to Others (Interpersonal Skills):

Empathic Response to Patricia's Distress: Acknowledges Patricia's exhaustion, fear, and emotional distress with genuine empathy. Responds to her opening statement with warmth and validation rather than immediately launching into clinical questions. Positive: Uses empathic language that specifically reflects Patricia's situation — e.g. acknowledges how frightening the aggression must be, how exhausting the sleep deprivation is, and how isolating it must feel to manage alone. Responds to emotional cues (e.g. if Patricia becomes tearful) with appropriate pauses and supportive statements rather than redirecting to clinical questions. Negative: Responds to Patricia's distress with a purely clinical or task-oriented approach — e.g. immediately begins asking screening questions without acknowledging her emotional state, or offers formulaic empathy ("that must be difficult") without engaging with the specific realities she describes.

Validating the Carer's Experience Without Judgement: Acknowledges Patricia's dedication to Brian's care and validates that she has been doing an extraordinary job, without implying criticism of her coping or suggesting she should have sought help sooner. Positive: Explicitly recognises how much Patricia has been doing and how well she has managed up to this point. Normalises her struggle without patronising her. Avoids any implication that she has been negligent or should have contacted services earlier. Negative: Implies criticism — e.g. "you should have called us sooner" or "you can't carry on like this" — or takes a tone that suggests Patricia is failing in her caring role rather than facing an impossible situation.

Addressing Guilt About Care Home Placement: Responds sensitively to Patricia's guilt and conflict about the possibility of residential care, acknowledging the promise she made to Brian and the emotional weight of potentially breaking it. Positive: Acknowledges the promise Patricia made to Brian and validates how important that is to her. Gently reframes the situation — e.g. explains that circumstances have changed in ways neither of them could have predicted, that wanting the best care for Brian is not a betrayal, and that keeping herself safe is also part of caring for him. Does not push for a decision. Negative: Dismisses the emotional significance of the promise ("you can't think like that") or avoids the topic entirely when Patricia raises it, leaving her guilt unaddressed.

Exploring Patricia's Ideas, Concerns, and Expectations: Actively elicits Patricia's own understanding of what is happening, what she is most worried about, and what she is hoping for from this consultation — rather than assuming her agenda. Positive: Asks what Patricia thinks might be causing the deterioration (eliciting her theory about the hospital admission), what she is most worried about (her safety, Brian's decline, the future), and what she is hoping will come from this conversation (practical help, not just reassurance). Uses this information to tailor the management plan. Negative: Does not explore Patricia's ideas, concerns, or expectations, instead imposing a management plan based on clinical assumptions without understanding what Patricia actually needs from this consultation.

Shared Decision-Making and Partnership: Collaborates with Patricia on the management plan, presenting options and supporting her to make informed choices rather than dictating a course of action. Respects her role as LPA holder and decision-maker. Positive: Presents management options clearly (non-pharmacological strategies, medication, referrals, support services) and invites Patricia's views on each. Checks what she feels comfortable with. Respects her preferences — e.g. if she is cautious about antipsychotics, works with her concerns rather than overriding them. Treats her as a partner in Brian's care. Negative: Adopts a paternalistic approach — telling Patricia what will happen rather than involving her in decisions. Or conversely, places all decision-making burden on Patricia without providing sufficient information or guidance for her to make an informed choice.

Clear and Accessible Communication: Uses language that Patricia can understand, avoiding jargon or overly clinical terminology. Explains medical concepts (e.g. BPSD, safeguarding, antipsychotic risks, CMHT role) in plain English. Positive: Explains terms like "behavioural and psychological symptoms of dementia" in accessible language, describes what the community mental health team does in practical terms, and explains medication risks in a way that is honest but not alarming. Checks Patricia's understanding at key points. Negative: Uses medical jargon without explanation (e.g. "BPSD," "CMHT," "first-generation antipsychotic") or provides information at a level of complexity that is unhelpful for a distressed 77-year-old carer in a crisis.

Sensitive Handling of Safeguarding Discussion: Raises the safeguarding dimension with care and sensitivity, recognising that Patricia may feel anxious or defensive about the implication that she or Brian is at risk. Positive: Frames the safeguarding conversation around support and protection for both Patricia and Brian. Explains clearly that safeguarding in this context is about ensuring they both get the right level of support, not about blame or removing Brian from her care. Checks how Patricia feels about this. Negative: Either avoids the safeguarding conversation entirely despite clear evidence of harm (bruising, risk of falls from pushing), or raises it in a way that alarms Patricia — e.g. using formal or legalistic language without adequate reassurance.

Acknowledging Patricia's Own Health and Vulnerability: Recognises that Patricia is herself elderly (77), has her own health conditions (arthritis), is severely sleep-deprived, and is at physical risk — and responds to this as a clinical concern in its own right, not merely as context for Brian's care. Positive: Explicitly acknowledges Patricia's own health and vulnerability — her arthritis making physical management difficult, her sleep deprivation affecting her own wellbeing and safety, and the risk to her if she falls or is injured. Offers to review her own health separately if needed. Negative: Treats Patricia purely as Brian's carer without recognising her as a person with her own health needs and vulnerabilities.

Providing Hope and Realistic Reassurance: Balances honesty about Brian's prognosis with realistic reassurance that things can be done to improve the situation — that the aggression may be modifiable, that support is available, and that Patricia is not alone. Positive: Provides realistic hope — explains that while the underlying dementia will progress, the acute behavioural crisis may be manageable with the right interventions (medication, specialist input, increased support). Avoids both false optimism and hopelessness. Leaves Patricia feeling that something concrete is being done. Negative: Either provides unrealistic reassurance ("I'm sure he'll settle down") or is so bluntly prognostic that Patricia feels hopeless and overwhelmed.

Clear Summary and Next Steps: Ends the consultation with a clear, structured summary of what has been agreed, what will happen next, who will do what, and when Patricia will hear back or be reviewed. Positive: Summarises the agreed plan clearly — which referrals are being made, what to expect from each, when the follow-up call will be, what to do in an emergency, and who to contact if things deteriorate before the next review. Checks Patricia has understood and agrees. Negative: Ends the consultation without a clear summary, leaving Patricia unsure about what has been decided, what will happen next, or who is responsible for the various actions discussed.

Clinical Learning Points

Understanding Behavioural and Psychological Symptoms of Dementia (BPSD)

●BPSD encompasses a broad range of non-cognitive symptoms in dementia — including agitation, physical and verbal aggression, wandering, sleep disturbance, psychotic features (hallucinations, delusions, misidentification), and altered mood — and affects up to 90% of people with dementia at some point in their illness.
●BPSD is not simply a marker of disease progression; it may indicate an unmet need (pain, fear, discomfort) or a superimposed reversible cause. Treat it as a clinical problem requiring systematic assessment, not an inevitable consequence to be managed with sedation.
●Sundowning — worsening agitation and confusion in the late afternoon and evening — is a recognised BPSD pattern. In this case, Brian's pacing and attempts to leave the house escalating in the evening fit this pattern and should inform the timing and content of environmental interventions.
●Misidentification syndromes (e.g. Capgras phenomenon — believing a familiar person has been replaced by an impostor) are recognised features of BPSD and are particularly distressing for carers. They do not represent a new psychiatric illness but reflect disrupted memory and recognition pathways in the context of dementia.

Screening for Reversible Causes Before Attributing to Disease Progression

●Any acute-on-chronic deterioration in a person with dementia should prompt a structured screen for reversible causes — even after a recent hospital admission with normal investigations. The hospital workup excludes common causes at that point in time; it does not preclude new problems developing after discharge.
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Key reversible causes to consider in this case:
- ●Pain — patients with advanced dementia cannot reliably self-report pain. Use behavioural pain indicators (grimacing, guarding, vocalisation during movement). Undertreated pain is a major driver of BPSD.
- ●Constipation — Brian has reduced oral intake and dietary change. Constipation is a common, easily missed, and highly treatable cause of agitation in this population.
- ●Hypoglycaemia risk — Brian is on metformin and has significantly reduced oral intake. Metformin does not directly cause hypoglycaemia, but reduced intake in a frail patient warrants dose review or temporary suspension; the broader question of whether strict glycaemic control remains a priority in advanced dementia is equally important.
- ●Dehydration — reduced fluid intake compounds confusion, constipation, and cardiovascular risk.
- ●Sensory deprivation — Brian has been removing his hearing aids. Hearing loss without amplification significantly worsens disorientation and agitation.
- ●Medication administration issues — verify whether crushing medications (including donepezil) is appropriate. Donepezil standard tablets can be crushed; however, this should be confirmed with the pharmacist and the patient's consistency of intake re-assessed.
- ●Environmental disruption — hospital admission is a well-recognised precipitant of acute deterioration in people with dementia. The unfamiliar environment, disrupted routine, and sensory overload of an acute ward can trigger BPSD that persists and escalates after discharge.

Non-Pharmacological Management of BPSD (First-Line per NICE NG97)

●NICE NG97 (Dementia: assessment, management and support) is unequivocal: non-pharmacological approaches must be offered as first-line management for BPSD. Pharmacological treatment should only be considered when these have been tried and have not adequately addressed the risk or distress.
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Evidence-based non-pharmacological strategies relevant to Brian's presentation:
- ●Maintain a predictable daily routine — familiar structure reduces disorientation and the anxiety that drives agitation.
- ●Reduce environmental stimulation — lower noise levels, reduce the number of people present, and ensure good lighting particularly in the evenings to minimise sundowning.
- ●Break personal care tasks into small steps — approach calmly, explain each step, allow Brian time to respond. Avoid rushing or restraining — this consistently provokes aggression.
- ●Do not correct or argue with delusional beliefs — if Brian believes Patricia is an impostor, contradiction escalates distress. Acknowledge the feeling and redirect: "I can see you're worried — let me get you a cup of tea."
- ●Familiar sensory stimulation — music from Brian's era, familiar scents, familiar objects. These can reduce agitation and improve mood.
- ●Distraction and redirection — when Brian tries to leave the house or becomes agitated, redirect to a familiar activity rather than confronting the behaviour directly.
- ●Specialist dementia carers — standard carers may not be trained in BPSD management. Specialist dementia care workers, who approach care tasks differently, may be better tolerated by Brian.

Pharmacological Management of BPSD — Antipsychotic Use

●Antipsychotic medication should be considered when BPSD is severe, persistent, and associated with a significant risk of harm — as in this case where Patricia has sustained physical injury. This represents a genuine clinical indication, not a shortcut around non-pharmacological management.
●Risperidone (starting at 0.25 mg twice daily) is the only antipsychotic licensed in the UK for short-term treatment of persistent aggression in moderate-to-severe Alzheimer's dementia (NICE NG97). It is used off-label in vascular dementia but remains the agent of choice in clinical practice.
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Critical risks to discuss with the carer:
- ●Increased cerebrovascular risk — approximately 3-fold increased risk of stroke/TIA. This is particularly significant given Brian's ischaemic heart disease and the vascular substrate of his dementia.
- ●Increased all-cause mortality — antipsychotics carry a small but real excess mortality risk in elderly patients with dementia. This must be disclosed as part of the management discussion.
- ●Sedation and falls risk — a genuine concern for Patricia; acknowledge it, explain that low starting doses minimise this risk, and agree on what level of sedation would be acceptable.
●NICE NG97 recommends that antipsychotic prescribing in dementia be reviewed every 6 weeks with an attempt to withdraw at 12 weeks unless the clinical situation warrants continuation.
●Given the severity of risk in this case, initiation is most appropriately done in close collaboration with the old age psychiatry or CMHT team rather than solely in primary care.

Medication Review in Advanced Dementia

●Advanced dementia with poor oral intake and functional decline is a trigger for comprehensive medication review. The question to ask for each drug is: does the benefit at this stage of illness outweigh the burden and risk?
●Metformin — in the context of significantly reduced oral intake, consider dose reduction or temporary suspension. In advanced dementia, the long-term cardiovascular benefits of tight glycaemic control must be weighed against the burden of medication administration and the risk of hypoglycaemia from erratic intake.
●Donepezil — at advanced stages of vascular dementia, the benefit of acetylcholinesterase inhibition diminishes and the drug can occasionally contribute to agitation. Discuss with the specialist team whether continuing at 10 mg remains appropriate.
●Aspirin and atorvastatin — consider whether secondary prevention targets remain the priority at this stage. A shift toward comfort-focused management may make deprescribing appropriate as part of a goals-of-care conversation.
●Medication administration — crushing tablets into food without checking licence terms is common but not always safe. Involve the pharmacist. Liquid formulations (e.g. donepezil oral solution) may be available and better tolerated.

Referral to Old Age Psychiatry and Community Mental Health Team

●NICE NG97 recommends referral to specialist mental health services when BPSD is severe, when there is risk of harm, or when primary care management is insufficient. In Brian's case — with documented physical aggression causing injury to his carer — specialist referral is clearly indicated.
●The community mental health team (CMHT) for older adults can provide: specialist behavioural assessment, initiation of pharmacological treatment where indicated, coordination of the care package, and ongoing support for both Brian and Patricia.
●Where the level of risk is acute, a crisis team referral or urgent same-day CMHT contact may be appropriate rather than a routine referral.
●Distinguish this from the memory clinic: the memory clinic manages diagnosis and stable ongoing review. The CMHT manages active psychiatric and behavioural crises. Patricia should understand the difference.

Carer's Assessment and Support

●Patricia is legally entitled to a carer's assessment under the Care Act 2014. This is not optional or discretionary — it is a right, and the GP has a role in ensuring it happens if it has not been offered.
●A carer's assessment can unlock: increased direct care hours, specialist dementia carers, respite care (day care or short residential respite), psychological support for carers, and financial benefits including Carer's Allowance.
●Frame respite care explicitly as supporting Patricia's capacity to continue caring — not as a step toward care home placement. Carers who have adequate respite are more likely to sustain caring at home for longer.
●Patricia is herself a 77-year-old woman with arthritis, severe sleep deprivation, and documented physical injury. Her own health is a legitimate clinical concern in its own right, not merely a factor in Brian's care.

Safeguarding in the Context of Dementia

●Brian's physical aggression — pushing, grabbing, causing bruising — constitutes a safeguarding concern for Patricia. The fact that this behaviour arises from dementia does not negate the need to address it through a safeguarding framework.
●Safeguarding in this context is about securing the right level of support and protection for both parties — it is not punitive and does not automatically lead to removal from home. Candidates must be able to explain this clearly to a carer who may feel alarmed by the word "safeguarding."
●A referral to adult social care with a safeguarding dimension is appropriate given the documented physical harm. The referral should be discussed with Patricia, not made without her knowledge.
●Patricia's reluctance to see herself as a "victim" is common among carers of people with dementia. The framing should be: "This is about making sure both of you are safe and supported."

Advance Care Planning in Advanced Dementia

●Advance care planning conversations should be initiated proactively in patients with progressive dementia. Where capacity has already been lost, explore previously expressed wishes and values with those who knew the patient best.
●Brian no longer has capacity for complex decisions. Patricia holds Lasting Power of Attorney (LPA) for health and welfare, which means she is the appropriate decision-maker for care and treatment decisions. Confirming LPA status early in the consultation establishes the legal basis for the entire management discussion.
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Key areas to address at this stage:
- ●Preferred place of care — Brian previously expressed a wish not to go into a care home; this must be weighed against the reality of Patricia's capacity to safely continue caring.
- ●DNACPR — whether a do-not-attempt-cardiopulmonary-resuscitation order has been considered or documented.
- ●Hospital admission threshold — given that hospitalisation appears to have accelerated Brian's decline, a frank discussion about the appropriate threshold for future admissions is warranted.
- ●Goals of care — as dementia advances, a shift from disease-modifying to comfort-focused goals of care is appropriate and should be introduced sensitively.

Safety-Netting

●Patricia must have a clear, specific plan for what to do in an acute crisis. Vague advice to "call the surgery" is inadequate in this situation.
●Call 999 immediately if: Patricia is in immediate physical danger from Brian's aggression, Brian falls and is injured, Brian has a seizure, or she cannot rouse him.
●Contact the GP urgently or attend A&E if: Brian develops fever, marked acute confusion beyond his current baseline, complete refusal of all fluids (particularly important given his ramipril — risk of acute kidney injury in dehydration), or new neurological symptoms.
●Practical safety planning for aggressive episodes: leave the room calmly without engaging; do not attempt to physically restrain; call for help; keep a phone accessible at all times.
●Arrange a specific, proactive follow-up — a telephone review within one week is appropriate given the severity. Do not leave Patricia with an open-ended "call us if things get worse."

Common Candidate Mistakes in This Case

●Failing to screen for reversible causes — accepting the hospital's conclusion without re-screening at the current point in time. Constipation, pain, dehydration, and sensory deprivation may have developed or worsened since discharge.
●Jumping to antipsychotics without discussing non-pharmacological approaches first — non-pharmacological strategies are mandated as first-line by NICE NG97. Even if medication is ultimately appropriate, candidates must demonstrate awareness of this hierarchy.
●Omitting the metformin and medication review — reduced oral intake in a patient on metformin in advanced dementia is a frequently missed prescribing safety issue. It signals broader questions about whether all existing medications remain appropriate.
●Not confirming LPA status — proceeding with management decisions about Brian's care and treatment without establishing who holds legal authority to make them is a significant omission.
●Treating Patricia only as an informant — Patricia is at risk of physical harm, severely sleep-deprived, socially isolated, and has never had a carer's assessment. Failing to acknowledge her as a patient in her own right is a common and consequential oversight.
●Raising care home placement too early or insensitively — Patricia has made an explicit promise to Brian. Raising this before adequate rapport is established, or without careful framing, will damage the therapeutic relationship and close down the conversation.

Free MRCGP SCA practice case for GP registrars covering Aggressive Behaviour in Dementia — Older Adults. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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