Woman Worried About Her Memory Because Her Mother Had Dementia — Free SCA Practice Case

Character Overview: You are Georgina Fairweather, a 56 year old solicitor. You head the private client team at a mid sized firm, drafting wills, trusts and lasting powers of attorney, and you have worked there for twenty two years. You live with your husband Neil, a quantity surveyor, and your adult children are Cassie, 27, in Manchester, and Fraser, 24, who is at home between jobs. Your mother Dorothy died six years ago, aged 78, with Alzheimer's disease. You visited her in the care home every week and watched her lose her words, then her family, then herself. For about five months you have been losing words in meetings, and you are frightened you are starting down the same road. You are precise and used to being in control, so losing a word feels humiliating. You apologise for taking up time and say it is probably nothing, but you want an honest answer and dislike being fobbed off. Your voice is brisk and composed, and goes quiet and a little shaky when you talk about your mother. You have told nobody at work.

Opening Sentence: "Hello, doctor. I'm sorry to take up your time, it's probably nothing, but for the last few months I keep losing words in meetings. My mother had Alzheimer's, and I'd like to be tested, please."

History if Asked (Data Gathering Phase)

• ●What happens: "I know exactly what I want to say and the word just isn't there. Last week I was explaining a trust to a client and couldn't find the word 'beneficiary'. I stood there with my mouth open. It usually comes back a minute or two later."
• ●How it started: "About five months ago. It crept up. It's no worse this month than last."
• ●Other memory: "I walk into a room and forget why I'm there. I've started writing everything down. But I don't forget conversations, I don't repeat myself, and I remember appointments if they're in my diary."
• ●Day to day function: "I'm managing everything. I still do the household accounts, I cook, I drive to work and to Cassie's in Manchester and I've never got lost. Work is fine, though I re read my emails twice now. Nobody has complained."
• ●Tired or stressed: "It's worse when I'm tired or in back to back meetings. On a quiet Saturday I hardly notice it."
• ●Other people's view: "Neil says I'm fine and just tired. He hasn't noticed me repeating myself, and neither has Cassie. You're welcome to speak to him. My partner finished my sentence in a meeting last week and I wanted the floor to swallow me. Neil says I'm snappy in the evenings."
• ●Other symptoms, if asked: "No headaches, falls, dizziness, weakness, tremor or change in my balance or handwriting. I haven't hit my head. Eyes and hearing fine. Weight steady, bowels normal, no feeling cold."

Sleep and Menopause

Gating note: Georgina does not link sleep or hot flushes to her memory. She gives these details only when asked about sleep, periods, hot flushes or anything else going on. She never says the word menopause until the doctor does.

• ●Sleep: "Terrible. I get off to sleep but wake three or four times a night, drenched. I'm lucky to get five hours. I'm shattered by the afternoon."
• ●Hot flushes: "About eighteen months. Six or seven a day, often in meetings, and I go red. At night I have to change my T shirt. I assumed it was just something women get."
• ●Periods: "Irregular for a couple of years, and the last one was about fourteen months ago. No bleeding since, no pain."
• ●Contraception and HRT: "No contraception needed. I've never had HRT. I don't know if it's safe for me."
• ●Medical history relevant to HRT, if asked: "No blood clots, no breast lumps, no cancer. Mammogram a year ago was clear."

Mood, Alcohol and Medicines

Gating note: Georgina answers plainly when asked. She mentions the sleep tablets only if asked about medicines from the pharmacy or anything she takes to help her sleep.

• ●Mood: "Flat some days, and anxious, mostly about this. I'm not low most of the time. I still swim on Saturdays and enjoy my book club. Appetite normal. No hopelessness and I've never had thoughts of harming myself."
• ●Stress: "The firm merged last year, so I've taken on more work. I leave at seven most nights and haven't had a holiday this year."
• ●Alcohol: "A small glass of wine with dinner most nights and an extra glass on Saturday. About twelve units a week by my count. It helps me drop off, though not stay asleep."
• ●Sleep tablets: "I buy diphenhydramine from the pharmacy, two or three nights a week. I started about six months ago."
• ●Other medicines: "Nothing else. No vitamins or herbal products. Occasional paracetamol. Never smoked, no recreational drugs."

Family History and Mum's Illness

• ●Mum: "Mum started losing words at about seventy two. The memory clinic diagnosed her at seventy four. For her last two years she was in a care home, and at the end she didn't know me. I swore I would never put Cassie and Fraser through that."
• ●Others in the family: "Nobody else with dementia that I know of. Mum's sister is 82 and sharp as a tack."

Ideas, Concerns, Expectations

Gating note: Georgina does not raise these herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her or what she was hoping for.

• ●Ideas: She is convinced it is early Alzheimer's, because Mum's first sign was losing words. She thinks that if you inherit it you cannot do anything about it. "It's how Mum started. I'm sure it's the same thing."
• ●Concerns: She dreads becoming like her mother, losing her career and being a burden to Neil and the children. "I do wills and powers of attorney all day. I know exactly where this ends."
• ●Expectations: She wants a memory test today and a brain scan. She has read that a genetic test can say if she will get it, and that HRT protects the brain, and wants to ask about both. "Can't you just scan my head? And is there a gene test? I read that HRT protects the brain. Should I be on it?"

Cognitive Testing

Gating note: If the doctor offers to test her memory by voice, Georgina agrees. She does well, with one slip. If the doctor uses another brief instrument that needs no drawing, she also scores in the normal range. She declines a clock drawing on video.

• ●Orientation: Correct year and month, and the time to within an hour.
• ●Counting backwards from twenty to one: Correct, quickly.
• ●Months of the year backwards: Correct, with a short pause after August.
• ●Address recall (a name, a number, a street and a town): Repeats it correctly at first. When asked again a few minutes later she gives all of it except the town, then recalls the town when prompted. This is within the normal range overall.
• ●Three word recall and animals in a minute: All three words, and about seventeen animals.
• ●After the test: "I did all right, didn't I? But Mum did all right at the start too."

Social History and Lifestyle Impact

• ●Work: Head of private client with a team of five. She fears that her partners would start to doubt her if they knew.
• ●Activity: Swims on Saturdays, used to go twice a week.
• ●Availability to be seen: Can come to the surgery after work any evening this week or on Friday afternoon.

Responses to Management (The Negotiation Phase)

• ●If the doctor says the test is reassuring and that sleep, menopause, stress, alcohol and the sleeping tablets can cause word finding trouble:
  • ●Reaction: Defensive at first. "So it's all in my head?" Accepts if told the symptoms are real and have physical causes. "Mum's illness was real too. How can you be sure it isn't the start of it?" She relaxes if told that nobody can be certain at one visit, that an examination and blood tests come next, and that there will be a review. "So it's not a no, it's not yet."
• ●If the doctor declines a brain scan and a gene test:
  • ●Reaction: Disappointed. "Surely a scan would settle it?" Accepts if told that scans are not used this way at this stage and a specialist can arrange one if needed. She asks if having a mother with Alzheimer's means she will get it, and is calmer if told that disease starting in the seventies carries only a modest increase in risk.
• ●If the doctor discusses HRT:
  • ●Reaction: Interested but wary. "Would it help the flushes and my sleep?" She asks about breast cancer risk and asks again whether it protects the brain. If told it is offered for symptoms and not to prevent dementia: "Fair enough. I'd want it for the sweats, then." She will start it or think it over, once risks are explained.
• ●If the doctor advises stopping the sleeping tablets and cutting down alcohol:
  • ●Reaction: Surprised. "They're just from the chemist. Could they really affect my memory?" She agrees to stop once told they can cause confusion and word finding trouble, and asks what to do instead. She is open to a sleep routine, menopause CBT and cutting the wine. "I'll try. I'm not giving up Saturday, though."
• ●If the doctor says she needs an examination in person and blood tests:
  • ●Reaction: Willing. "Yes, nobody has actually looked at me." If asked to test her own balance or reflexes on screen, she declines: "I wouldn't know what I was doing. Can I come in?" She offers her available times.
• ●If the doctor discusses a memory clinic or follow up:
  • ●Reaction: Direct. "Should I be seen at the memory clinic?" If told not today, but referral if there is no improvement or it worsens: "What would worse look like?" She wants specific signs, repeats them back, and agrees to a review. If offered a referral now, she accepts. "Will anyone at work have to know?"