In this series, the 10 key areas CSA candidates struggle with have been identified. The articles address how these problem areas are covered in the CSA exam, what to do in an exam situation and how to prepare for each scenario.
The first of this new series focuses on consulting with elderly patients in the CSA.
How it is covered in the CSA exam
The CSA covers consulting with patients of all ages. General practice has to deal with the ageing population in the UK, and you may expect at least one patient to be in an older age group. The role players used in the exam to play elderly patients will usually be near to the age of the patient portrayed.
An elderly patient is likely to have significant chronic conditions and comorbidities. They may also have acute illnesses, social and psychological problems particularly related to their age group and you would be expected to be able to prioritise the conditions presented and use a team approach.
Continuity of care is an important aspect of GP work, so do not feel you have to deal with every problem in one consultation - this is where safety netting, teamwork and follow-up are particularly important.
At the very least you need to be confident in managing a number of conditions common in the elderly, for example, TIA and stroke, Parkinson's disease, falls, cardiovascular disease, dementia and confusion. Dealing with polypharmacy is also a possibility in an elderly patient CSA case.
What to do in the exam
During the exam, your communication skills with an elderly patient should reflect their needs. History taking and explanations may have to be at a slower pace. If dementia may be present, take this into account when giving instructions regarding treatment and follow-up.
Treat your patient with respect and avoid patronising them. Be gentle when you are examining them - you will be marked down if you are not. Elderly role players are less resilient, and may have to have the same part of their body examined 26 times on an average exam day.
When prescribing drugs you should consider any repeat prescriptions that may be listed in the candidates briefing notes and how you might optimise compliance if this is an issue.
It might be that you want to involve a relative or carer in the management plan, in which case consent and confidentiality issues should be explicitly considered.
How to prepare
Make sure you can perform a mental state assessment confidently and effectively. Know how to manage dementia, delerium and confusion.
Ensure you are able to advise appropriately on various support services, such as home care and hearing aids and what can be provided by other members of the primary healthcare team and allied health professionals.
Know about different types of daycare and residential and nursing home accommodation, and any relevant statutory or voluntary associations.
Don't forget ethical issues such as capacity and consent, DVLA regulations and fitness to drive, advance directives (living wills) and assisted suicide.
- Dr Denney is a MRCGP examiner and GP in Edinburgh