CCFP priority topic 24 of 105
Dementia on the CCFP exam
10 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 10 key features for Dementia. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 10
Spotting it early
Think of dementia early, and confirm it with a family history, daily function and a proper test.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Canadian Task Force on Preventive Health Care
On the exam
A daughter says her father, 79, has been more forgetful for two years. Expect a short menu (pick several from a list).
Pick what confirms the diagnosis today.
Common mistakes
Stopping at one normal screening score, or trusting his view that it is just age. Asking only what day and place it is misses early disease too.
Approach
- Take a worry from the patient or family seriously. The Canadian Task Force advice against screening covers only older adults with no symptoms and no concerns.
- Get the story from someone who knows the patient well. Insight often fades early.
- Ask about daily tasks: money, pills, cooking, shopping, driving, getting lost.
- Use a proper, tested memory and thinking tool. Knowing the day and place stays intact until later, so it misses early disease.
- A normal score does not rule out dementia when the history shows a clear decline.
- Examine for weakness on one side, stiffness and slowness, and poor hearing or vision. Grasp and snout reflexes are common in healthy older adults and do not help.
Key feature 2 of 10
Dementia, delirium or depression
When thinking is clearly impaired, choose tests that find a treatable cause, and look for delirium, low mood and drinking.
CFPC skill Clinical reasoningPhase Investigation, hypothesis generationSources Choosing Wisely Canada / national participating organizations, Choosing Wisely Canada
On the exam
A man has two years of slow memory loss. His labs were normal three months ago. Expect a short menu (pick several from a list).
Pick the tests that will change the plan.
Common mistakes
Adding folate, or testing his urine for a slow decline. Bacteria in his urine would explain nothing and invite needless antibiotics.
Approach
- Delirium starts over hours or days, and attention comes and goes. Treat it as an urgent search for the cause.
- Depression brings low mood, slow thinking and many “I don't know” answers. It can sit alongside dementia.
- Ask about alcohol, cannabis, sleeping pills and other drugs. Each can cloud thinking.
- Test to find what you can treat, guided by the history and exam.
- Skip folate unless there is anemia with large red cells, or white cells with too many lobes, and you suspect poor nutrition. Canada has added folic acid to white flour since 1998.
- Do not test urine in an older adult whose thinking has changed, unless there are clear signs of infection.
- In long-term care, confusion alone is not a urinary infection in a resident without a catheter. In a resident with a catheter, new delirium can count, but only once other causes are ruled out. Look for other causes.
| Starts | Clues | |
|---|---|---|
| Dementia | Slowly, over months to years | Alert. Memory and daily tasks slip step by step. |
| Delirium | Over hours or days | Attention comes and goes. Often a drug, an illness or a new setting. |
| Depression | Over weeks | Low mood, slow answers, “I don't know”. Can sit with dementia. |
Key feature 3 of 10
Which dementia
Decide whether a dementia is Alzheimer disease or another type, since care and outlook are not the same.
CFPC skill Clinical reasoningPhase Diagnosis
On the exam
A man with memory loss, whose mother had Alzheimer disease, now sees people who are not there and moves stiffly. Expect one best answer.
Name the most likely type.
Common mistakes
Calling it Alzheimer disease because his mother had it. Early visual hallucinations, swings in alertness and stiffness point to Lewy body dementia instead.
Approach
- Ask what came first: memory, behaviour, language, movement, or a stroke.
- Ask about seeing things, good and bad days, and acting out dreams in sleep.
- Look for stiffness, slowness and a shuffle, and for weakness on one side.
- A parent with late-onset Alzheimer disease does not make this patient's dementia Alzheimer disease.
- Refer when the type is unclear, the onset is early, or the decline is fast.
| Type | Comes first | Other clues |
|---|---|---|
| Alzheimer disease | Loss of recent memory | Slow, steady decline. Words, planning and finding the way go later. |
| Lewy body dementia | Thinking and attention change | Seeing things early, alertness that swings, stiffness and slowness. |
| Frontotemporal dementia | Behaviour or language change | Younger onset. Memory spared early. |
| Vascular dementia | Slow thinking after strokes | Drops in steps, past strokes, weakness on one side. |
Key feature 4 of 10
When function drops
When someone with dementia gets worse, look for a new cause before you blame the disease.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada, Health Canada
On the exam
A man with dementia is more confused and seeing things, a week after starting a bladder pill. Expect one best answer.
Pick the first step.
Common mistakes
Telling the family that decline is expected, or adding a drug for the hallucinations. The new bladder pill is the likely cause, and it has to stop first.
Approach
- A change over days or weeks is something new until proven otherwise.
- Review every medicine. Many medicines in older adults raise the risk of side effects and of worse thinking.
- Bladder pills such as oxybutynin block acetylcholine, a brain messenger. Stop the new drug first.
- Look for pain, constipation, trouble passing urine, infection, low mood, alcohol and new illness. Pain often drives new behaviour.
- Do not treat bacteria in the urine without urinary symptoms. It brings no benefit and adds side effects.
- A sharp drop after a loss, with low mood and drinking, needs treatment. Do not call it grief or the dementia.
Key feature 5 of 10
Telling the diagnosis
Share a dementia diagnosis with kindness, and protect the patient's choices, privacy and safety.
CFPC skill Patient-centred approach, communication, professionalismPhase Diagnosis, treatment
On the exam
Tests confirm early Alzheimer disease. The patient's son asks you to keep it from her. Expect a short menu (pick several from a list).
Pick how to share the news.
Common mistakes
Agreeing to hide it, or telling her son before her. She has the right to know, and to decide who else hears.
Approach
- Ask what the patient knows, what they want to know, and who they want in the room.
- Use plain words. Name the illness, not just “memory trouble”.
- Get the patient's permission before you share details with family.
- Go at the patient's pace. Check what was heard, and book a visit soon.
- Raise safety early: driving, cooking, money, living alone.
- Name next steps: support, treatment choices, and planning ahead while the patient can still decide.
Key feature 6 of 10
Capacity
Check whether a person with dementia can make this particular choice, and include them where you can.
CFPC skill Clinical reasoningPhase Diagnosis, treatmentSources CMPA
On the exam
A widow with dementia, low mood and heavy drinking refuses home care. Expect a short menu (pick several from a list).
Pick what decides her capacity.
Common mistakes
Taking her clear “no” as proof, or letting her son decide. A clear choice is not enough, and a substitute steps in only once she is found incapable.
Approach
- Capacity is about one decision. A person may manage one choice and not another.
- Check that she understands what is offered, what it would do, the other options, and what happens if she refuses.
- Do not rely on “Do you understand?” Ask her to explain it back in her own words.
- No memory score decides capacity.
- Treat what clouds judgement, such as low mood or drinking, and check again.
- If she is incapable, follow your province's rules for the substitute decision-maker.
- Judging capacity for a care decision is your job. Refer only when it is unclear or disputed.
Key feature 7 of 10
Ongoing care
At each follow-up, track function and thinking, plan ahead as things change, and review every drug.
CFPC skill Clinical reasoning, patient-centred approach, selectivityPhase Follow-up, physical, treatmentSources Choosing Wisely Canada
On the exam
Three years into dementia, a man shouts and hits out when he is bathed and dressed. Expect a short menu (pick several from a list).
Pick the first steps for his agitation.
Common mistakes
Starting haloperidol, quetiapine or a sedative first. Find the cause and try non-drug steps. An antipsychotic comes only after non-drug steps fail, for severe distress or danger.
Approach
- Track daily function and thinking at each visit, against the patient's own usual.
- Find the trigger. Pain and other causes often drive the behaviour.
- Try non-drug steps first. Avoid physical restraints: they cause injury and more agitation.
- Use an antipsychotic only after non-drug steps fail, and only for symptoms that cause severe distress or put the person or others in danger. These drugs help little and can cause early death.
- Review dementia drugs such as donepezil and memantine regularly. Think about stopping with no benefit, harms that outweigh benefits, or advanced dementia.
- Check the full medicine list before you add one. Stop long-term drugs with no clear reason.
- Plan early: goals of care, advance care planning, home safety, and when to move to care.
| Treatment | When to use | Why |
|---|---|---|
| Antipsychotics | After non-drug steps fail, for severe distress or danger | Little benefit. Serious harm, including early death. |
| Benzodiazepines and sleeping pills | Not as a first choice in older adults | Can more than double the risk of falls, hip fractures and car crashes. |
| Donepezil and similar drugs, memantine | Only with regular review of benefit | Some people get no real benefit. Side effects. |
| Physical restraints | Avoid for behaviour | Injury, pressure sores, more agitation. |
| Feeding tube in advanced dementia | Not advised. Help the person eat by hand. | No better than hand-feeding. More agitation and restraint. |
Key feature 8 of 10
Caregivers
Find out what the person caring for someone with dementia needs, and what help they have.
CFPC skill Patient-centred approachPhase History
On the exam
An exhausted wife brings her husband, who has had three weeks of outbursts. Expect a short menu (pick several from a list).
Pick the questions about her needs.
Common mistakes
Asking more about his memory, his stage, or her own risk of dementia. None tells you if she is safe, coping, or close to breaking.
Approach
- See the caregiver alone for part of the visit.
- Ask whether she has been hurt, or feels unsafe at home.
- Ask about her sleep, mood, health and time for herself. Look for depression and burnout.
- Ask what help she has: family, home care, day programs, short respite stays.
- Ask what she finds hardest, and which tasks set off his outbursts.
- Hold talk of a care home until the cause of the change is found and help at home is tried.
Key feature 9 of 10
Driving
Tell the licensing authority when you think a patient with dementia may be unsafe to drive.
CFPC skill Professionalism, clinical reasoningPhase Treatment
On the exam
A farm widow with dementia, who drives weekly, got lost by day on a road she knows well. Expect one best answer.
Pick the next step on driving.
Common mistakes
Limiting her to daytime or short trips, or waiting for a road test or for treatment to work. She drives every week, so report now.
Approach
- Ask family about getting lost, near misses, new dents and tickets.
- Do not rely on the patient's own rating. Insight is often poor in dementia.
- Getting lost on a known route, or poor judgement, is a red flag. Low mileage and a long clean record do not cancel it.
- A GPS or a no-night-driving rule does not fix poor judgement.
- If you think the patient is unsafe, report to the licensing authority now. It can order a road test.
- Tell the patient what you are reporting and why, and write it down. Then help plan other ways to get around.
- Know your province's rule. In some, reporting is a duty.
Key feature 10 of 10
Early onset and genes
When dementia starts early in life, think about an inherited cause and a gene test.
CFPC skill Clinical reasoning, patient-centred approachPhase Hypothesis generation, history
On the exam
A man's mother had Alzheimer disease that began at 84. He asks for a gene test. Expect one best answer.
Pick the right reply to his request.
Common mistakes
Ordering an APOE test or testing his siblings. Onset at 84 is late-onset disease, where gene tests do not help him.
Approach
- Ask the age when symptoms began, in the patient and in each affected relative.
- Early onset, or many affected relatives over generations, raises a single-gene cause. Refer to genetics for counselling and testing.
- Late onset in one older parent does not call for gene testing.
- APOE is a gene linked to Alzheimer risk. Its result neither confirms nor rules out the disease, so do not order it to diagnose or predict.
- Counselling comes before any test. Results affect children and siblings too.
Flashcards
Answer it first, then check.
KF 1A daughter reports two years of memory loss. Does “don't screen” apply?
No. That advice covers older adults with no symptoms. A family worry means you assess. Source: Canadian Task Force on Preventive Health Care
KF 2A resident with no catheter is more confused, with no fever. Send a urine culture?
No. Confusion alone is not a urinary infection. Look for other causes first. Source: Choosing Wisely Canada / national participating organizations
KF 2Should you order folate as part of a dementia work-up?
Not routinely. Only with anemia and large red cells, or many-lobed white cells, and suspected poor nutrition. Source: Choosing Wisely Canada
KF 3Memory loss, then seeing things, swings in alertness and stiffness. Which dementia?
Lewy body dementia. These early features do not fit Alzheimer disease.
KF 7When may an antipsychotic be used for aggression in dementia?
Only after causes are treated and non-drug steps fail, for severe distress or danger to anyone. Source: Choosing Wisely Canada
KF 7A patient has taken donepezil for years. What do you do at follow-up?
Review the benefit. Think about stopping if there is none, harms outweigh it, or dementia is advanced. Source: Choosing Wisely Canada
KF 6What must a patient understand to refuse a treatment?
What it is, what it would do, the other options, and what happens if they refuse. Source: CMPA
KF 9A patient with dementia got lost driving a familiar road. Wait for a road test?
No. Report to the licensing authority now. The authority can order the test.
FAQ
Should I screen healthy older adults for dementia?
Not with a test if they have no symptoms. The Canadian Task Force advises against it. Once the patient, the family or you notice a change, assess fully.
Do I need a specialist to make the diagnosis?
Usually not. A family physician can diagnose dementia from the history, a family account, a proper test, the exam and labs. Refer when the picture is unclear or onset is early.
Is a dementia diagnosis enough to stop someone driving?
Not by itself. The question is whether this patient can drive safely now. If you think not, report to the licensing authority as your province requires, and do not wait.
Can a positive urine culture explain new confusion?
Rarely on its own. In a resident without a catheter, confusion alone does not meet the minimum signs needed to call it a urinary infection. Look for other causes before you blame the bacteria.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Published prevention guidelinesCanadian Task Force on Preventive Health Care
- Using antibiotics wisely in long-term careChoosing Wisely Canada / national participating organizations
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada
- Consent and capacity resourcesCMPA