Vascular cognitive impairment and dementia — assessment and management (MEQ)

(i) Formulation. Working diagnosis: major vascular neurocognitive disorder / vascular dementia within the VCI spectrum, multi-infarct stepwise features plus evolving subcortical ischaemic phenotype (executive slowing, apathy, gait). Functional interference with medications and finances indicates major rather than mild NCD. Mixed AD pathology remains possible but core story is vascular. Not DLB (no RBD/visual hallucinations cluster).^[3][8]

(ii) Criteria anchors. Historical NINDS-AIREN: dementia + cerebrovascular disease + relationship (stroke-related onset/stepwise). Modern: VASCOG vascular cognitive disorders; VICCCS major VCI with multi-infarct/subcortical/post-stroke phenotypes; DSM-5-TR major NCD due to vascular disease (probable/possible language by certainty of vascular link).^[1][2][3]

(iii) Assessment and investigations. Collateral tempo and stroke timeline; MSE with executive emphasis; MoCA interpretation; neurologic exam (focal signs, gait); vascular risk inventory; delirium screen. Bloods (glucose, lipids, B12, TSH, etc.), ECG/INR in AF, MRI preferred for infarcts/lacunes/WMH using STRIVE vocabulary educationally without fabricating a specific patient report; carotid/cardiac work-up as stroke pathway indicates.^[6][8]

(iv) Management. Primary disease modification: smoking cessation, individualised BP control (SPRINT MIND intensive SBP signal for MCI/composite cognitive outcomes in eligible hypertensives — translate carefully to frailty), glycaemia, lipids, continue indicated anticoagulation for AF, secondary stroke prevention adherence, exercise, alcohol limits, rehab, carer support.^[4][8] Cognitive drugs: counsel modest RCT/meta-analysis benefits (donepezil VaD trials; Kavirajan); if used after local formulary review, example donepezil 5 mg orally daily for ≥4 weeks then 10 mg daily if tolerated, with GI/bradycardia monitoring and 3-month benefit review — never instead of risk control.^[5]

(v) Capacity, driving, delirium. Decision-specific capacity (understand, appreciate, reason, communicate choice) for treatment and finances; driving advice/cessation pathway; educate family that acute fluctuation equals delirium or new stroke until proven otherwise.^[7][8]