Psych · Old age psychiatry — neurocognitive disorders
Vascular cognitive impairment and dementia
Also known as Vascular dementia · VaD · Vascular cognitive impairment · VCI · Major vascular neurocognitive disorder · Multi-infarct dementia · Subcortical ischaemic vascular dementia · Post-stroke dementia
Exam-exhaustive fellowship reference on vascular cognitive impairment and vascular dementia — VCI spectrum, NINDS-AIREN/VASCOG/VICCCS/DSM-5-TR criteria, multi-infarct stepwise versus subcortical small-vessel phenotypes, STRIVE imaging vocabulary, post-stroke dementia epidemiology, SPRINT MIND blood-pressure signal, secondary stroke prevention as disease modification, and modest AChEI/memantine trial evidence. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Acute fluctuating inattention on a vascular brain — treat as delirium first; do not attribute solely to 'known VaD'
- Hyperacute focal neurology or suspected TIA/stroke — emergency stroke pathway, not memory clinic delay
- Rapid stepwise decline with new focal signs — urgent neurovascular work-up for recurrent stroke
- Atrial fibrillation without anticoagulation review when CHA2DS2-VASc and bleeding risk warrant specialist decision
- Antipsychotic for mild apathy or irritability in vascular dementia — mortality risk in elderly dementia; non-drug first
- Young-onset recurrent lacunar strokes with migraine/family history — consider CADASIL and specialist genetics pathway
- Unsafe driving, fire risk, financial exploitation, or carer collapse — capacity and safeguarding, not only a MoCA score
Meet the patient
A 76-year-old former lorry driver presents with two years of gradually slowing thinking, a short-stepped shuffling gait, and new urinary urgency. His MMSE is 27 out of 30, and on that number he has been twice reassured that this is normal ageing.[22][27]
He has hypertension, type 2 diabetes, and an old lacunar stroke. His MoCA is 19, his clock is disorganised, and his MRI shows confluent white-matter hyperintensities and several lacunes. His daughter mentions, almost as an aside, that he has not taken his blood-pressure tablets for a month.[14][15]
Two exam questions own this topic. What is the cognitive syndrome, and what is the single most important thing you can do to change its trajectory? The second answer is not donepezil.[3][11]
References27ShowHide
- [1]Román GC, Tatemichi TK, Erkinjuntti T, et al. Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop Neurology, 1993.PMID 8094895
- [2]Sachdev P, Kalaria R, O'Brien J, et al. Diagnostic criteria for vascular cognitive disorders: a VASCOG statement Alzheimer Dis Assoc Disord, 2014.PMID 24632990
- [3]Gorelick PB, Scuteri A, Black SE, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association Stroke, 2011.PMID 21778438
- [4]Hachinski V, Iadecola C, Petersen RC, et al. National Institute of Neurological Disorders and Stroke-Canadian Stroke Network vascular cognitive impairment harmonization standards Stroke, 2006.PMID 16917086
- [5]O'Brien JT, Thomas A Vascular dementia Lancet, 2015.PMID 26595643
- [6]Dichgans M, Leys D Vascular Cognitive Impairment Circ Res, 2017.PMID 28154105
- [7]van der Flier WM, Skoog I, Schneider JA, et al. Vascular cognitive impairment Nat Rev Dis Primers, 2018.PMID 29446769
- [8]Skrobot OA, O'Brien J, Black S, et al. The Vascular Impairment of Cognition Classification Consensus Study Alzheimers Dement, 2017.PMID 27960092
- [9]Skrobot OA, Black SE, Chen C, et al. Progress toward standardized diagnosis of vascular cognitive impairment: Guidelines from the Vascular Impairment of Cognition Classification Consensus Study Alzheimers Dement, 2018.PMID 29055812
- [10]Pendlebury ST, Rothwell PM Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis Lancet Neurol, 2009.PMID 19782001
- [11]Williamson JD, Pajewski NM, Auchus AP, et al. Effect of Intensive vs Standard Blood Pressure Control on Probable Dementia: A Randomized Clinical Trial JAMA, 2019.PMID 30688979
- [12]Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission Lancet, 2020.PMID 32738937
- [13]Livingston G, Sommerlad A, Orgeta V, et al. Dementia prevention, intervention, and care Lancet, 2017.PMID 28735855
- [14]Wardlaw JM, Smith EE, Biessels GJ, et al. Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration Lancet Neurol, 2013.PMID 23867200
- [15]Pantoni L Cerebral small vessel disease: from pathogenesis and clinical characteristics to therapeutic challenges Lancet Neurol, 2010.PMID 20610345
- [16]Kavirajan H, Schneider LS Efficacy and adverse effects of cholinesterase inhibitors and memantine in vascular dementia: a meta-analysis of randomised controlled trials Lancet Neurol, 2007.PMID 17689146
- [17]Black S, Román GC, Geldmacher DS, et al. Efficacy and tolerability of donepezil in vascular dementia: positive results of a 24-week, multicenter, international, randomized, placebo-controlled clinical trial Stroke, 2003.PMID 12970516
- [18]Wilkinson D, Doody R, Helme R, et al. Donepezil in vascular dementia: a randomized, placebo-controlled study Neurology, 2003.PMID 12939421
- [19]Erkinjuntti T, Kurz A, Gauthier S, et al. Efficacy of galantamine in probable vascular dementia and Alzheimer's disease combined with cerebrovascular disease: a randomised trial Lancet, 2002.PMID 11965273
- [20]Orgogozo JM, Rigaud AS, Stöffler A, et al. Efficacy and safety of memantine in patients with mild to moderate vascular dementia: a randomized, placebo-controlled trial (MMM 300) Stroke, 2002.PMID 12105362
- [21]Sachdev PS, Blacker D, Blazer DG, et al. Classifying neurocognitive disorders: the DSM-5 approach Nat Rev Neurol, 2014.PMID 25266297
- [22]Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment J Am Geriatr Soc, 2005.PMID 15817019
- [23]McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease Alzheimers Dement, 2011.PMID 21514250
- [24]Kales HC, Gitlin LN, Lyketsos CG Assessment and management of behavioral and psychological symptoms of dementia BMJ, 2015.PMID 25731881
- [25]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
- [26]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
- [27]Folstein MF, Folstein SE, McHugh PR Mini-mental state. A practical method for grading the cognitive state of patients for the clinician J Psychiatr Res, 1975.PMID 1202204