Vascular cognitive impairment and dementia — assessment and management (MEQ) · Psych MEQs / SAQs

Prompt

A 78-year-old man with hypertension, type 2 diabetes, atrial fibrillation on warfarin, and two prior ischaemic strokes is referred six months after his last stroke. His daughter reports stepwise decline after each stroke plus progressive slowing, apathy, and unsteady gait between events. He needs help with medications and finances but still dresses with prompting. MoCA is 18/30 with marked executive and processing-speed deficits; free recall is impaired but recognition is relatively better. He is a current smoker. There is no REM sleep behaviour disorder or well-formed visual hallucinations. (i) Formulate the cognitive syndrome using VCI spectrum language and phenotype. (ii) Outline criteria anchors you would cite (historical and modern). (iii) Detail bedside assessment and investigations including imaging principles. (iv) Give a management plan prioritising vascular risk control, and state how you would counsel about cholinesterase inhibitors/memantine including a named dose example if used. (v) Address capacity, driving, and delirium risk. (20 marks)

Model answer

Reveal model answer

(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]

Common errors

Calling this pure AD or pure depression without vascular formulation.
Opening with donepezil before smoking, BP, AF, and secondary prevention.
Mis-stating SPRINT MIND as a significant primary-endpoint win on dementia alone.
Inventing detailed fictional MRI measurements as if reporting a real scan.
Ignoring capacity and driving. [4][5][7]

Examiner notes

Full marks require spectrum/phenotype language, named criteria, imaging principles, risk control first, modest pharmacotherapy with a named dose, and capacity/delirium safety. [1][3][5]

References

[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]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
[4]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
[5]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
[6]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
[7]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
[8]O'Brien JT, Thomas A Vascular dementia Lancet, 2015.PMID 26595643

Model answer

Reveal model answer

Common errors

Calling this pure AD or pure depression without vascular formulation.

Opening with donepezil before smoking, BP, AF, and secondary prevention.

Mis-stating SPRINT MIND as a significant primary-endpoint win on dementia alone.

Inventing detailed fictional MRI measurements as if reporting a real scan.

Ignoring capacity and driving. [4][5][7]

Examiner notes

Full marks require spectrum/phenotype language, named criteria, imaging principles, risk control first, modest pharmacotherapy with a named dose, and capacity/delirium safety. [1][3][5]

References

[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]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
[4]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
[5]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
[6]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
[7]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278
[8]O'Brien JT, Thomas A Vascular dementia Lancet, 2015.PMID 26595643