Vascular cognitive impairment and dementia — structured clinical viva · Psych Vivas

Prompt

You are the old-age psychiatry registrar. A 81-year-old woman with hypertension, diabetes, and multiple lacunes on prior MRI is referred for 'possible vascular dementia versus Alzheimer disease.' Family describe years of gradual executive decline and gait change, with two clearer steps after hospitalised strokes. Discuss definition of VCI, criteria systems, multi-infarct versus subcortical phenotypes, imaging language (STRIVE), SPRINT MIND and risk-factor management, evidence for donepezil/memantine, BPSD antipsychotic caution, and capacity assessment.

Interpretation

Reveal interpretation

Define VCI as the cerebrovascular cognitive spectrum from mild impairment to dementia. Use NINDS-AIREN historically, then VASCOG and VICCCS for modern mild/major VCI and phenotypes, and DSM-5-TR major/mild vascular NCD for independence-based severity.[1][2][3]

This stem mixes subcortical gradual features with stepwise multi-infarct events — formulate hybrid vascular phenotype and allow mixed AD-vascular rather than forcing purity. Imaging: discuss lacunes/WMH using STRIVE terms; do not invent a scan report.[7]

Management lead: BP (SPRINT MIND — intensive control reduced MCI; probable dementia alone NS), glycaemia, smoking, secondary prevention, AF if present, rehab, carer support. AChEI/memantine: modest benefits (Kavirajan); example donepezil 5→10 mg if used after counselling. BPSD: non-drug first; antipsychotics time-limited with mortality signal (Schneider). Capacity: Appelbaum four abilities, decision-specific.[4][5][6][8]

Key points

[3] [4] [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]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
[7]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
[8]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278

Interpretation

Reveal interpretation

Key points

[3]

[4]

[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]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
[7]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
[8]Appelbaum PS, Grisso T Assessing patients' capacities to consent to treatment N Engl J Med, 1988.PMID 3200278