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geriatrics.dementia-vascular.core.v1PRODUCTION
geriatrics.dementia-vascular.core.v1

Vascular dementia

general_internal_medicinechronicgeriatricadult
Hard-required inputs
0 / 16
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm scope: chronic cognitive impairment attributable to cerebrovascular disease (VCI continuum — vascular MCI → vascular dementia) in an older adult; not acute confusion (delirium) or a primary neurodegenerative amnestic syndrome (NINDS-AIREN)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Chronic cognitive impairment with a plausible cerebrovascular basis established; acute/rapid course excluded or pivoted (NINDS-AIREN)

Patient inputs (16)

Prior stroke/TIA, focal deficits, and temporal/topographic link to cognitive decline are diagnostic anchors (NINDS-AIREN)

HTN/DM/AF/dyslipidemia/smoking/carotid disease define the modifiable secondary-prevention targets that slow progression (AHA/ASA VCID)

Informant/collateral required — anosognosia and aphasia underestimate deficits; defines functional decline and tempo (VASCOG)

IADL-then-ADL decline defines dementia vs vascular MCI and drives staging and disposition (VASCOG)

Anticholinergic/sedative burden is a reversible contributor; antithrombotic/anticoagulant status and ChEI bradycardia risk inform the plan (AGS Beers 2023)

Caregiver availability/burden and decision-making capacity drive ACP, driving, finances, and disposition (VASCOG)

Executive dysfunction / processing-speed / attention predominant with relatively preserved early episodic memory is the VaD signature vs amnestic AD (VASCOG)

Step-wise/fluctuating course with temporal link to cerebrovascular events distinguishes VaD from insidious AD and from acute delirium (NINDS-AIREN)

VaD risk rises with age; early onset (<60) with family history prompts CADASIL/hereditary small-vessel workup (NOTCH3) (VASCOG)

B12 deficiency is a reversible/contributing cause — mandatory exclusion before attributing decline to cerebrovascular disease (VASCOG)

Hypothyroidism is a reversible/contributing cause — mandatory exclusion (VASCOG)

Diabetes is a major modifiable vascular driver; HbA1c quantifies glycemic target for secondary prevention (AHA/ASA VCID)

LDL drives small-vessel and large-artery disease; high-intensity statin is a cornerstone of progression-slowing (AHA/ASA VCID)

MRI grades infarcts, lacunes, white-matter hyperintensities (Fazekas), microbleeds, and atrophy — significant CVD with temporal/topographic link is a diagnostic requirement (NINDS-AIREN)

Post-stroke depression and vascular depression mimic/compound cognitive decline and are reversible — GDS-15 screen (AHA/ASA VCID)

Early gait disturbance, urinary incontinence, and pseudobulbar affect support subcortical small-vessel VaD and prompt NPH consideration (AHA/ASA VCID)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningacute_stroke_superimposed
    Acute new focal neurologic deficit or suspected acute stroke/TIA superimposed on baseline vascular dementia (AHA/ASA Stroke)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdelirium_superimposed_on_dementia
    Acute fluctuating inattention/altered consciousness superimposed on baseline vascular dementia (NICE NG97)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererapidly_progressive_dementia
    Cognitive decline progressing to dementia over <1-2 years (or weeks-months) — atypical for typical VaD trajectory (VASCOG)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebpsd_danger_to_self_or_others
    Behavioral & psychological symptoms with danger to self/others or severe unrelievable distress (NICE NG97)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenph_triad_potentially_reversible
    Gait disturbance + urinary incontinence + cognitive impairment triad with ventriculomegaly disproportionate to atrophy (AHA/ASA VCID)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateyoung_or_familial_cadasil_pattern
    Early-onset (<60) cognitive decline with subcortical small-vessel pattern, migraine with aura, recurrent lacunar strokes, and a family history of stroke/dementia (CADASIL/hereditary small-vessel) (VASCOG)
    Trigger could not be auto-evaluated — needs clinician judgement.

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INITIAL_WORKUPrequiredDrives screening
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Recommended regimen

Vascular cognitive impairment care ladder — exclude reversible/confirm vascular → AGGRESSIVE secondary vascular prevention (cornerstone) → ChEI/memantine modest/uncertain → depression/PBA/apathy → non-pharm/caregiver/ACP → BPSD non-pharm-first → deprescribe + rehab/falls
axis: vci_care_ladderstep 1 - Step 1 — Exclude reversible/contributing causes + confirm vascular (or mixed) etiology
Selected step "Step 1 — Exclude reversible/contributing causes + confirm vascular (or mixed) etiology" — Any patient before attributing decline to cerebrovascular disease or starting the care ladder
  • reversible_cause_workup
    first line
    diagnostic_action
    triggers: cognitive_decline_new
    VASCOG — B12, TSH, depression (GDS-15), medication/anticholinergic burble, and structural MRI (NPH/subdural/tumor) excluded or treated before attributing decline to cerebrovascular disease
  • cerebrovascular_imaging_confirmation
    first line
    diagnostic_action
    triggers: cognitive_decline_new, vascular_risk_factors
    NINDS-AIREN — significant CVD on MRI (infarcts, lacunes, confluent white-matter hyperintensities/Fazekas, microbleeds) with a temporal/topographic link to cognition is a diagnostic requirement; assess mixed AD with biomarkers when an amnestic/insidious component coexists

outpatient playbook — drug actions (5)

  1. 1. reversible-cause workup + cerebrovascular imaging confirmation
    n/a • n/a • at diagnosis
    trigger: New cognitive decline
    VASCOG / NINDS-AIREN — exclude B12/TSH/depression/meds/NPH; confirm significant CVD with temporal/topographic link; assess mixed AD if amnestic component
  2. 2. secondary vascular prevention bundle (BP control, high-intensity statin, antithrombotic per etiology, AF anticoagulation, glycemic control, smoking cessation, carotid eval, exercise/diet)
    agent/dose per comorbidity and guideline targets • PO/SC • daily/ongoing
    trigger: VaD confirmed
    AHA/ASA VCID — cornerstone; the only intervention proven to slow vascular cognitive decline
  3. 3. ChEI / memantine (limited-evidence trial, esp. mixed AD)
    donepezil 5→10 mg / galantamine 8→24 mg / memantine 5→20 mg • PO/transdermal • per agent
    trigger: Symptomatic trial considered, strongest if mixed AD
    AHA/ASA VCID — modest/uncertain benefit; trial-with-review, NOT a strong recommendation
  4. 4. SSRI for depression / dextromethorphan-quinidine for PBA
    sertraline 25-50 mg; DM 20 mg/quinidine 10 mg • PO • daily→BID
    trigger: Post-stroke depression / pseudobulbar affect
    AHA/ASA VCID — treat reversible mood/affect contributors; avoid anticholinergic antidepressants
  5. 5. risperidone (BPSD, last resort)
    0.25-0.5 mg lowest effective, time-limited • PO • once-twice daily, review 6-12 wk
    trigger: Severe agitation/psychosis with danger, non-pharm failed, NOT Lewy features
    NICE NG97 — boxed mortality + cerebrovascular events; trigger search + non-pharm FIRST

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Step-wise or fluctuating cognitive decline with prominent executive/processing-speed slowing (informant-corroborated); Post-stroke / post-TIA cognitive impairment on surveillance (multi-infarct or strategic infarct); Heavy vascular-risk burden (HTN/DM/AF/carotid disease/smoking) with new cognitive concern + gait change/early incontinence.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Vascular dementia** (geriatrics.dementia-vascular.core.v1).
Phenotype framing: Vascular dementia subtype assignment (post-stroke/multi-infarct, strategic single-infarct, subcortical small-vessel/Binswanger, mixed AD+vascular [common], hereditary CADASIL, post-hemorrhage) vs Alzheimer disease (insidious amnestic, no infarct burden), DLB (early visual hallucinations/parkinsonism/RBD/fluctuation), FTD (early behavioral/language, younger), NPH (gait+incontinence+cognition triad, reversible), pseudodementia (vascular/post-stroke depression), reversible (B12/TSH/meds), delirium (acute fluctuating inattention) (VASCOG)
Scope: Confirm scope: chronic cognitive impairment attributable to cerebrovascular disease (VCI continuum — vascular MCI → vascular dementia) in an older adult; not acute confusion (delirium) or a primary neurodegenerative amnestic syndrome (NINDS-AIREN)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Vascular cognitive impairment care ladder — exclude reversible/confirm vascular → AGGRESSIVE secondary vascular prevention (cornerstone) → ChEI/memantine modest/uncertain → depression/PBA/apathy → non-pharm/caregiver/ACP → BPSD non-pharm-first → deprescribe + rehab/falls** — step "Step 1 — Exclude reversible/contributing causes + confirm vascular (or mixed) etiology".
1. reversible_cause_workup (diagnostic_action, first line) — VASCOG — B12, TSH, depression (GDS-15), medication/anticholinergic burble, and structural MRI (NPH/subdural/tumor) excluded or treated before attributing decline to cerebrovascular disease
2. cerebrovascular_imaging_confirmation (diagnostic_action, first line) — NINDS-AIREN — significant CVD on MRI (infarcts, lacunes, confluent white-matter hyperintensities/Fazekas, microbleeds) with a temporal/topographic link to cognition is a diagnostic requirement; assess mixed AD with biomarkers when an amnestic/insidious component coexists

Setting playbook (outpatient) — Diagnose and subtype VaD, exclude reversible causes, initiate and titrate AGGRESSIVE secondary vascular prevention to target, establish non-pharm/caregiver/ACP cornerstone, treat depression/PBA/apathy, and run rehab/falls support
3. reversible-cause workup + cerebrovascular imaging confirmation n/a n/a at diagnosis — New cognitive decline (VASCOG / NINDS-AIREN — exclude B12/TSH/depression/meds/NPH; confirm significant CVD with temporal/topographic link; assess mixed AD if amnestic component)
4. secondary vascular prevention bundle (BP control, high-intensity statin, antithrombotic per etiology, AF anticoagulation, glycemic control, smoking cessation, carotid eval, exercise/diet) agent/dose per comorbidity and guideline targets PO/SC daily/ongoing — VaD confirmed (AHA/ASA VCID — cornerstone; the only intervention proven to slow vascular cognitive decline)
5. ChEI / memantine (limited-evidence trial, esp. mixed AD) donepezil 5→10 mg / galantamine 8→24 mg / memantine 5→20 mg PO/transdermal per agent — Symptomatic trial considered, strongest if mixed AD (AHA/ASA VCID — modest/uncertain benefit; trial-with-review, NOT a strong recommendation)
6. SSRI for depression / dextromethorphan-quinidine for PBA sertraline 25-50 mg; DM 20 mg/quinidine 10 mg PO daily→BID — Post-stroke depression / pseudobulbar affect (AHA/ASA VCID — treat reversible mood/affect contributors; avoid anticholinergic antidepressants)
7. risperidone (BPSD, last resort) 0.25-0.5 mg lowest effective, time-limited PO once-twice daily, review 6-12 wk — Severe agitation/psychosis with danger, non-pharm failed, NOT Lewy features (NICE NG97 — boxed mortality + cerebrovascular events; trigger search + non-pharm FIRST)

Non-pharmacologic actions:
- Aggressive multidomain vascular-risk reduction (BP, LDL, glucose, smoking, weight, OSA, diet, exercise)
- Cognitive stimulation, structured routine, orientation aids, environmental modification
- Caregiver education, skills training, support groups, respite referral
- Advance care planning, surrogate, driving assessment, financial/legal capacity early
- Rehabilitation (PT/OT/SLP) and multifactorial falls prevention / gait aids / continence management
- Deprescribe anticholinergics/sedatives; minimize benzodiazepines
- NPH evaluation referral if gait + incontinence + cognition triad with ventriculomegaly

AVOID / contraindication checks:
- Antipsychotic_boxed_increased_mortality_and_stroke_in_dementia_lowest_dose_time_limited (NICE NG97)
- Avoid_antipsychotic_if_lewy_features_severe_neuroleptic_hypersensitivity (NICE NG97)
- Avoid_benzodiazepines_in_dementia_delirium_falls_paradoxical_agitation (AGS Beers 2023)
- Cholinesterase_inhibitor_bradycardia_syncope_GI_caution_baseline_HR_and_cardiac_history (AHA/ASA VCID)
- Do_not_lower_BP_excessively_in_established_high_grade_carotid_or_intracranial_stenosis_hypoperfusion (AHA/ASA VCID)
- Do_not_combine_antiplatelet_and_anticoagulant_without_specific_indication_bleeding_microbleed_risk (AHA/ASA Stroke)
- Individualize_anticoagulation_when_extensive_cerebral_microbleeds_or_amyloid_angiopathy (AHA/ASA Stroke)
- Avoid_abrupt_anticholinergic_or_benzodiazepine_withdrawal_taper_gradually (AGS Beers 2023)
- Dextromethorphan_quinidine_check_QTc_and_CYP2D6_interactions_for_PBA (AHA/ASA VCID)

Monitoring

Regimen monitoring:
- vascular risk targets BP LDL HbA1c antithrombotic adherence smoking status each visit (AHA/ASA VCID)
- cognitive and functional executive weighted MoCA ADL IADL q6-12mo and after new vascular event (AHA/ASA VCID)
- recurrent stroke TIA surveillance watch for stepwise decline (NINDS-AIREN)
- cholinesterase inhibitor tolerability GI HR syncope if symptomatic trial used (AHA/ASA VCID)
- memantine renal dose check CrCl (NICE NG97)
- caregiver burden screen each visit (NICE NG97)
- anticholinergic burden ACB reassessment after deprescribing (AGS Beers 2023)

Setting (outpatient) monitoring:
- Vascular-risk targets (BP, LDL, HbA1c, antithrombotic/anticoagulation adherence, smoking) each visit (AHA/ASA VCID)
- Executive-weighted MoCA + ADL/IADL q6-12mo and after any new vascular event (NINDS-AIREN)
- ChEI tolerability — GI, HR/syncope at each titration if trial used (AHA/ASA VCID)
- Caregiver burden screen each visit (NICE NG97)

Follow-up plan: Reinforce and re-titrate secondary prevention at each visit (BP/LDL/HbA1c/anticoagulation/smoking); advance care planning revisited at each transition; driving/finances/capacity reviewed; caregiver respite and support referral; rehab continuity and falls prevention; palliative/end-of-life planning and ChEI/memantine deprescribing decision in advanced (severe) disease (VASCOG)
- Close-out criterion: Secondary-prevention plan re-titrated to target; ACP documented; caregiver support arranged; next cognitive review and goals-of-care interval scheduled (VASCOG)

Monitoring phase: Vascular-risk target surveillance (BP, LDL, HbA1c, antithrombotic/anticoagulation adherence, smoking status) at each visit; cognitive/functional re-assessment (executive-weighted MoCA + ADL/IADL) every 6-12 months and after any new vascular event (watch for step-wise drops); recurrent stroke/TIA vigilance; ChEI tolerability (GI, bradycardia/syncope) if a trial is used; caregiver burden screening at each visit; deprescribing follow-through (AHA/ASA VCID)

Disposition

Current setting: outpatient — Diagnose and subtype VaD, exclude reversible causes, initiate and titrate AGGRESSIVE secondary vascular prevention to target, establish non-pharm/caregiver/ACP cornerstone, treat depression/PBA/apathy, and run rehab/falls support

Disposition criteria:
- Continue outpatient stroke-prevention/geriatrics/neurology co-management with rehab when stable (AHA/ASA VCID)
- Refer long-term care/placement planning as disease advances and caregiver capacity is exceeded (NICE NG97)

Escalation triggers (move to higher acuity):
- Acute new focal deficit / suspected acute stroke or TIA → acute stroke pathway, not chronic VaD (AHA/ASA Stroke)
- Superimposed delirium or acute deterioration → inpatient workup (NICE NG97)
- BPSD with danger to self/others not controllable in clinic → inpatient/urgent (NICE NG97)
- Rapid progression (<1-2y) → rapid-dementia workup (CJD/autoimmune/paraneoplastic) (VASCOG)
- NPH triad with ventriculomegaly → neurosurgical evaluation (AHA/ASA VCID)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute new focal neurologic deficit or suspected acute stroke/TIA superimposed on baseline vascular dementia (AHA/ASA Stroke)
- [LIFE_THREATENING] Acute fluctuating inattention/altered consciousness superimposed on baseline vascular dementia (NICE NG97)
- [SEVERE] Cognitive decline progressing to dementia over <1-2 years (or weeks-months) — atypical for typical VaD trajectory (VASCOG)

Citations

- AHA/ASA Scientific Statement — Vascular Contributions to Cognitive Impairment and Dementia (VCID) + 2024-2025 vascular cognitive impairment reviews; NINDS-AIREN and VASCOG diagnostic criteria; DSM-5 vascular neurocognitive disorder; NICE NG97 Dementia; AGS Beers 2023 [PMID:21778438](https://pubmed.ncbi.nlm.nih.gov/21778438/)
- Cited evidence (PMID 8255398) [PMID:8255398](https://pubmed.ncbi.nlm.nih.gov/8255398/)
- Cited evidence (PMID 24632990) [PMID:24632990](https://pubmed.ncbi.nlm.nih.gov/24632990/)
- Cited evidence (PMID 19131666) [PMID:19131666](https://pubmed.ncbi.nlm.nih.gov/19131666/)
- Cited evidence (PMID 16876668) [PMID:16876668](https://pubmed.ncbi.nlm.nih.gov/16876668/)

Last reconciled with current guidelines: 2026-05-16.
References
  • AHA/ASA Scientific Statement — Vascular Contributions to Cognitive Impairment and Dementia (VCID) + 2024-2025 vascular cognitive impairment reviews; NINDS-AIREN and VASCOG diagnostic criteria; DSM-5 vascular neurocognitive disorder; NICE NG97 Dementia; AGS Beers 2023 — PMID:21778438
  • Cited evidence (PMID 8255398) — PMID:8255398
  • Cited evidence (PMID 24632990) — PMID:24632990
  • Cited evidence (PMID 19131666) — PMID:19131666
  • Cited evidence (PMID 16876668) — PMID:16876668