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neuro.vascular-dementia.v1PRODUCTION
neuro.vascular-dementia.v1

Vascular Cognitive Impairment / Vascular Dementia

neurologychronicsubacuteadultgeriatric
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Care setting:

Encounter flow

12/12 authored

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

Current phase

Frame

Detailed

Cognitive decline temporally + spatially linked to cerebrovascular disease meeting AHA/ASA VCI 2019 + NINDS-AIREN + VASCOG criteria (Iadecola PMID 21778438; Roman PMID 8094895; Sachdev PMID 24632990)

Inputs
2
Actions
0
Advance rule
Set
Advance when

VaD criteria met (probable / possible / mixed)

Patient inputs (18)

Mean age ~75; younger onset → CADASIL / CAA / monogenic (Iadecola PMID 21778438)

Prior stroke / TIA establishes vascular substrate; temporal relationship (within 3 mo) supports VaD (NINDS-AIREN PMID 8094895)

Vascular RF bundle; secondary prevention targets per AHA/ASA 2021 PMID 34024117

Major vs mild VCI hinges on functional independence (VASCOG 2014 PMID 24632990)

Post-stroke depression common + treatable; pseudodementia mimic (AHA/ASA VCI 2019)

Anticholinergic burden reversibly worsens cognition (AGS Beers 2023)

Step-wise (each stroke episode) OR insidious (chronic SVD) — both VaD patterns (NINDS-AIREN)

DM control reduces SVD progression (AHA/ASA 2021)

LDL <55 mg/dL per AHA/ASA 2021 secondary stroke prevention

Hypothyroid + B12 deficiency reversible mimics (AAN 2018)

MRI with SWI/T2*/FLAIR: lacunar infarcts + WMH (Fazekas) + microbleeds (CAA hint) + superficial siderosis; strategic infarcts (thalamus, caudate)

Acute confusion in stroke patient often delirium not VaD; CAM must be negative for chronic VaD label

Aspirin / DAPT / DOAC / warfarin for secondary prevention; CAA limits anticoag

BP control target <130/80 per AHA/ASA 2021 PMID 34024117; SPRINT-MIND PMID 30688979 supports intensive <120 in select older adults

AF + LV thrombus + PFO + LV systolic dysfunction → cardioembolic source for VCI workup (AHA/ASA 2021)

NOTCH3 sequencing for CADASIL (young-onset stroke + migraine + family history + anterior temporal WMH)

Mixed AD-vascular common; CSF Aβ42 + p-tau identifies AD biology overlap to guide mAb eligibility (NIA-AA 2018)

Caregiver Zarit ≥21 → institutionalization risk (APA 2024)

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

Severity triggers (11)

11 need judgement
  • informationalseverestrategic_infarct_dementia
    Strategic infarct (thalamus / caudate / angular gyrus / posterior cerebral) producing focal cognitive syndrome
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremulti_infarct_dementia
    Multiple cortical infarcts producing step-wise decline; classic NINDS-AIREN pattern (Roman PMID 8094895)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecerebral_amyloid_angiopathy_overlap
    CAA — lobar microbleeds + superficial siderosis + lobar ICH history; CAA-related dementia + bleed risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecadasil_notch3
    CADASIL — autosomal-dominant cerebral arteriopathy from NOTCH3 mutation; migraine + young-onset stroke + dementia + mood disturbance + anterior temporal WMH
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepost_stroke_cognitive_decline
    Cognitive decline within 3 mo of stroke meeting AHA/ASA VCI 2019 criteria (Iadecola PMID 21778438)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesubcortical_small_vessel_disease
    Subcortical SVD — multiple lacunes + Fazekas 2-3 WMH; lower-body gait apraxia + executive dysfunction
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemixed_vad_ad
    Mixed VaD-AD — common in elderly; vascular substrate + biomarker AD positive (CSF Aβ low + p-tau elevated)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateleukoaraiosis_severe
    Severe leukoaraiosis (Fazekas 3) with confluent periventricular + deep WMH; cognitive trajectory accelerated
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebp_control_secondary_prevention
    BP not at goal (<130/80) — major modifiable VaD progression driver
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildvascular_mci_progressing
    VCI-mild (MCI vascular subtype) progressing to VaD; conversion rate higher with continued vascular insults
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildsglt2i_cognitive_benefit_signal
    T2DM + CKD overlap + VCI — SGLT2i (empagliflozin/dapagliflozin) for cardiorenal + emerging cognitive signal (forward-looking adjunct)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

Secondary stroke prevention bundle — statin + BP + antiplatelet/anticoag + glycemic + smoking cessation (AHA/ASA 2021 PMID 34024117; SPRINT-MIND PMID 30688979)
axis: vad_secondary_stroke_prevention
Selected axis "Secondary stroke prevention bundle — statin + BP + antiplatelet/anticoag + glycemic + smoking cessation (AHA/ASA 2021 PMID 34024117; SPRINT-MIND PMID 30688979)" by default fallback (first axis)
  • atorvastatin
    first line
    statin_high_intensity
    40-80 mg PO daily • PO • daily (max: 80 mg/day)
    triggers: post_stroke, high_ASCVD
    AHA/ASA 2021 PMID 34024117 — LDL <55 mg/dL target post-stroke; high-intensity statin
    rxcui 617310
  • rosuvastatin
    first line
    statin_high_intensity
    20-40 mg PO daily • PO • daily
    triggers: atorvastatin_intolerance
    Alternative high-intensity statin
    rxcui 301542
  • aspirin
    first line
    antiplatelet
    81 mg PO daily • PO • daily
    triggers: non_cardioembolic_stroke, TIA
    AHA/ASA 2021 — first-line antiplatelet for non-cardioembolic; DAPT (aspirin + clopidogrel) × 21 d for minor stroke / high-risk TIA per CHANCE / POINT
    rxcui 1191
  • clopidogrel
    first line
    P2Y12_inhibitor
    75 mg PO daily (after 300-600 mg load) • PO • daily
    triggers: aspirin_intolerance, DAPT_x_21d_per_CHANCE_POINT
    AHA/ASA 2021 — DAPT × 21 d for minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4); long-term mono for aspirin intolerance
    rxcui 32968
  • apixaban
    first line
    DOAC
    5 mg PO BID (2.5 mg BID if 2 of: age ≥80, weight ≤60 kg, Cr ≥1.5) • PO • BID
    triggers: atrial_fibrillation, cardioembolic_stroke
    AHA/ASA 2021 — DOAC preferred over warfarin for non-valvular AF; lowest bleed risk vs other DOAC
    rxcui 1364430
  • rivaroxaban
    first line
    DOAC
    20 mg PO daily with food (15 mg if CrCl 15-50) • PO • daily with food
    triggers: atrial_fibrillation_alt_doac
    Alternative DOAC for AF
    rxcui 1114195
  • warfarin
    second line
    vitamin_K_antagonist
    5 mg PO daily (target INR 2-3) • PO • daily; INR-titrated
    triggers: mechanical_valve, DOAC_contraindication
    Mechanical valve or DOAC contraindication; INR 2-3
    rxcui 11289
  • lisinopril
    first line
    ACE_inhibitor
    10 mg PO daily; titrate to 20-40 mg • PO • daily (max: 40 mg/day)
    triggers: hypertension, post_stroke
    AHA/ASA 2021 — BP <130/80 target; SPRINT-MIND PMID 30688979 signal for intensive <120 in select older adults
    rxcui 29046
  • amlodipine
    add on
    calcium_channel_blocker
    5 mg PO daily; titrate to 10 mg • PO • daily (max: 10 mg/day)
    triggers: hypertension_add_on
    AHA/ASA 2021 BP combination
    rxcui 104416
  • hydrochlorothiazide
    add on
    thiazide_diuretic
    12.5-25 mg PO daily • PO • daily
    triggers: hypertension_add_on
    AHA/ASA 2021 BP combination
    rxcui 5487
  • metformin
    first line
    biguanide
    500 mg PO BID with meals • PO • BID (max: 2000 mg/day)
    triggers: T2DM
    ADA 2026 first-line DM; glycemic control reduces SVD progression
    rxcui 6809
  • empagliflozin
    add on
    SGLT2_inhibitor
    10 mg PO daily; titrate to 25 mg • PO • daily
    triggers: T2DM_CKD_or_HF
    EMPA-KIDNEY + EMPEROR — cardiorenal benefit; emerging cognitive signal in CKD overlap (forward-looking adjunct)
    rxcui 1545653
  • dapagliflozin
    add on
    SGLT2_inhibitor
    10 mg PO daily • PO • daily
    triggers: T2DM_CKD_or_HF_alt
    DAPA-CKD — cardiorenal benefit
    rxcui 1488564
  • smoking cessation counseling + varenicline / NRT
    first line
    lifestyle
    triggers: active_smoker
    AHA/ASA 2021 — smoking cessation reduces stroke recurrence

outpatient playbook — drug actions (7)

  1. 1. atorvastatin
    40-80 mg PO daily • PO • daily
    trigger: LDL <55
    AHA/ASA 2021
  2. 2. aspirin OR clopidogrel OR DOAC
    Aspirin 81 / Clopidogrel 75 / Apixaban 5 BID • PO • daily / BID
    trigger: Per stroke mechanism
    AHA/ASA 2021
  3. 3. lisinopril ± amlodipine ± HCTZ
    Titrate to <130/80 • PO • daily
    trigger: BP control
    SPRINT-MIND signal
  4. 4. metformin ± SGLT2i
    500 mg BID titrate; empagliflozin 10-25 mg daily • PO • BID + daily
    trigger: T2DM ± CKD / HF
    ADA 2026 + EMPA-KIDNEY
  5. 5. donepezil
    5-10 mg PO QHS • PO • daily
    trigger: Symptomatic cognitive Rx
    AAN 2018 / Cochrane
  6. 6. memantine
    5 mg titrate to 10 mg BID • PO • BID
    trigger: Moderate-severe (MMSE ≤14)
    AAN 2018 add-on
  7. 7. sertraline
    25-100 mg PO daily • PO • daily
    trigger: Post-stroke depression / pseudobulbar
    APA 2024

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Cognitive decline within 3 mo of stroke (AHA/ASA VCI 2019 PMID 21778438); Step-wise cognitive decline with cerebrovascular events (NINDS-AIREN PMID 8094895); Severe periventricular + deep white-matter hyperintensities (Fazekas 2-3) on MRI.

Objective

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

Assessment

**Vascular Cognitive Impairment / Vascular Dementia** (neuro.vascular-dementia.v1).
Phenotype framing: Probable VaD (NINDS-AIREN) vs possible VaD vs mixed VaD-AD vs pure AD (route to neuro.alzheimer.v1) vs FTD (route to neuro.frontotemporal-dementia.v1) vs DLB / PDD (route to neuro.parkinson.v1) vs NPH (Hakim triad) vs reversible mimics — CAA, CADASIL, post-stroke depression
Scope: Cognitive decline temporally + spatially linked to cerebrovascular disease meeting AHA/ASA VCI 2019 + NINDS-AIREN + VASCOG criteria (Iadecola PMID 21778438; Roman PMID 8094895; Sachdev PMID 24632990)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Secondary stroke prevention bundle — statin + BP + antiplatelet/anticoag + glycemic + smoking cessation (AHA/ASA 2021 PMID 34024117; SPRINT-MIND PMID 30688979)**.
1. atorvastatin 40-80 mg PO daily PO daily (statin_high_intensity, first line) — AHA/ASA 2021 PMID 34024117 — LDL <55 mg/dL target post-stroke; high-intensity statin
2. rosuvastatin 20-40 mg PO daily PO daily (statin_high_intensity, first line) — Alternative high-intensity statin
3. aspirin 81 mg PO daily PO daily (antiplatelet, first line) — AHA/ASA 2021 — first-line antiplatelet for non-cardioembolic; DAPT (aspirin + clopidogrel) × 21 d for minor stroke / high-risk TIA per CHANCE / POINT
4. clopidogrel 75 mg PO daily (after 300-600 mg load) PO daily (P2Y12_inhibitor, first line) — AHA/ASA 2021 — DAPT × 21 d for minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4); long-term mono for aspirin intolerance
5. apixaban 5 mg PO BID (2.5 mg BID if 2 of: age ≥80, weight ≤60 kg, Cr ≥1.5) PO BID (DOAC, first line) — AHA/ASA 2021 — DOAC preferred over warfarin for non-valvular AF; lowest bleed risk vs other DOAC
6. rivaroxaban 20 mg PO daily with food (15 mg if CrCl 15-50) PO daily with food (DOAC, first line) — Alternative DOAC for AF
7. warfarin 5 mg PO daily (target INR 2-3) PO daily; INR-titrated (vitamin_K_antagonist, second line) — Mechanical valve or DOAC contraindication; INR 2-3
8. lisinopril 10 mg PO daily; titrate to 20-40 mg PO daily (ACE_inhibitor, first line) — AHA/ASA 2021 — BP <130/80 target; SPRINT-MIND PMID 30688979 signal for intensive <120 in select older adults
9. amlodipine 5 mg PO daily; titrate to 10 mg PO daily (calcium_channel_blocker, add on) — AHA/ASA 2021 BP combination
10. hydrochlorothiazide 12.5-25 mg PO daily PO daily (thiazide_diuretic, add on) — AHA/ASA 2021 BP combination
11. metformin 500 mg PO BID with meals PO BID (biguanide, first line) — ADA 2026 first-line DM; glycemic control reduces SVD progression
12. empagliflozin 10 mg PO daily; titrate to 25 mg PO daily (SGLT2_inhibitor, add on) — EMPA-KIDNEY + EMPEROR — cardiorenal benefit; emerging cognitive signal in CKD overlap (forward-looking adjunct)
13. dapagliflozin 10 mg PO daily PO daily (SGLT2_inhibitor, add on) — DAPA-CKD — cardiorenal benefit
14. smoking cessation counseling + varenicline / NRT (lifestyle, first line) — AHA/ASA 2021 — smoking cessation reduces stroke recurrence

Setting playbook (outpatient) — Comprehensive VaD management q3-6 mo: secondary stroke prevention bundle + symptomatic cognitive Rx + mood + lifestyle + advance directives + driving review
15. atorvastatin 40-80 mg PO daily PO daily — LDL <55 (AHA/ASA 2021)
16. aspirin OR clopidogrel OR DOAC Aspirin 81 / Clopidogrel 75 / Apixaban 5 BID PO daily / BID — Per stroke mechanism (AHA/ASA 2021)
17. lisinopril ± amlodipine ± HCTZ Titrate to <130/80 PO daily — BP control (SPRINT-MIND signal)
18. metformin ± SGLT2i 500 mg BID titrate; empagliflozin 10-25 mg daily PO BID + daily — T2DM ± CKD / HF (ADA 2026 + EMPA-KIDNEY)
19. donepezil 5-10 mg PO QHS PO daily — Symptomatic cognitive Rx (AAN 2018 / Cochrane)
20. memantine 5 mg titrate to 10 mg BID PO BID — Moderate-severe (MMSE ≤14) (AAN 2018 add-on)
21. sertraline 25-100 mg PO daily PO daily — Post-stroke depression / pseudobulbar (APA 2024)

Non-pharmacologic actions:
- Aerobic exercise 150 min/wk (AHA/ASA 2021)
- MIND / Mediterranean diet
- Smoking cessation
- Alcohol moderation
- Sleep + OSA workup
- Hearing aids + glasses (Lancet 2024 commission)
- Caregiver education + support
- Driving evaluation
- Advance directives + POLST + capacity
- Vaccinations annual
- Cardiology + neurology comanagement

AVOID / contraindication checks:
- DOAC_avoid_if_severe_CKD_eGFR_<15 (apixaban dose adjust; rivaroxaban avoid; dabigatran avoid)
- Warfarin_INR_2_3_for_AF_2.5_3.5_mechanical_valve
- CAA_with_microbleeds_or_superficial_siderosis_AVOID_anticoag (high ICH risk)
- DAPT_x_21d_only_for_minor_stroke_NIHSS_<=3_or_high_risk_TIA_ABCD2_>=4 (CHANCE / POINT)
- Long_term_DAPT_bleed_risk_outweighs_benefit (revert to mono after 21 d)
- Statin_LFT_baseline_monitor (rare hepatotoxicity)
- SGLT2i_DKA_risk_in_T1DM_or_brittle_T2DM (educate patient)

Monitoring

Regimen monitoring:
- BP at every visit (target <130/80 AHA/ASA 2021; consider <120 SPRINT-MIND PMID 30688979 in select older adults)
- LDL q3 mo until <55 then annually (AHA/ASA 2021)
- HbA1c q3 mo until at goal then q6 mo (ADA 2026)
- INR weekly initial then q4 wk if warfarin
- CBC + creatinine q6 mo if DOAC
- Annual CV risk re-assessment
- Annual carotid Doppler if stenosis monitored

Setting (outpatient) monitoring:
- MoCA q6 mo
- BP + lipids q3-6 mo
- HbA1c q3 mo if DM
- Carotid Doppler annually if stenosis
- Echo as indicated for cardioembolic surveillance

Follow-up plan: Caregiver education + dementia care navigator; driving cessation per MoCA / on-road eval; advance directives / POLST; palliative referral at FAST 7 (NICE 2024 dementia)
- Close-out criterion: Caregiver + advance care plan established

Monitoring phase: Annual MoCA; quarterly BP + lipids (titrate); HbA1c q3 mo if DM; annual carotid Doppler if stenosis; echo as indicated; AGS Beers 2023 deprescribe q6 mo (APA 2024)

Disposition

Current setting: outpatient — Comprehensive VaD management q3-6 mo: secondary stroke prevention bundle + symptomatic cognitive Rx + mood + lifestyle + advance directives + driving review

Disposition criteria:
- Continue indefinite cognitive + stroke clinic q3-6 mo
- Palliative / hospice at FAST 7

Escalation triggers (move to higher acuity):
- Recurrent TIA / stroke → ED + stroke alert
- Delirium superimposed → ED
- Severe BPSD → geriatric psychiatry
- Caregiver burnout → respite + APS

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Strategic infarct (thalamus / caudate / angular gyrus / posterior cerebral) producing focal cognitive syndrome
- [SEVERE] Multiple cortical infarcts producing step-wise decline; classic NINDS-AIREN pattern (Roman PMID 8094895)
- [SEVERE] CAA — lobar microbleeds + superficial siderosis + lobar ICH history; CAA-related dementia + bleed risk

Citations

- AHA/ASA VCI 2019 (Iadecola PMID 21778438) + AHA/ASA 2021 stroke prevention (PMID 34024117) + NINDS-AIREN (Roman PMID 8094895) + VASCOG 2014 (Sachdev PMID 24632990) + SPRINT-MIND (Williamson JAMA 2019 PMID 30688979) + Hachinski Ischemic Score (PMID 1164215) + AAN 2018 + APA 2024 BPSD + AGS Beers 2023 [PMID:21778438](https://pubmed.ncbi.nlm.nih.gov/21778438/)
- Cited evidence (PMID 34024117) [PMID:34024117](https://pubmed.ncbi.nlm.nih.gov/34024117/)
- Cited evidence (PMID 30688979) [PMID:30688979](https://pubmed.ncbi.nlm.nih.gov/30688979/)
- Cited evidence (PMID 8094895) [PMID:8094895](https://pubmed.ncbi.nlm.nih.gov/8094895/)
- Cited evidence (PMID 1164215) [PMID:1164215](https://pubmed.ncbi.nlm.nih.gov/1164215/)

Last reconciled with current guidelines: 2026-05-15.
References
  • AHA/ASA VCI 2019 (Iadecola PMID 21778438) + AHA/ASA 2021 stroke prevention (PMID 34024117) + NINDS-AIREN (Roman PMID 8094895) + VASCOG 2014 (Sachdev PMID 24632990) + SPRINT-MIND (Williamson JAMA 2019 PMID 30688979) + Hachinski Ischemic Score (PMID 1164215) + AAN 2018 + APA 2024 BPSD + AGS Beers 2023 — PMID:21778438
  • Cited evidence (PMID 34024117) — PMID:34024117
  • Cited evidence (PMID 30688979) — PMID:30688979
  • Cited evidence (PMID 8094895) — PMID:8094895
  • Cited evidence (PMID 1164215) — PMID:1164215