FFinalistSouthampton · 2027
Neurology
AKT · Neurology/Movement & neurodegeneration

Vascular dementia

Cerebrovascular disease → stepwise cognitive decline

Overview

The second commonest dementia, from cerebrovascular disease. Classically a STEPWISE decline (each step after a vascular event) in a patient with vascular risk factors and focal neurological signs — distinct from the smooth decline of Alzheimer.

Recognise

  • STEPWISE deterioration (plateaus then sudden drops), often after strokes/TIAs
  • Vascular risk factors (hypertension, AF, diabetes, smoking); focal neurology, gait disturbance
  • Patchy/"frontal" cognitive profile (slowed processing, executive/attention) rather than pure amnesia

Red flags

  • Acute decline = new vascular event; manage stroke risk aggressively

Differentials & how to tell them apart

Alzheimer's diseasesmooth gradual decline, early amnesia, hippocampal atrophy, fewer focal signs
Mixed dementiafeatures of BOTH AD and vascular — integrate, do not pick one
Lewy body dementiafluctuation + hallucinations + parkinsonism
Depression (pseudodementia)mood-driven, reversible

Investigations

Cognitive testing; MRI/CT (small-vessel disease, infarcts, white-matter change); vascular work-up (BP, glucose/HbA1c, lipids, ECG for AF); exclude reversible causes.

Management

Aggressive vascular secondary prevention; cholinesterase inhibitors only if coexisting Alzheimer

  1. 1Optimise vascular risk factors (BP, antiplatelet/anticoagulant, statin, diabetes, smoking) to slow progression; cognitive and functional support.Gate: Cholinesterase inhibitors are NOT routinely used for pure vascular dementia — reserve them for mixed/coexisting Alzheimer disease
  2. 2Treat the underlying cerebrovascular disease; manage mood and behaviour; carer support.
No specific cognitive drug — cholinesterase inhibitors NOT routinely indicated (only if mixed/coexisting AD)
Vascular secondary prevention — antiplatelet/statin/BP/glycaemic control

Key points

Stepwise decline + vascular risk + focal signs = vascular dementia; smooth amnestic decline = Alzheimer. Many have BOTH (mixed) — see the Mixed dementia card.

Monitor & prognosis

Vascular risk control, cognition, function, new events.

Stepwise progression; slowed by vascular risk-factor control.

Source: NICE NG97 (dementia)