Synopsis
Recognise cognitive and functional impairment caused by cerebrovascular injury, distinguish acute stroke and mixed dementia, use imaging and collateral chronology coherently, and prevent further vascular harm without prescribing dementia drugs outside supported indications.
- Vascular dementia requires cognitive decline interfering with function plus cerebrovascular disease judged sufficient to explain it; imaging lesions alone are not diagnosis.
- The phenotype often emphasises slowed processing, attention, executive function, gait and focal findings more than isolated early amnesia.
- Decline may be stepwise after strokes, but small-vessel disease can progress gradually; absence of obvious steps does not exclude it.
- First investigate any sudden new deficit as acute stroke and any fluctuating inattention as delirium.
- MRI better characterises infarcts, lacunes, white-matter disease and microbleeds; interpret burden, location and chronology together.
- Assess AF, blood pressure, lipids, diabetes, smoking, activity and previous stroke while avoiding targets that cause falls or hypoglycaemia.
- Secondary prevention follows the actual stroke or cardiovascular indication; do not give aspirin solely for a vascular-dementia label.
- NICE advises AChE inhibitors or memantine in vascular dementia only when comorbid Alzheimer, Parkinson dementia or DLB is suspected.
- Rehabilitation, cognitive support, hearing, vision, mood care, exercise and environmental adaptation remain central.
- Use shared decisions to balance recurrent-stroke prevention against bleeding, posture, medicine burden, prognosis and goals.
Key red flags
A new focal deficit or sudden step requires stroke or intracranial haemorrhage assessment rather than a routine memory appointment.
Acute inattention and fluctuation is delirium, which can be triggered by stroke, infection or medicines in vascular cognitive impairment.
Rapid progression without new vascular events, seizure or systemic features requires a non-vascular differential and specialist review.
Falls, early gait change, urinary symptoms and executive failure may indicate small-vessel disease but also hydrocephalus, Parkinsonism or drug harm.
Antiplatelet or anticoagulant treatment needs a separate vascular indication and bleeding assessment; dementia alone is not an indication.
A high vascular burden does not prove every cognitive symptom is vascular, because mixed Alzheimer pathology is common.
Sudden focal or cognitive deficit remains an emergency regardless of established dementia.
Investigation priorities
Connect vascular events to acquired decline.
Management branches
Persistent cognitive decline occurs with stroke or vascular disease.
- Exclude acute stroke and delirium and obtain a dated collateral cognitive and functional trajectory.
- Complete executive, focal, mood and gait assessment with MRI or CT and vascular risk evaluation.
- Diagnose vascular or mixed dementia only when lesion burden and location plausibly fit the impairment.
A cerebrovascular mechanism and modifiable risks are present.
- Determine cardioembolic, non-cardioembolic, haemorrhagic or primary-prevention context before prescribing antithrombotic therapy.
- Individualise pressure, lipid, diabetes, smoking, exercise and nutrition measures against posture, bleeding and treatment burden.
- Monitor adherence, organ function and functional adverse effects and coordinate stroke, primary and memory care.