Vascular dementia

NINDS-AIREN criteria for the diagnosis of vascular dementia[70]Roman GC, Tatemichi TK, Erkinjuntti T, et al. Vascular dementia: diagnostic criteria for research studies; report of the NINDS-AIREN International Workshop. Neurology. 1993 Feb;43(2):250-60. http://www.ncbi.nlm.nih.gov/pubmed/8094895?tool=bestpractice.com

1. Dementia

Impairment in memory and at least 2 other domains:

• Orientation

• Attention

• Language

• Visuospatial functions

• Executive functions, motor control, and praxis

2. Cerebrovascular disease

Focal signs on neurological examination (hemiparesis, lower facial weakness, Babinski's sign, sensory deficit, hemianopia, and dysarthria).

Evidence of relevant cerebrovascular disease by brain imaging (CT):

• Large-vessel infarcts

• Single strategically placed infarct

• Multiple basal ganglia and white matter lacunes

• Extensive periventricular white matter lesions

• Combinations thereof

3. A relationship between the above disorders manifested or inferred by the presence of at least 1 of the following:

• Onset of dementia within 3 months after a recognised stroke

• Abrupt deterioration in cognitive functions

• Fluctuating, stepwise progression of cognitive deficits

4. Clinical features consistent with a diagnosis of probable vascular dementia:

• Early presence of a gait disturbance

• History of unsteadiness or frequent, unprovoked falls

• Early urinary incontinence

• Pseudobulbar palsy

• Personality and mood changes

5. Features that make a diagnosis of vascular dementia uncertain:

• Early onset of memory deficit and progressive worsening of memory and other cognitive functions

• In the absence of focal neurological signs and cerebrovascular lesions on CT or MRI

Diagnostic and Statistical Manual of Mental Disorders, 5th ed., text revision (DSM-5-TR) criteria for major or mild vascular neurocognitive disorder[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.[3]American Psychiatric Association. DSM-5-TR neurocognitive disorders supplement. Updated excerpts for delirium codes major and mild neurocognitive disorders. October 2022. https://psychiatryonline.org/pb-assets/dsm/update/DSM-5-TR_Neurocognitive-Disorders-Supplement_2022_APA_Publishing.pdf

For a diagnosis of major or mild vascular neurocognitive disorder, the following criteria must be met:

A. The criteria are met for major or mild cognitive disorder:

1. Major neurocognitive disorder: evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains that interferes with independence in everyday activities. The cognitive deficits do not occur exclusively in the context of a delirium and are not better explained by another mental disorder.

   1. Specify severity:

      1. Mild: difficulties with instrumental activities of daily living (e.g., housework, managing money)

      2. Moderate: difficulties with basic activities of daily living (e.g., feeding, dressing)

      3. Severe: fully dependent

   2. Specify:

      1. With agitation: If the cognitive disturbance is accompanied by clinically significant agitation

      2. With anxiety: If the cognitive disturbance is accompanied by clinically significant anxiety

      3. With mood symptoms: If the cognitive disturbance is accompanied by clinically significant mood symptoms (e.g., dysphoria, irritability, euphoria)

      4. With psychotic disturbance: If the cognitive disturbance is accompanied by delusions or hallucinations

      5. With other behavioural or psychological disturbance: If the cognitive disturbance is accompanied by other clinically significant behavioural or psychological disturbance (e.g., apathy, aggression, disinhibition, disruptive behaviours or vocalisations, sleep or appetite/eating disturbance)

      6. Without accompanying behavioural or psychological disturbance: If the cognitive disturbance is not accompanied by any clinically significant behavioural or psychological disturbance

2. Mild neurocognitive disorder: evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains that does not interfere with independence in everyday activities. Greater effort, compensatory strategies, or accommodation may be required to preserve independence in complex instrumental activities of daily living (e.g., paying bills, managing medications). The cognitive deficits do not occur exclusively in the context of a delirium and are not better explained by another mental disorder.

   1. Specify:

      1. Without behavioural disturbance: If the cognitive disturbance is not accompanied by any clinically significant behavioural disturbance

      2. With behavioural disturbance (specify disturbance): If the cognitive disturbance is accompanied by a clinically significant behavioural disturbance (e.g., apathy, agitation, anxiety, mood symptoms, psychotic disturbance, or other behavioural symptoms)

B. The clinical features are consistent with a vascular aetiology, as suggested by either of the following:

1. Onset of cognitive deficits is temporally related to one or more cerebrovascular events

2. Evidence for decline is prominent in complex attention (including processing speed) and frontal-executive function

C. There is evidence of the presence of cerebrovascular disease from history, physical examination, and/or neuroimaging considered sufficient to account for the neurocognitive deficits.

D. The symptoms are not better explained by another brain disease or systemic disorder.

Probable vascular neurocognitive disorder is diagnosed if one of the following is present; otherwise possible vascular neurocognitive disorder should be diagnosed:

1. Clinical criteria are supported by neuroimaging evidence of significant parenchymal injury attributed to cerebrovascular disease (neuroimaging-supported)

2. The neurocognitive syndrome is temporally related to one or more documented cerebrovascular events

3. Both clinical and genetic (e.g., cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) evidence of cerebrovascular disease is present

Possible vascular neurocognitive disorder is diagnosed if the clinical criteria are met but neuroimaging is not available and the temporal relationship of the neurocognitive syndrome with one or more cerebrovascular events is not established.