⚠️

DRAFT - Pending Review

This plan requires physician review before clinical use.

Vascular Dementia

DIAGNOSIS: Vascular Dementia ICD-10: F01.50 (Vascular dementia without behavioral disturbance); F01.51 (Vascular dementia with behavioral disturbance); I67.3 (Progressive vascular leukoencephalopathy — Binswanger disease); I67.89 (Other cerebrovascular disease) SYNONYMS: VaD; Vascular cognitive impairment; Multi-infarct dementia; Post-stroke dementia; Subcortical ischemic vascular dementia; Binswanger disease; Strategic infarct dementia SCOPE: Diagnosis using NINDS-AIREN and DSM-5 criteria, neuroimaging evaluation for strategic infarcts and white matter disease, vascular risk factor modification, secondary stroke prevention, cholinesterase inhibitors for cognitive symptoms, and management of post-stroke depression, apathy, and behavioral symptoms. Primarily outpatient-focused with coverage for ED and hospital presentations.

VERSION: 1.1 CREATED: January 27, 2026 REVISED: January 30, 2026

STATUS: Draft - Pending Review

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PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

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SECTION A: ACTION ITEMS

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1. LABORATORY WORKUP

1A. Essential/Core Labs (Reversible Causes and Vascular Risk Factors)

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (85025)	STAT	STAT	ROUTINE	-	Polycythemia, anemia, infection affecting cognition	Normal
BMP (80048)	STAT	STAT	ROUTINE	-	Metabolic causes of confusion; renal function for medication dosing	Normal electrolytes, renal function
TSH (84443)	URGENT	ROUTINE	ROUTINE	-	Hypothyroidism is reversible cause of cognitive impairment	0.4-4.0 mIU/L
Vitamin B12 (82607)	URGENT	ROUTINE	ROUTINE	-	Deficiency causes reversible cognitive decline and may worsen vascular dementia	>300 pg/mL (>400 optimal)
Folate (82746)	-	ROUTINE	ROUTINE	-	Deficiency contributes to hyperhomocysteinemia and cognitive impairment	>3 ng/mL
Hemoglobin A1c (83036)	URGENT	ROUTINE	ROUTINE	-	Diabetes is major vascular risk factor; assess chronic glucose control	<7.0% (individualized 7-8% in frail elderly)
Fasting lipid panel (80061)	-	ROUTINE	ROUTINE	-	Assess LDL for secondary stroke prevention; target <70 mg/dL	LDL <70 mg/dL
Urinalysis (81001)	STAT	STAT	ROUTINE	-	UTI common cause of acute confusion in elderly	Negative for infection
PT/INR, PTT (85610/85730)	STAT	ROUTINE	ROUTINE	-	Baseline coagulation; assess if on anticoagulation	Normal or therapeutic

1B. Extended Workup (Second-line)

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
Homocysteine (83090)	-	ROUTINE	ROUTINE	-	Elevated levels increase stroke risk and contribute to vascular dementia	<15 μmol/L
Lipoprotein(a) (83695)	-	ROUTINE	ROUTINE	-	Independent cardiovascular risk marker; elevated increases stroke risk	<50 nmol/L (or <30 mg/dL)
hsCRP (86141)	-	ROUTINE	ROUTINE	-	Inflammatory marker; elevated predicts vascular events	<2 mg/L
Vitamin D, 25-hydroxy (82306)	-	ROUTINE	ROUTINE	-	Deficiency associated with cognitive decline and vascular disease	>30 ng/mL
RPR or VDRL (86592)	-	ROUTINE	ROUTINE	-	Neurosyphilis is treatable cause of dementia	Nonreactive
HIV testing (86701)	-	ROUTINE	ROUTINE	-	HIV-associated neurocognitive disorder if risk factors	Negative
Hepatic panel (80076)	-	ROUTINE	ROUTINE	-	Hepatic encephalopathy; nutritional status; statin safety	Normal
BNP/NT-proBNP (83880)	URGENT	ROUTINE	ROUTINE	-	Heart failure; atrial fibrillation risk assessment	Age-adjusted normal
Uric acid (84550)	-	ROUTINE	ROUTINE	-	Elevated associated with increased stroke and dementia risk	<6 mg/dL

1C. Rare/Specialized (Refractory or Atypical)

Test (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
APOE genotyping (81401)	-	-	ROUTINE	-	Risk stratification; mixed AD/VaD assessment	APOE status for prognosis
Hypercoagulability panel (85306/85307)	-	EXT	EXT	-	Age <50, cryptogenic strokes, recurrent events	Negative
Antiphospholipid antibodies (86147/86148)	-	EXT	EXT	-	Lupus anticoagulant, anticardiolipin; young-onset vascular disease	Negative
ESR, ANA (85652/86038)	-	EXT	EXT	-	Suspected CNS vasculitis causing multi-infarct state	Normal/Negative
ANCA panel (86235)	-	EXT	EXT	-	Vasculitis workup if suspected	Negative
Fabry disease testing, alpha-galactosidase A (82657)	-	-	EXT	-	Young-onset stroke; angiokeratomas; neuropathy	Normal enzyme activity
NOTCH3 genetic testing (81406)	-	-	EXT	-	Suspected CADASIL (family history, migraine, early WM disease)	No pathogenic mutation
Mitochondrial DNA analysis (81401)	-	-	EXT	-	Suspected MELAS or mitochondrial disease	No pathogenic mutation

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2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain without contrast (70551)	URGENT	ROUTINE	ROUTINE	-	At initial evaluation	Strategic infarcts (thalamus, basal ganglia, angular gyrus); confluent WMH (Fazekas ≥2); lacunar infarcts	MRI-incompatible devices, severe claustrophobia
CT Head non-contrast (70450)	STAT	STAT	ROUTINE	-	If MRI unavailable or contraindicated	Rule out hemorrhage, mass, hydrocephalus; may show old infarcts, leukoaraiosis	None
MRA Head and Neck (70544/70547)	URGENT	ROUTINE	ROUTINE	-	With initial MRI	Intracranial and extracranial atherosclerosis; assess for stenosis >50%	MRI contraindications
CTA Head and Neck (70496/70498)	URGENT	ROUTINE	ROUTINE	-	Alternative to MRA	Vascular stenosis; atherosclerotic burden	Contrast allergy, CKD (relative)
Carotid duplex ultrasound (93880)	-	ROUTINE	ROUTINE	-	Within 1 week of diagnosis	Assess carotid stenosis; plaque characterization	None
ECG, 12-lead (93000)	STAT	STAT	ROUTINE	-	At diagnosis	Assess for atrial fibrillation, LVH, prior MI	None
Transthoracic echocardiogram (93306)	-	ROUTINE	ROUTINE	-	Within 2 weeks	LV function; valvular disease; intracardiac thrombus	None

2B. Extended

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI Brain with SWI/GRE sequences (70551)	-	ROUTINE	ROUTINE	-	With initial MRI	Microbleeds (CAA pattern vs hypertensive); hemosiderin	MRI contraindications
MRI volumetrics (70553)	-	-	ROUTINE	-	Baseline for progression	Quantify WM lesion volume; global and regional atrophy	MRI contraindications
FDG-PET Brain (78816)	-	-	ROUTINE	-	Differentiate VaD from AD; atypical cases	Scattered hypometabolism (vs temporoparietal in AD)	None
Amyloid PET (78811)	-	-	EXT	-	Distinguish pure VaD from mixed AD/VaD	Negative suggests pure VaD; positive suggests mixed pathology	None
Cardiac telemetry/Holter monitor (93224)	URGENT	ROUTINE	-	-	Screen for paroxysmal AF	Sinus rhythm; detect occult AF	None
Extended cardiac monitoring, 14-30 day (93241)	-	-	ROUTINE	-	Cryptogenic strokes; suspected occult AF	Sinus rhythm; detect paroxysmal AF	None
EEG (95819)	URGENT	ROUTINE	ROUTINE	-	Encephalopathy; seizures; rapid decline	Non-specific slowing (not CJD pattern)	None
Sleep study, polysomnography (95811)	-	-	ROUTINE	-	Sleep apnea is vascular risk factor; assess for OSA	AHI <5 (or treat if elevated)	None

2C. Rare/Specialized

Study (CPT)	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Vessel wall MRI (70553)	-	EXT	EXT	-	Suspected CNS vasculitis or reversible vasoconstriction	No vessel wall enhancement or thickening	MRI contraindications
DSA, cerebral angiogram (36224)	-	EXT	EXT	-	Vasculitis confirmation; moyamoya; intracranial stenosis	Define vascular anatomy	Contrast allergy, bleeding risk
SPECT, perfusion (78607)	-	-	EXT	-	Alternative to PET if unavailable	Regional hypoperfusion patterns	None
Transesophageal echocardiogram (93312)	-	EXT	EXT	-	Cryptogenic strokes; suspected aortic arch atheroma or PFO	No embolic source	Esophageal pathology

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LUMBAR PUNCTURE

Indication: Atypical presentation; rapid progression; suspected CNS vasculitis or infection; young-onset (<65); differentiate from AD or inflammatory causes Timing: ROUTINE for diagnostic clarification; URGENT if infectious or inflammatory etiology suspected Volume Required: 10-15 mL standard diagnostic

Study (CPT)	ED	HOSP	OPD	ICU	Rationale	Target Finding
Cell count, protein, glucose (89051/84157/82947)	URGENT	ROUTINE	ROUTINE	-	Rule out infection, inflammation, vasculitis	WBC <5, protein <45 mg/dL, glucose >60% serum
CSF Aβ42 and Aβ42/Aβ40 ratio (83519)	-	ROUTINE	ROUTINE	-	Differentiate from Alzheimer's disease	Normal Aβ42 in pure VaD; low suggests mixed AD/VaD
CSF total tau and p-tau181 (83519)	-	ROUTINE	ROUTINE	-	Elevated in AD; can help distinguish VaD from AD	Normal or mildly elevated in pure VaD; high p-tau suggests AD
CSF NfL, neurofilament light (83519)	-	ROUTINE	ROUTINE	-	Non-specific marker of neuronal damage; elevated in vascular injury	Elevated suggests ongoing neurodegeneration
Oligoclonal bands, IgG index (86327/86325)	-	ROUTINE	ROUTINE	-	Rule out inflammatory/demyelinating disease	Negative
VDRL (86593)	-	ROUTINE	ROUTINE	-	Neurosyphilis	Nonreactive
Autoimmune encephalitis panel (86255)	-	EXT	EXT	-	Atypical presentation; subacute onset	Negative

Special Handling: CSF biomarkers require polypropylene tubes; freeze within 1 hour; send to qualified reference lab Contraindications: Coagulopathy (INR >1.5, platelets <50k); mass effect on imaging; skin infection at puncture site

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3. TREATMENT

3A. Acute/Emergent

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Treat reversible causes	Various	Identified metabolic or infectious etiology	Per specific cause :: Various :: per protocol :: Correct hyponatremia slowly, treat UTI, replace B12, treat hypothyroidism	Depends on intervention	Cognitive reassessment after treatment	STAT	STAT	ROUTINE	-
Thiamine	IV/PO	Suspected Wernicke's; alcoholism; malnutrition	500 mg :: IV :: TID x 3 days :: 500 mg IV TID x 3 days if Wernicke suspected; then 100 mg PO daily maintenance	None	Clinical improvement in confusion	STAT	STAT	ROUTINE	-
Aspirin (loading)	PO	Immediate antiplatelet therapy for secondary stroke prevention	325 mg :: PO :: x1 load :: 325 mg loading dose if no recent stroke, then 81 mg daily ongoing	Active GI bleed; aspirin allergy	GI symptoms, bleeding	STAT	STAT	ROUTINE	-
Blood pressure management (acute)	Various	Acute delirium or new stroke	Per protocol :: Various :: per protocol :: Do NOT lower BP aggressively unless >220/120 or end-organ damage; permissive hypertension first 24-48h of stroke	Symptomatic hypotension	BP q1h initially	STAT	STAT	-	-

3B. Vascular Risk Factor Modification (Secondary Stroke Prevention)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Atorvastatin	PO	High-intensity statin for secondary stroke prevention; LDL target <70	40 mg :: PO :: daily :: Start 40-80 mg daily; target LDL <70 mg/dL; 80 mg preferred for established vascular disease	Active liver disease; pregnancy	LFTs at baseline, 6-12 weeks, then annually; myalgias	-	ROUTINE	ROUTINE	-
Rosuvastatin	PO	Alternative high-intensity statin; may be better tolerated	20 mg :: PO :: daily :: Start 20 mg daily; max 40 mg; potent LDL lowering	Active liver disease; pregnancy; Asian dose adjustment (10 mg start)	LFTs; myalgias; CK if symptomatic	-	ROUTINE	ROUTINE	-
Aspirin (long-term)	PO	Lifelong antiplatelet for secondary stroke prevention	81 mg :: PO :: daily :: 81 mg daily indefinitely for non-cardioembolic vascular dementia	Active GI bleeding; aspirin allergy	GI symptoms; annual CBC	-	ROUTINE	ROUTINE	-
Clopidogrel	PO	Alternative to aspirin if aspirin-intolerant; or after DAPT period	75 mg :: PO :: daily :: 75 mg daily; may use instead of aspirin if intolerant	Active bleeding	Bleeding signs	-	ROUTINE	ROUTINE	-
Lisinopril	PO	Blood pressure control; target <130/80 for secondary prevention	5 mg :: PO :: daily :: Start 5-10 mg daily; titrate to goal BP <130/80; max 40 mg daily	Angioedema history; pregnancy; bilateral RAS; hyperkalemia	K+, Cr at 1-2 weeks; BP	-	ROUTINE	ROUTINE	-
Amlodipine	PO	BP control; add-on or alternative antihypertensive	5 mg :: PO :: daily :: Start 5 mg daily; may increase to 10 mg daily	Severe aortic stenosis (relative)	Peripheral edema; BP	-	ROUTINE	ROUTINE	-
Chlorthalidone	PO	Thiazide-like diuretic for BP control; effective for stroke prevention	12.5 mg :: PO :: daily :: Start 12.5 mg daily; may increase to 25 mg daily	Severe hypokalemia; hyponatremia	K+, Na+, uric acid, glucose	-	ROUTINE	ROUTINE	-
Metformin	PO	First-line for type 2 diabetes if eGFR >30	500 mg :: PO :: daily :: Start 500 mg daily with meal; titrate by 500 mg weekly; max 2000-2550 mg/day in divided doses	eGFR <30; acute illness; contrast within 48h	eGFR; B12 annually; lactic acidosis symptoms	-	ROUTINE	ROUTINE	-
Empagliflozin	PO	SGLT2 inhibitor for diabetes with cardiovascular benefit	10 mg :: PO :: daily :: Start 10 mg daily; may increase to 25 mg; cardiovascular mortality benefit	eGFR <20; Type 1 DM; DKA history	eGFR; volume status; genital infections	-	ROUTINE	ROUTINE	-
Ezetimibe	PO	Add-on for LDL not at goal on statin	10 mg :: PO :: daily :: 10 mg daily with or without food	Severe hepatic impairment	LDL; LFTs	-	ROUTINE	ROUTINE	-
Apixaban	PO	Atrial fibrillation-related vascular dementia	5 mg :: PO :: BID :: 5 mg BID (2.5 mg BID if ≥2 of: age ≥80, weight ≤60 kg, Cr ≥1.5)	Active major bleeding; mechanical valve	CrCl; bleeding signs	-	ROUTINE	ROUTINE	-
Rivaroxaban	PO	AF-related vascular dementia	20 mg :: PO :: daily :: 20 mg daily with dinner (15 mg if CrCl 15-50)	Active bleeding; mechanical valve	CrCl; bleeding	-	ROUTINE	ROUTINE	-
Warfarin	PO	Mechanical valve; select hypercoagulable states; AF if DOACs contraindicated	5 mg :: PO :: daily :: Start 5 mg daily; adjust to INR 2-3	Active bleeding; frequent falls; poor adherence	INR weekly then monthly	-	ROUTINE	ROUTINE	-

3C. Cholinesterase Inhibitors (Cognitive Enhancement - Modest Benefit)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Donepezil (Aricept)	PO	Vascular dementia cognitive symptoms; modest but measurable benefit	5 mg :: PO :: qHS :: Start 5 mg qHS x 4-6 weeks; if tolerated, increase to 10 mg qHS; benefit smaller than in AD	Sick sinus syndrome; second/third degree heart block without pacemaker; active GI bleeding	Heart rate; GI symptoms (nausea, diarrhea); vivid dreams	-	ROUTINE	ROUTINE	-
Rivastigmine oral (Exelon)	PO	Vascular dementia; executive dysfunction; may help mixed AD/VaD	1.5 mg :: PO :: BID :: Start 1.5 mg BID with meals; increase by 1.5 mg BID every 2 weeks; target 6 mg BID	Sick sinus; severe hepatic impairment	GI symptoms; weight loss; bradycardia	-	ROUTINE	ROUTINE	-
Rivastigmine patch (Exelon Patch)	TD	Vascular dementia; better GI tolerability than oral	4.6 mg/24hr :: TD :: daily :: Start 4.6 mg/24hr patch; increase every 4 weeks; target 9.5-13.3 mg/24hr	Same as oral	Skin irritation; rotate sites	-	ROUTINE	ROUTINE	-
Galantamine (Razadyne)	PO	Vascular dementia; dual mechanism may benefit executive function	4 mg :: PO :: BID :: Start 4 mg BID with meals x 4 weeks; increase to 8 mg BID x 4 weeks; target 8-12 mg BID	Sick sinus; severe renal impairment (CrCl <9); severe hepatic impairment	GI symptoms; bradycardia	-	ROUTINE	ROUTINE	-
Memantine (Namenda)	PO	Moderate-severe vascular dementia; add to cholinesterase inhibitor	5 mg :: PO :: daily :: Start 5 mg daily x 1 week; increase by 5 mg/week: 5 mg BID, then 5/10 mg, then 10 mg BID	Severe renal impairment (reduce dose if CrCl 5-29: max 5 mg BID)	Confusion, dizziness, constipation	-	ROUTINE	ROUTINE	-

3D. Post-Stroke Depression and Apathy

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Sertraline (Zoloft)	PO	Post-stroke depression (evidence-based; FLAME trial); first-line	25 mg :: PO :: daily :: Start 25 mg daily; increase by 25 mg every 1-2 weeks; typical 50-100 mg daily; max 200 mg	MAOIs; concurrent QT-prolonging drugs (high doses)	GI upset initially; bleeding risk with anticoagulants; sexual dysfunction	-	ROUTINE	ROUTINE	-
Escitalopram (Lexapro)	PO	Post-stroke depression; well-tolerated in elderly	5 mg :: PO :: daily :: Start 5 mg daily in elderly; increase to 10 mg after 1 week; max 20 mg (10 mg if >65y)	MAOIs; QT prolongation	QTc if cardiac risk; GI symptoms	-	ROUTINE	ROUTINE	-
Citalopram (Celexa)	PO	Depression; agitation in dementia	10 mg :: PO :: daily :: Start 10 mg daily; max 20 mg in elderly due to QT prolongation risk	QT prolongation; concurrent QT-prolonging drugs	ECG at baseline if cardiac risk; QTc monitoring	-	ROUTINE	ROUTINE	-
Mirtazapine (Remeron)	PO	Depression with poor appetite, weight loss, and insomnia	7.5 mg :: PO :: qHS :: Start 7.5-15 mg qHS; may increase to 30-45 mg qHS; lower doses more sedating	MAOIs; angle-closure glaucoma	Weight gain (often desired); sedation	-	ROUTINE	ROUTINE	-
Bupropion SR/XL	PO	Depression with fatigue and apathy; no sexual side effects; avoid if seizure risk	100 mg :: PO :: daily :: Start 100 mg SR daily or 150 mg XL daily; may increase after 3 days; max 400 mg/day	Seizure disorder; anorexia/bulimia; abrupt alcohol/benzo withdrawal	Seizure risk; insomnia; anxiety	-	ROUTINE	ROUTINE	-
Methylphenidate	PO	Apathy refractory to antidepressants; psychomotor retardation	2.5 mg :: PO :: BID :: Start 2.5-5 mg BID (morning and noon); titrate by 2.5-5 mg every 3-5 days; max 30 mg/day	Severe hypertension; cardiac arrhythmias; hyperthyroidism; glaucoma	BP, HR; appetite; sleep	-	EXT	ROUTINE	-
Modafinil	PO	Apathy; fatigue; excessive daytime sleepiness	100 mg :: PO :: daily :: Start 100 mg each morning; may increase to 200 mg daily	Severe hepatic impairment; cardiac arrhythmias	BP, HR; sleep disturbance	-	EXT	ROUTINE	-

3E. Behavioral and Psychological Symptoms of Dementia (BPSD)

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Trazodone	PO	Insomnia; sundowning; mild agitation	25 mg :: PO :: qHS :: Start 25-50 mg qHS; titrate by 25-50 mg every 3-5 days; typical 50-150 mg qHS	MAOIs; significant QT prolongation	Orthostatic hypotension (fall risk); priapism (rare)	-	ROUTINE	ROUTINE	-
Melatonin	PO	Sleep disturbance; circadian rhythm dysfunction; sundowning	3 mg :: PO :: qHS :: Start 3 mg qHS, 30 min before bed; may increase to 6 mg if needed	None significant	Daytime drowsiness	-	ROUTINE	ROUTINE	-
Quetiapine (Seroquel)	PO	Severe agitation/psychosis when non-pharmacologic interventions fail	12.5 mg :: PO :: qHS :: Start 12.5-25 mg qHS; titrate slowly; keep dose as low as possible	Black box: increased mortality and stroke in dementia; Parkinson's (less risk than others)	Metabolic effects; sedation; falls; QTc	-	EXT	ROUTINE	-
Risperidone (Risperdal)	PO	Severe aggression/psychosis (short-term use only)	0.25 mg :: PO :: BID :: Start 0.25 mg BID; increase by 0.25 mg BID weekly; max 1 mg BID; limit to 6-12 weeks	Black box: increased mortality and CVA in dementia	EPS, metabolic effects, stroke risk, prolactin	-	EXT	ROUTINE	-
Haloperidol	IM/IV/PO	Acute severe agitation in delirium-crisis only (avoid chronic use)	0.5 mg :: IM :: PRN :: 0.5-2 mg IM/IV q4-6h PRN; short-term acute use only; avoid chronic use in dementia	QT prolongation; Parkinson's disease	QTc; EPS; akathisia	STAT	EXT	-	-
Carbamazepine	PO	Agitation/aggression refractory to other treatments	100 mg :: PO :: BID :: Start 100 mg BID; titrate to 200-400 mg BID based on response; monitor levels	Bone marrow suppression; AV block	CBC; LFTs; Na; drug levels	-	EXT	ROUTINE	-
Dextromethorphan-quinidine (Nuedexta)	PO	Pseudobulbar affect (emotional lability) post-stroke	20/10 mg :: PO :: daily :: Start 20/10 mg daily x 7 days, then increase to 20/10 mg BID	MAOIs; concurrent quinidine; prolonged QT; complete heart block	QTc; drug interactions (quinidine inhibits CYP2D6)	-	ROUTINE	ROUTINE	-

Non-Pharmacologic Approaches (First-Line for BPSD): - Identify and treat underlying causes (pain, infection, constipation, urinary retention) - Environmental modifications (reduce noise, adequate lighting, consistent routine) - Music therapy, reminiscence therapy, art therapy - Structured activities appropriate to cognitive level - Caregiver education on redirection and validation techniques - Avoid confrontation; redirect instead

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4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation	ED	HOSP	OPD	ICU
Neurology/Cognitive neurology for diagnosis confirmation, differentiation from AD, and treatment planning	-	ROUTINE	ROUTINE	-
Neuropsychology for formal cognitive testing to characterize executive dysfunction and memory profile	-	-	ROUTINE	-
Cardiology for atrial fibrillation management, anticoagulation decisions, and heart failure optimization	-	ROUTINE	ROUTINE	-
Vascular surgery consultation for symptomatic carotid stenosis ≥50% to evaluate for endarterectomy	-	URGENT	ROUTINE	-
Physical therapy for gait training, balance assessment, and fall prevention given motor involvement	-	ROUTINE	ROUTINE	-
Occupational therapy for ADL assessment, cognitive strategies, and home safety evaluation	-	ROUTINE	ROUTINE	-
Speech therapy for communication strategies, cognitive-linguistic exercises, and swallowing evaluation if dysphagia	-	ROUTINE	ROUTINE	-
Social work for caregiver support resources, community services, and long-term care planning	-	ROUTINE	ROUTINE	-
Geriatric psychiatry for behavioral symptoms, depression management, and capacity evaluation	-	ROUTINE	ROUTINE	-
Registered dietitian for Mediterranean/DASH diet counseling and sodium restriction education	-	ROUTINE	ROUTINE	-
Smoking cessation program with pharmacotherapy for current smokers	-	ROUTINE	ROUTINE	-
Sleep medicine for obstructive sleep apnea evaluation and CPAP initiation if indicated	-	-	ROUTINE	-
Palliative care for advanced vascular dementia symptom management and goals of care discussions	-	ROUTINE	ROUTINE	-

4B. Patient Instructions

Recommendation	ED	HOSP	OPD
Call 911 immediately if new stroke symptoms develop (sudden weakness, speech difficulty, vision changes)	STAT	STAT	ROUTINE
Return immediately if sudden worsening of confusion which may indicate new stroke, infection, or delirium	STAT	STAT	ROUTINE
Take all medications as prescribed especially antiplatelet/anticoagulant and statin which prevent further strokes	-	ROUTINE	ROUTINE
Complete advance directives (living will, healthcare proxy, POLST) while patient has capacity	-	ROUTINE	ROUTINE
Do not drive if cognitive impairment affects judgment or reaction time; formal driving evaluation may be needed	-	ROUTINE	ROUTINE
Use pill organizers, alarms, or caregiver supervision to ensure medication adherence	-	ROUTINE	ROUTINE
Check blood pressure at home regularly; notify provider if consistently >140/90 or <90/60	-	ROUTINE	ROUTINE
Wear medical alert bracelet with diagnosis and emergency contact in case of wandering or emergency	-	ROUTINE	ROUTINE
Keep environment safe: remove throw rugs, install grab bars, ensure adequate lighting, secure stove knobs	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention

Recommendation	ED	HOSP	OPD
Blood pressure target <130/80 mmHg to reduce progression and prevent further strokes (SPRINT-MIND data)	-	ROUTINE	ROUTINE
LDL target <70 mg/dL with high-intensity statin for secondary vascular prevention	-	ROUTINE	ROUTINE
Smoking cessation immediately; reduces stroke risk by 50% within 1 year of quitting	-	ROUTINE	ROUTINE
Mediterranean or MIND diet emphasizing vegetables, berries, fish, whole grains, nuts, and olive oil	-	ROUTINE	ROUTINE
Limit sodium to <2300 mg/day (ideally <1500 mg if hypertensive) to improve blood pressure control	-	ROUTINE	ROUTINE
Limit alcohol to ≤1 drink daily as excess alcohol increases stroke risk and worsens cognition	-	ROUTINE	ROUTINE
Regular aerobic exercise (150 min/week moderate intensity) to improve cardiovascular health and cognition	-	ROUTINE	ROUTINE
Treat obstructive sleep apnea with CPAP as OSA worsens vascular risk and cognitive function	-	ROUTINE	ROUTINE
Strict glycemic control (HbA1c <7% or individualized 7-8% in frail elderly) to reduce microvascular damage	-	ROUTINE	ROUTINE
Social engagement and cognitive stimulation to support cognitive reserve	-	ROUTINE	ROUTINE
Weight management with target BMI 18.5-27 kg/m² (less stringent in elderly)	-	ROUTINE	ROUTINE
Fall prevention with home safety modifications and assistive devices as needed	-	ROUTINE	ROUTINE
CPAP compliance for sleep apnea patients to reduce nocturnal hypoxia and vascular events	-	-	ROUTINE

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SECTION B: REFERENCE

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5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Alzheimer's disease	Insidious onset; gradual decline; memory predominant; no focal signs; no stepwise progression	MRI: hippocampal atrophy without significant WM disease; CSF Aβ42 low, p-tau elevated; amyloid PET positive
Mixed dementia (AD + VaD)	Features of both; memory impairment with vascular burden	Amyloid PET positive with significant WM disease; CSF biomarkers show AD pattern
Dementia with Lewy bodies	Visual hallucinations; parkinsonism; REM sleep behavior disorder; fluctuating cognition	DaTscan reduced; clinical criteria; may have less WM disease
Frontotemporal dementia (behavioral)	Personality/behavior changes; disinhibition; apathy; hyperorality; often age <65	FDG-PET frontal hypometabolism; less vascular disease on MRI
Normal pressure hydrocephalus	Triad: gait disturbance (prominent), urinary incontinence, dementia; ventriculomegaly disproportionate to atrophy	MRI: ventriculomegaly with effaced sulci; high-volume LP with gait improvement
Chronic traumatic encephalopathy (CTE)	History of repetitive head trauma; mood and behavioral changes; no diagnostic test in life	History; clinical pattern; cavum septum pellucidum on MRI (suggestive)
CADASIL	Migraine with aura; early WM disease; family history; temporal pole and external capsule involvement	NOTCH3 genetic testing; skin biopsy showing GOM deposits
CNS vasculitis	Younger age; headache; encephalopathy; multifocal strokes; elevated inflammatory markers	Vessel wall MRI; DSA; brain/leptomeningeal biopsy
Creutzfeldt-Jakob disease	Rapid progression (weeks-months); myoclonus; periodic sharp waves on EEG; MRI DWI ribboning	CSF RT-QuIC; 14-3-3; EEG
Delirium superimposed on dementia	Acute change; fluctuating attention; identifiable precipitant (infection, medication, metabolic)	Treat cause; reassess cognition when clear

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6. MONITORING PARAMETERS

Parameter	Frequency	Target/Threshold	Action if Abnormal	ED	HOSP	OPD	ICU
Cognitive testing (MoCA)	Every 6-12 months	Establish baseline; track trajectory; MoCA assesses executive function	Adjust support; consider treatment changes	-	ROUTINE	ROUTINE	-
Blood pressure	Each visit; daily at home	<130/80 mmHg	Titrate antihypertensives; reduce if symptomatic hypotension	-	ROUTINE	ROUTINE	-
LDL cholesterol	Baseline, 6 weeks, then annually	<70 mg/dL	Intensify statin; add ezetimibe or PCSK9 inhibitor	-	ROUTINE	ROUTINE	-
HbA1c	Baseline, then q3mo if diabetic	<7% (7-8% if frail)	Optimize diabetes regimen	-	ROUTINE	ROUTINE	-
Functional status (ADL/IADL, FAQ)	Every 6-12 months	Document for staging and care planning	Increase support services; OT referral	-	ROUTINE	ROUTINE	-
Weight	Each visit	Stable; monitor for malnutrition	Nutritional consult; assess swallowing	-	ROUTINE	ROUTINE	-
Neuropsychiatric symptoms (NPI)	Each visit	Monitor depression, apathy, BPSD	Non-pharmacologic first; consider medications	-	ROUTINE	ROUTINE	-
MRI Brain	Every 1-2 years or if new symptoms	Monitor WM disease progression; new infarcts	Optimize vascular risk factors; investigate new events	-	ROUTINE	ROUTINE	-
ECG/Cardiac rhythm	Annually or if symptomatic	Sinus rhythm; no new AF	Anticoagulation if AF detected	-	ROUTINE	ROUTINE	-
Caregiver burden (Zarit scale)	Every 6-12 months	Early identification of burnout	Support resources; respite care	-	-	ROUTINE	-
Fall risk assessment	Each visit	Minimize fall risk	PT referral; home safety evaluation; assistive devices	-	ROUTINE	ROUTINE	-
Driving status	Each visit	Safe for patient and community	Formal driving evaluation; DMV report if unsafe	-	-	ROUTINE	-
Creatinine/eGFR	Annually; with medication changes	Dose-adjust medications appropriately	Adjust ACE-I, metformin, anticoagulants	-	ROUTINE	ROUTINE	-

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7. DISPOSITION CRITERIA

Disposition	Criteria
Discharge home	Stable cognition; no acute stroke; safe environment; adequate caregiver support; outpatient follow-up arranged; reversible causes treated
Admit to floor	Acute delirium requiring workup; new stroke symptoms; behavioral crisis unsafe for home; aspiration pneumonia; falls with injury
Admit to stroke unit	New stroke with progression; recurrent TIAs; symptomatic carotid stenosis requiring urgent intervention
Admit to psychiatry	Severe behavioral disturbance requiring specialized psychiatric management; danger to self or others
Long-term care/Memory care	Progressive decline; caregiver unable to manage safely; wandering; 24-hour supervision needed
Hospice	End-stage vascular dementia; recurrent aspiration; weight loss; goals focused on comfort
Outpatient follow-up	Neurology every 3-6 months initially; every 6-12 months when stable; PCP for vascular risk factor management

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8. EVIDENCE & REFERENCES

Recommendation	Evidence Level	Source
NINDS-AIREN criteria for vascular dementia diagnosis	Class II, Level B	Roman et al. Neurology 1993
Cholinesterase inhibitors for vascular dementia (modest benefit)	Class I, Level A	Kavirajan & Schneider. Lancet Neurol 2007
Donepezil efficacy in vascular dementia	Class I, Level A	Erkinjuntti et al. Lancet 2002
Galantamine for mixed AD/VaD	Class I, Level A	Erkinjuntti et al. Lancet Neurol 2002
Memantine for vascular dementia	Class II, Level B	Orgogozo et al. Stroke 2002
Intensive BP lowering reduces dementia risk (SPRINT-MIND)	Class I, Level A	SPRINT MIND Investigators. JAMA 2019
High-intensity statin for secondary stroke prevention	Class I, Level A	Amarenco et al. NEJM 2006 (SPARCL)
Antiplatelet therapy for secondary stroke prevention	Class I, Level A	Antithrombotic Trialists. BMJ 2002
DOACs preferred over warfarin for AF-related stroke	Class I, Level A	Ruff et al. Lancet 2014
Sertraline for post-stroke depression	Class II, Level B	Chollet et al. Lancet Neurol 2011 (FLAME)
Mediterranean diet reduces dementia risk	Class II, Level B	Scarmeas et al. Ann Neurol 2006
Physical exercise may slow cognitive decline	Class II, Level B	Livingston et al. Lancet 2020 (Lancet Commission)
Avoid antipsychotics long-term in dementia (mortality risk)	Class I, Level A	Schneider et al. JAMA 2005
CEA for symptomatic carotid stenosis 70-99%	Class I, Level A	NASCET Collaborators. NEJM 1991
CPAP treatment improves cognition in OSA patients	Class II, Level B	Osorio et al. Neurology 2015
CSF biomarkers help differentiate VaD from AD	Class II, Level B	Skillback et al. Dement Geriatr Cogn Disord 2015

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CHANGE LOG

v1.1 (January 30, 2026) - Standardized lab tables: reordered columns to Test (CPT) | ED | HOSP | OPD | ICU | Rationale | Target Finding - Added CPT codes to all lab tests (1A: 9 rows, 1B: 9 rows, 1C: 8 rows) - Standardized imaging tables: reordered columns to Study (CPT) | ED | HOSP | OPD | ICU | Timing | Target Finding | Contraindications - Added CPT codes to all imaging studies (2A: 7 rows, 2B: 8 rows, 2C: 4 rows) - Standardized LP table: reordered columns with CPT codes (7 rows) - Fixed structured dosing first fields across all treatment sections (3A-3E): starting dose only in first field - Added SYNONYMS line - Added VERSION/CREATED/REVISED header block

v1.0 (January 27, 2026) - Initial template creation - NINDS-AIREN diagnostic framework - Comprehensive vascular risk factor modification (BP, lipids, diabetes, smoking) - Secondary stroke prevention with antiplatelet and anticoagulation therapies - Cholinesterase inhibitors coverage (donepezil, rivastigmine, galantamine, memantine) with note on modest benefit - Post-stroke depression management with SSRIs (sertraline first-line) - Apathy treatment options (methylphenidate, modafinil, bupropion) - BPSD management with non-pharmacologic approaches prioritized - Differentiation from Alzheimer's and other dementias - Structured dosing format for order sentence generation - Focus on OPD setting with ED/HOSP coverage

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APPENDIX A: NINDS-AIREN Diagnostic Criteria for Vascular Dementia

Probable Vascular Dementia (All Required)

1. Dementia defined by cognitive decline from a previously higher level, manifested by:
2. Memory impairment AND
3. Impairment in two or more cognitive domains (orientation, attention, language, visuospatial, executive, motor control, praxis)
4. Deficits severe enough to interfere with ADLs

5. Not due to physical effects of stroke alone

6. Cerebrovascular disease defined by:

7. Focal neurological signs consistent with stroke (hemiparesis, facial weakness, Babinski sign, sensory deficit, hemianopia, dysarthria) AND

8. Evidence of relevant CVD on neuroimaging (CT or MRI) including:

   • Multiple large-vessel infarcts
   • Single strategically placed infarct (angular gyrus, thalamus, basal forebrain, PCA or ACA territory)
   • Multiple basal ganglia and white matter lacunes
   • Extensive periventricular white matter lesions
   • Combinations of the above

9. Relationship between dementia and CVD inferred by:

10. Onset of dementia within 3 months of recognized stroke OR
11. Abrupt deterioration in cognitive functions OR
12. Fluctuating, stepwise progression of cognitive deficits

Features Consistent with Diagnosis

• Early gait disturbance
• History of unsteadiness and frequent falls
• Early urinary frequency, urgency, and incontinence not explained by urological disease
• Pseudobulbar palsy
• Personality and mood changes (abulia, depression, emotional incontinence)
• Preserved insight and judgment until late stages

Features Making Diagnosis Uncertain

• Early memory impairment with progressive worsening without imaging changes
• Absence of focal neurological signs
• Absence of CVD lesions on imaging

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APPENDIX B: Neuroimaging Findings in Vascular Dementia

Strategic Infarct Locations

Location	Clinical Manifestation
Thalamus (bilateral)	Severe amnesia, apathy, executive dysfunction
Angular gyrus (dominant)	Alexia, agraphia, anomia, Gerstmann syndrome
Anterior cerebral artery	Abulia, apathy, executive dysfunction
Posterior cerebral artery	Visual agnosia, amnesia (hippocampal involvement)
Basal ganglia (caudate)	Executive dysfunction, behavioral changes
Hippocampus	Anterograde amnesia

White Matter Disease Grading (Fazekas Scale)

Grade	Description	Clinical Implication
0	Absent	Normal
1	Punctate foci	Mild; may be age-related
2	Beginning confluence of foci	Moderate; clinically significant
3	Large confluent areas	Severe; strongly associated with VaD

Microbleed Distribution

Pattern	Associated Condition
Lobar (cortical-subcortical)	Cerebral amyloid angiopathy
Deep (basal ganglia, thalamus)	Hypertensive microangiopathy
Mixed	Both pathologies may coexist

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APPENDIX C: Differentiating Vascular Dementia from Alzheimer's Disease

Feature	Vascular Dementia	Alzheimer's Disease
Onset	Abrupt or stepwise	Insidious, gradual
Progression	Stepwise or fluctuating	Gradual, continuous
Memory	Variable; may be preserved early	Prominent early memory loss
Executive function	Prominently impaired	Impaired later
Focal neurological signs	Often present	Usually absent
Gait disturbance	Early and prominent	Late feature
Incontinence	Early	Late
MRI findings	Strategic infarcts, WM disease, lacunes	Hippocampal/MTL atrophy
Amyloid PET	Negative (or positive if mixed)	Positive
CSF Aβ42	Normal	Low
CSF p-tau	Normal or mildly elevated	Elevated
Response to ChEIs	Modest	More robust
Vascular risk factors	Prominent	May be present

Note: Mixed dementia (AD + VaD) is common, especially in elderly patients. Look for features of both pathologies.