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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)

CPT CODES: 85025 (CBC with differential), 80048 (BMP), 84443 (TSH), 82607 (Vitamin B12), 82746 (Folate), 83036 (Hemoglobin A1c), 80061 (Fasting lipid panel), 81001 (Urinalysis), 83090 (Homocysteine), 83695 (Lipoprotein(a)), 86141 (hsCRP), 82306 (Vitamin D, 25-hydroxy), 86592 (RPR or VDRL), 86701 (HIV testing), 80076 (Hepatic panel), 83880 (BNP/NT-proBNP), 84550 (Uric acid), 81401 (APOE genotyping), 86235 (ANCA panel), 82657 (Fabry disease testing, alpha-galactosidase A), 81406 (NOTCH3 genetic testing), 70551 (MRI Brain without contrast), 70450 (CT Head non-contrast), 93880 (Carotid duplex ultrasound), 93000 (ECG, 12-lead), 93306 (Transthoracic echocardiogram), 70553 (MRI volumetrics), 78816 (FDG-PET Brain), 78811 (Amyloid PET), 93224 (Cardiac telemetry/Holter monitor), 93241 (Extended cardiac monitoring, 14-30 day), 95819 (EEG), 95811 (Sleep study, polysomnography), 36224 (DSA, cerebral angiogram), 78607 (SPECT, perfusion), 93312 (Transesophageal echocardiogram), 83519 (CSF Aβ42 and Aβ42/Aβ40 ratio), 86593 (VDRL), 86255 (Autoimmune encephalitis panel) 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: Approved

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

SECTION A: ACTION ITEMS

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

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

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

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

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

SECTION B: REFERENCE

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

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 -

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

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

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

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

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

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.