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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Second most common cause of dementia (~15–20%). Mixed dementia (AD + vascular) is very common
- Stepwise decline often with temporal relationship to cerebrovascular events
- MRI: white matter hyperintensities, lacunar infarcts, cortical infarcts
- No specific pharmacotherapy — AChEIs are NOT recommended for pure vascular dementia (NICE NG97)
- Management focuses on secondary prevention of cardiovascular risk factors: BP control, statin, antiplatelet, diabetes management
Overview
Vascular dementia (VaD) results from cerebrovascular disease causing cognitive impairment sufficient to affect daily functioning. It encompasses several subtypes: multi-infarct dementia (cortical infarcts), subcortical ischaemic vascular dementia (small vessel disease with lacunar infarcts and white matter lesions), strategic single-infarct dementia (e.g. thalamic stroke), and post-haemorrhagic dementia. Mixed dementia (concurrent AD and vascular pathology) is extremely common, particularly in older patients. Vascular dementia accounts for approximately 15–20% of dementia cases.
Epidemiology
VaD prevalence is approximately 150,000 in the UK. Risk factors are identical to those for stroke and cardiovascular disease: hypertension (most important), diabetes, hyperlipidaemia, smoking, AF, previous stroke/TIA, obesity, and physical inactivity. It is more common in men and in those of Black African/Caribbean and South Asian descent. Onset is typically older than AD but younger than average for pure VaD.
Clinical Features
Symptoms
Stepwise cognitive decline — periods of stability punctuated by sudden deterioration (often correlating with vascular events)
Executive dysfunction (planning, decision-making, sequencing) — often more prominent than memory loss early on
Slowed processing speed
Gait disturbance — small-stepping, broad-based (marche à petits pas)
Urinary incontinence (early compared to AD)
Emotional lability (pseudobulbar affect)
Depression — common
Signs
Focal neurological signs: hemiparesis, reflex asymmetry, extensor plantars (from previous strokes)
Pseudobulbar palsy: brisk jaw jerk, spastic dysarthria, emotional lability
Gait apraxia
Hypertension
Cognitive profile: executive dysfunction > memory loss (contrasts with AD)
Investigations
First-line
Cognitive assessmentACE-III/MMSE — executive function and processing speed typically more impaired than episodic memory (contrast with AD)
MRI brainWhite matter hyperintensities (leukoaraiosis), lacunar infarcts, cortical infarcts, cerebral atrophy. Fazekas scale grades white matter disease severity
BloodsAs for dementia screen: FBC, U&Es, TFTs, B12, folate, glucose, lipids, HbA1c
Second-line
CT headIf MRI unavailable — shows infarcts and white matter changes but less sensitive than MRI
Vascular risk assessmentBP, ECG (AF screen), lipid profile, HbA1c, carotid Doppler if indicated
Specialist
Neuropsychological assessmentDetailed profiling to distinguish VaD from AD — subcortical pattern (executive/speed > memory)
Management
NICE NG97 (Dementia), 20181
Cardiovascular risk factor management
- BP control: target per NICE hypertension guidelines
- Statin therapy: atorvastatin for secondary prevention
- Antiplatelet: clopidogrel 75 mg (if no AF) or DOAC (if AF)
- Diabetes management, smoking cessation, exercise, healthy diet
2
Pharmacological
- AChEIs and memantine are NOT recommended for pure vascular dementia (NICE NG97)
- If mixed dementia (AD + vascular): treat as AD — offer AChEI
- Treat depression: SSRI (avoid tricyclics if possible due to anticholinergic effects)
3
Non-pharmacological and support
- Cognitive stimulation therapy
- Regular exercise — evidence for cardiovascular and cognitive benefit
- Advance care planning, lasting power of attorney
- Carer support, social care assessment, Alzheimer's Society referral
Complications
- Further strokes: Ongoing risk — each stroke can cause stepwise decline
- Falls: Gait disturbance and cognitive impairment — high fracture risk
- Depression: Very common — screen and treat
- Aspiration pneumonia: Dysphagia from pseudobulbar palsy
- Delirium: Increased vulnerability — any intercurrent illness
UKMLA Exam Tips
- 1Vascular dementia: stepwise decline, vascular risk factors, executive dysfunction > memory, focal neurology, early gait/urinary problems
- 2Alzheimer's: insidious progressive memory loss, no focal signs early, temporal lobe atrophy
- 3AChEIs NOT recommended for pure vascular dementia — only for AD or mixed dementia
- 4MRI: white matter hyperintensities + lacunar infarcts = small vessel disease
- 5Mixed dementia is extremely common — treat the AD component with AChEI
- 6Secondary prevention of vascular risk factors is the mainstay of management
practicetest your knowledge on vascular dementiaApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — neurology and beyond.
open q-bank