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Vascular Dementia — MRCPsych Paper B MCQ

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HardOld Age PsychiatryVascular DementiaMRCPsych Paper B

A 71-year-old man has severe cognitive impairment following several abrupt, stepwise deteriorations temporally related to strokes. MRI shows multiple cortical infarcts and extensive small-vessel ischaemic disease. There was no preceding progressive amnestic syndrome, and he has no parkinsonism, cognitive fluctuations or recurrent visual hallucinations. Donepezil was previously stopped after causing symptomatic bradycardia. Memantine is subsequently started specifically for his vascular dementia. According to NICE NG97, is starting memantine appropriate?

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Correct answer: E — No, because no qualifying comorbid neurodegenerative dementia is suspected

The correct answer is E. NICE NG97 recommends considering an acetylcholinesterase inhibitor or memantine in vascular dementia only when comorbid Alzheimer's disease, Parkinson's disease dementia or dementia with Lewy bodies is suspected. The stepwise post-stroke course and absence of an antecedent progressive amnestic syndrome, parkinsonism, fluctuations or visual hallucinations make such comorbidity unsupported here. Memantine is therefore not indicated solely for his vascular dementia. Severe impairment does not create a vascular-dementia indication, so D is incorrect. Acetylcholinesterase-inhibitor intolerance supports memantine in specified circumstances in Alzheimer's disease or dementia with Lewy bodies, but not in otherwise pure vascular dementia, excluding E. Combination with donepezil is neither required nor appropriate here, excluding C.

Reference: National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers (NG97), recommendation 1.5.14. 2018, current guideline page: https://www.nice.org.uk/guidance/ng97/chapter/Recommendations