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Vascular Dementia — MRCPsych Paper B MCQ

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EasyOld Age PsychiatryVascular DementiaMRCPsych Paper B

A 72-year-old man has a 3-year history of cognitive decline that now impairs his ability to manage his medication and finances. His deterioration has occurred in distinct steps, particularly after two previous ischaemic strokes. He has emotional lability and gait disturbance. His medical history includes hypertension and diabetes mellitus. MRI shows multiple lacunar infarcts and confluent white-matter hyperintensities. Reversible causes of cognitive impairment have been excluded. Which is the most likely dementia subtype?

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Correct answer: E — Vascular dementia

The most likely diagnosis is **vascular dementia**. The discriminating features are cognitive decline affecting daily functioning, stepwise deterioration temporally associated with cerebrovascular events, vascular risk factors, gait disturbance, emotional lability and MRI evidence of lacunar infarction and small-vessel disease. Imaging abnormalities should not establish the diagnosis alone, but here they support a compatible clinical syndrome. Alzheimer's disease more typically causes a gradually progressive, predominantly amnestic presentation. Dementia with Lewy bodies is characterised by cognitive fluctuations, recurrent visual hallucinations, REM sleep behaviour disorder and spontaneous parkinsonism. Frontotemporal dementia usually presents earlier with prominent behavioural or language change. Creutzfeldt-Jakob disease causes rapidly progressive dementia, usually over weeks or months, often with myoclonus, ataxia and characteristic neurological investigations.

Reference: National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers (NG97), recommendations 1.2.9, 1.2.12, 1.2.13 and 1.2.26–1.2.27. 2018; last reviewed 2025. https://www.nice.org.uk/guidance/ng97/chapter/Recommendations