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AChEIs Mixed Dementia — MRCPsych Paper B MCQ

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ModerateOld Age PsychiatryAChEIs Mixed DementiaMRCPsych Paper B

A 78-year-old woman has a 3-year history of gradually progressive episodic memory impairment and declining ability to manage complex activities. MRI shows hippocampal atrophy together with extensive cerebral small-vessel disease and several lacunar infarcts. She is diagnosed with mild to moderate mixed Alzheimer's and vascular dementia. She has no contraindication to cognitive-enhancing medication. Which approach is most consistent with NICE guidance?

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Correct answer: C — Consider an acetylcholinesterase inhibitor because comorbid Alzheimer's disease is present

Explanation lettering: C = shown as B · B = shown as C

The correct answer is B. NICE advises that acetylcholinesterase inhibitors may be considered in vascular dementia when comorbid Alzheimer's disease is suspected. Here, the gradual amnestic syndrome and hippocampal atrophy support an Alzheimer's component, while the small-vessel disease and lacunar infarcts support additional vascular pathology. The presence of vascular disease therefore does not preclude an acetylcholinesterase inhibitor. Options A and E incorrectly treat cerebrovascular pathology as an exclusion criterion. Option C is wrong because vascular pathology does not contraindicate acetylcholinesterase inhibitors, and memantine is not automatically preferred; in Alzheimer's disease it is principally used for severe disease or moderate disease when acetylcholinesterase inhibitors are contraindicated or not tolerated. Option D incorrectly restricts cognitive-enhancing treatment to pure Alzheimer's disease.

Reference: National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers (NG97), recommendations 1.5.2–1.5.3 and 1.5.14. 2018, current guideline with minor updates through June 2025. https://www.nice.org.uk/guidance/ng97/chapter/Recommendations