2. Management of Vascular Cognitive Impairment

Notes

VCI is a complex and heterogeneous syndrome that creates challenges for care processes and clinical decision making. Clinical management of VCI thus requires a collaborative process designed to achieve optimal well-being by care coordination and continuity. The main elements of management include evidence-based interventions, education of individuals with VCI and family, person-centred perspectives, and systems approaches to improve care navigation and continuity.

Recommendations and/or Clinical Considerations

2.1 Principles of Vascular Cognitive Impairment Management

1. Individuals with VCI should have a personalized management plan that includes a person-centred approach, shared decision-making, and culturally appropriate and agreed-upon goals and preferences [Strong recommendation; Low quality of evidence]. 
   
   1. The management care plan should include follow-up and monitoring and be revisited regularly as VCI evolves over time [Strong recommendation; Low quality of evidence].  
   2. Treatment goals and selected interventions should consider the strengths and weaknesses of the affected individual’s cognitive profile (including clinical presentation and severity), communication abilities, etiology/prognosis, comorbid conditions, decisional capacity, care and living environment (including family and caregiver availability) [Strong recommendation; Low quality of evidence].
   3. Interventions should consider the long-term goals to maintain and/or to facilitate resumption of desired activities and participation (e.g., self-care, home and financial management, leisure, driving, return to work), in the context of best available evidence [Strong recommendation; Low quality of evidence]. 
2. Non-pharmacological and pharmacological approaches to management of VCI and cognitive rehabilitation should be used [Strong recommendation; Moderate quality of evidence]. 
3. Management of vascular risk factors should be optimized [Strong recommendation; High quality of evidence]. Refer to the CSBPR Secondary Prevention of Stroke module and C-CHANGE guidelines for additional information. (Gladstone et al. 2022; Jain et al. 2022) Refer to Palliative Care section 5.2 for additional information.
4. The individual with VCI, their family and caregivers, should be educated at multiple points and transitions in their journey with VCI about the expected clinical course and impact on cognition and function [Strong recommendation; Moderate quality of evidence]. Refer to Appendix Five, VCI Journey Map for additional information.

Section 2.1 Clinical Considerations

1. A coordinated management care plan should support continuity of care across the trajectory of vascular cognitive impairment and the continuum of care.
2. The approach to management of VCI should consider elements of goal setting, social support, cognitive scaffolding (using specific approaches to cognitive tasks such as checklists), lifestyle management, task training, and environment.
3. In individuals with significant comorbidities and/or for whom goals of care considerations prioritize comfort and/or palliative approaches, discussions regarding less aggressive or withdrawal of vascular risk reduction strategies may become appropriate.  Refer to Palliative Care section 5.2 for additional information.

2.2 Non-Pharmacological Management of VCI

1. Individuals with VCI should be assessed for medical (e.g., hypertension, diabetes, lipids, atrial fibrillation, sleep disorders) and lifestyle vascular risk factors (e.g., diet, sodium intake, cholesterol, exercise, weight, alcohol intake, smoking) [Strong recommendation; Moderate quality of evidence]. 
2. Medical and lifestyle vascular risk factors should be managed to achieve maximum risk reduction for first-ever or recurrent stroke, as these are associated with cognitive impairment [Strong recommendation; Moderate quality of evidence]. 
3. Referrals to appropriate specialists should be made to support and manage specific medical and lifestyle vascular risk factors and comorbidities (e.g., dysphagia) where required [Strong recommendation; Moderate quality of evidence].
4. Individuals with vascular cognitive impairment may require additional support (e.g., communication tools, memory aids, caregiver and family participation and support) as appropriate to optimize participation in goal-setting and/or engagement in interventions [Strong recommendation; Low quality of evidence] 

Refer to CSBPR Secondary Prevention of Stroke module (Gladstone et al. 2022) for additional information. Refer to Sections 2.6 to 2.9 below for additional information on specific non-pharmacological strategies.

2.3 Pharmacological Management of VCI

1. Cholinesterase inhibitors (donepezil, rivastigmine and galantamine)* and the N-methyl-D-aspartate (NMDA) receptor antagonist memantine* may be considered in individual persons with vascular or mixed dementia, based on randomized trials showing small magnitude benefits in cognitive outcomes [Conditional recommendation; High quality of evidence]. Refer to Section 2.3 clinical considerations 1 and 2 for additional information on cholinesterase inhibitors.
2. Physicians who are following individuals with VCI should pay close attention to the medications that the individual is prescribed, as certain classes of medication may increase the risk of cognitive fluctuations or cognitive decline [Strong recommendation; Moderate quality of evidence]. 

*Note: These medications are currently approved by Health Canada for the treatment of Alzheimer’s disease. They have not received approval for vascular cognitive impairment. Many dementias include both Alzheimer’s disease and vascular dementia (i.e., mixed) pathology.

Refer to Section 2.4 for recommendations on anti-thrombotic use and Section 2.5 for Management of Hypertension. Also refer to Canadian Stroke Best Practice Recommendations for Secondary Prevention of Ischemic Stroke for general guidance on stroke prevention (Gladstone et al. 2022).

Section 2.3 Clinical Considerations

1. The use of cholinesterase inhibitors for pure VCI without Alzheimer’s disease is controversial. The use of these medications should be based on clinical judgment that small improvements in cognition would have a meaningful impact on the quality of life of the individual. Adverse events can occur. Severity of VCI should be considered in decisions for pharmacological management. 
2. Consideration can be given for discontinuing cholinesterase inhibitors if adverse events occur, if there is no apparent benefit and/or if their use is no longer consistent with goals of care due to progression to severe impairments.
3. There may be a role for psychostimulants for selected individuals with VCI (e.g., those with significant apathy or inattentiveness impacting their daily function), although the evidence is currently insufficient to issue a recommendation. Further studies are required for safety and efficacy in this population.

2.4 Anti-thrombotic Agents

1. Antiplatelet or antithrombotic use should be guided by existing primary and secondary stroke or vascular prevention indications [Strong recommendation; High quality of evidence]. (Bainey et al. 2024; Gladstone et al. 2022; Heran et al. 2022)
2. VCI should not be considered as a contraindication for guideline-based antithrombotic therapy [Strong recommendation; Low quality of evidence]. 
3. The effects of low dose acetylsalicylic acid (ASA) in individuals with VCI or vascular dementia who have covert brain infarcts detected on neuroimaging without history of stroke have not been defined. The use of ASA in this setting could be considered, but the benefit is unclear [Conditional recommendation; Low quality of evidence]. (Smith et al. 2020)

Refer to the CSBPR Secondary Prevention of Stroke module (Gladstone et al. 2022), CSBPR Acetylsalicylic Acid (ASA) for Prevention of Vascular Events module (Wein et al. 2020)  and C-CHANGE guidelines (Jain et al. 2022) for additional information.

2.5 Management of Hypertension

1. Long-term treatment of hypertension may reduce cognitive decline and should be addressed for all individuals with elevated blood pressure who are at high risk for or have already experienced VCI [Strong recommendation; Moderate quality of evidence].
2. For individuals with cognitive disorders in which a vascular contribution is known or suspected, antihypertensive therapy should be strongly considered for individuals with an average diastolic blood pressure consistently ≥90 mmHg, or for individuals with an average systolic blood pressure consistently ≥140 mmHg [Strong recommendation; Moderate quality of evidence]. Refer to the CSBPR Secondary Prevention of Stroke module (Gladstone et al. 2022), Hypertension Canada (Rabi et al. 2020), and C-CHANGE guidelines (Jain et al. 2022) for additional information.
   
   1. Antihypertensive therapy and specific blood pressure targets should be guided by existing primary and secondary stroke or vascular prevention indications [Strong recommendation; High quality of evidence]. Refer to the CSBPR Secondary Prevention of Stroke module (Gladstone et al. 2022), Hypertension Canada (Rabi et al. 2020), and C-CHANGE guidelines (Jain et al. 2022) for additional information.

2.6 Management of Mood in Vascular Cognitive Impairment

1. Healthcare providers should monitor individuals with VCI for changes in mood and behaviour, based on clinical presentation and/or the individual or their caregiver reports over the trajectory of VCI [Strong recommendation; Moderate quality of evidence].
1. Depression, anxiety, apathy and emotional reactivity are common in individuals with VCI and can be assessed using validated tools and/or interviews [Strong recommendation; Moderate quality of evidence]. Refer to the CSBPR Rehabilitation, Recovery and Participation module, Mood section for additional information.(Lanctôt et al. 2020)
2. Treatment for mood and anxiety may include psychotherapy, non-pharmacological therapies (such as exercise), and/or pharmacotherapy alone or in combination [Strong recommendation; High quality of evidence], as appropriate to the individual’s health state and presence of cognitive and communication deficits [Strong recommendation; Moderate quality of evidence]. Refer to the CSBPR Rehabilitation, Recovery and Participation module, Mood section for additional information.(Lanctôt et al. 2020)
3. For patients with mild VCI it is reasonable to consider either cognitive-behavioural therapy, interpersonal therapy or behavioural activation as one of the first-line treatments for depressive and anxious symptoms, as a monotherapy [Strong recommendation; Moderate quality of evidence].
4. For individuals with severe VCI (showing marked cognitive deficits, poor initiation or self-direction), personalized treatments to enhance quality of life and to reduce behavioural and psychological symptoms, should be considered. Such approaches can include environmental management and behavioural activation, physical activity, music therapy, and reminiscence therapy [Strong recommendation; Low quality of evidence]. 

Section 2.6 Clinical Considerations

1. When choosing interventions for mood issues in individuals with VCI, clinicians should consider the nature of the issues and the cognitive profile of a specific individual with VCI. The nature and degree of the cognitive impairment [e.g., memory, executive functions] may be important in determining feasibility of a specific intervention or appropriate goals.
2. Cognitive-behavioural therapy and interpersonal therapy may be more appropriate for individuals with sufficient attention, memory and executive skills. Behavioral activation may be more appropriate for individuals who require supported engagement. 
3. Monitoring and screening for changes in mood and behaviour may be on the same schedule as other clinic-specific routine screening protocols for monitoring other chronic diseases, at transitions of care and/or other annual or follow-up visits. 
4. Agitation, irritability, emotional reactivity can be behavioural consequences of VCI and may be appropriately addressed through behavioural interventions, family interventions and/or medication under the supervision and support of qualified healthcare providers.
5. It is important to identify and address barriers in adjustment to the diagnosis and changes in cognition and function across the trajectory of vascular cognitive impairment.
6. For individuals with known or suspected VCI and communication difficulties, screening, assessment, and management of depression and/or anxiety should be performed using measures and approaches that are appropriate for their cognitive and communication levels, and when possible, validated for this purpose. Refer to CSBPR Rehabilitation, Recovery and Participation module, Mood section for additional information.(Lanctôt et al. 2020)

2.7 Behaviour Management

1. Individuals with known or suspected VCI should be screened for behaviour changes that may cause distress or disruption, including through interviews with the individual, family members and members of their healthcare team [Strong recommendation; Moderate quality of evidence]. 
2. For individuals demonstrating new behavioural changes, investigating and treating potential underlying causes should be undertaken (e.g., pain or presence of a urinary tract infection as underlying causes) [Strong recommendation; Moderate quality of evidence].
3. Non-pharmacological strategies should be considered as first-line management of an individual with VCI who is displaying behaviour changes [Strong recommendation; Moderate quality of evidence].
   1. For those individuals with mild VCI, cognitive behavioral, interpersonal, and / or problem-solving deficits, psychotherapeutic strategies may be considered to facilitate adaptive coping [Conditional recommendation; Low quality of evidence]. 
4. Structured and tailored activities that are individualized and aligned to current capabilities and take into account previous roles and interests may be considered [Strong recommendation; Low quality of evidence] (Scottish Intercollegiate Guidelines Network 2023).
5. Pharmacological intervention may be considered if the individual, their family or other caregivers are severely distressed, or there is an immediate risk of harm to the individual with VCI or others (i.e., very severe symptoms) [Strong recommendation; Low quality of evidence]. 
   1. If pharmacological management is used, this should complement, not replace, non-pharmacological approaches [Strong recommendation; Low quality of evidence].
   2. Pharmacological strategies for behavioural management can have potential harm. Involvement of specialists in adult behaviour management should be considered [Strong recommendation; Low quality of evidence].
6. In complex cases, referral to a specialist in behavioral management in the context of neurocognitive impairment should be considered [Conditional recommendation; Low quality of evidence].
7. For individuals with severe symptoms of VCI, activity-based interventions that are tailored to individual abilities and preferences (e.g., Montessori activities for older adults with VCI, activation interventions) can increase positive affect [Strong recommendation; Moderate quality of evidence] and reduce agitation [Conditional recommendation; Moderate quality of evidence].

Section 2.7 Clinical Considerations

1. The focus of intervention may vary over the trajectory of an individual’s experience with VCI, and with progression from milder VCI to severe VCI and dementia. When the level of impairment is severe the focus will evolve, from treatment interventions designed to impact on disability and quality of life, to interventions that are designed to promote the quality of life of individuals living with dementia. 
2. For individuals with moderate to severe VCI and agitation, the antecedent-behaviour-consequences (ABC) charting approach can be used for behavioural management. The ABC approach can include systematic tracking of agitation, over several days, to identify environmental and somatic/ physical triggers for agitation that can be used to inform behavioural management strategies.
3. For individuals with mild VCI living in less structured environments (e.g., at home or retirement home), behavioral charting may help to identify environmental and somatic/physical triggers for agitation to inform strategies to minimize the impact of these factors. 
4. In the context of severe VCI/dementia, supporting the ability of the caregiver to provide care for their family member or friend, as well as their ability to be a partner in care may be appropriate.
5. The specifics of the services provided will need to align with the specific environmental contexts of individuals (e.g., rural vs. urban communities).
6. If pharmacological treatment of behavior is required (which is not the first line), most evidence comes from treatment of behavioural symptoms in dementia in general rather than VCI specifically. The Canadian Coalition for Seniors’ Mental Health has issued detailed guidelines for managing behavioral symptoms of dementia. In this recommendation, the reader is referred to Section 5 (managing agitation in dementia), recommendations 3-9 review non-pharmacological strategies and 10-30 highlight considerations for pharmacological management including medications that may be beneficial or may cause harm. Sections 6 (managing psychosis in dementia), 7 (managing depressive symptoms in dementia) and 8 (managing anxiety in dementia) may also be helpful. (Canadian Coalition for Seniors’ Mental Health 2024)

2.8 Safety and Risk Management

1. The presence of VCI may increase safety risks for ADL/IADL related activities. Individuals with VCI should be assessed and monitored for safety risks [Strong recommendation; Low quality of evidence]. Refer to Box 2A for additional information.
2. Assessment of individuals for potential safety risks may include an understanding of the relationship between the individual’s cognitive status (e.g., insight, memory, planning) and the individual’s:
   
   1. autonomy and decision-making capacity [Strong recommendation; Low quality of evidence].
   2. behavioural status (e.g., agitation or apathy) [Strong recommendation; Low quality of evidence].
   3. environment (such as the physical environment, and social determinants of health) [Strong recommendation; Low quality of evidence].
   4. risk for falls [Strong recommendation; Moderate quality of evidence].
   5. activities and occupations (e.g., ADLs, IADLs and leisure activities) [Strong recommendation; Low quality of evidence]. 
   6. driving status [Strong recommendation; Moderate quality of evidence].
3. The individual, family and care providers should be provided with education regarding safety risks and mitigation strategies [Strong recommendation; Low quality of evidence].
4. Physical exercise, balance training, and environmental aids should be considered to reduce the risk of falls [Strong recommendation; Low quality of evidence]. For additional information related to stroke and falls risk, refer to CSBPR Rehabilitation and Recovery following Stroke (Teasell et al. 2020).

Section 2.8 Clinical Considerations

1. The assessment of safety and risk may include information from the individual with VCI and those familiar with the individual (e.g., family, care providers). This information may include cognitive functioning, life demands, setting familiarity, potential impact on safety of others and currently available supports for the individual’s quality of life and current ability to function in the least restrictive environment.
2. An individualized safety plan should be developed in partnership with the individual with VCI, their family and caregivers, and the healthcare team, and may include:
   
   1. identifying personal supports (e.g., family/caregivers to observe, check-in and/or support health and/or financial decision making);
   2. technological supports (e.g., personal alarm systems);
   3. environmental changes/supports (e.g., nightlights to reduce falls in low light, modification of cooking equipment, creating routine and structure to tasks);
   4. considerations for future anticipated needs and supports;
   5. regular review and updating as required.

2.9 Environmental Supports

1. The physical environment should be assessed for factors that may impact the ability of individuals to perform ADL [Strong recommendation; Moderate quality of evidence]. Refer to Box 2A for additional information on impact of VCI on ADLs.
2. The use of assistive technologies (e.g., automatic prompting for ADL, automatic lighting) should be considered to aid functional skills, such as during mealtime, hygiene and self-care (e.g., handwashing, dental care, dressing, and toileting), and orientation to time [Strong recommendation; Low quality of evidence].
3. The use of cues (e.g., signs, pictures, arrows) should be considered to orient an individual to time and setting [Strong recommendation; Low quality of evidence]. 
4. The use of individually tailored environmental adaptations, such as ambient features (e.g., music, lighting, personal photographs), and leisure activities (e.g., gardening) should be considered [Strong recommendation; Low quality of evidence].

2.9.1 Environmental Supports for Individuals with VCI and Aphasia

1. Individuals with VCI and aphasia should be assessed for their potential to benefit from using augmentative and alternative communication or other communication support tools (e.g., iPad, tablet, electronic devices, alphabet board) [Strong recommendation; Low quality of evidence].
2. Treatment to improve functional communication should include supported conversation techniques for potential communication partners of the individual with aphasia [Strong recommendation; High quality of evidence].

Section 2.9 Clinical Considerations

1. Factors to consider when assessing an individual’s physical environment: 
   1. size of the environment (smaller environments may be more manageable); 
   2. architectural layout (rooms that are enclosed with an obvious function are more supportive than open concept); 
   3. homelike atmosphere (e.g., private bedrooms, larger windows) 
   4. physical layout of the environment and potential hazards (such as carpets or furniture that may increase tripping risk).
2. When determining appropriate environmental supports, the above recommendations may need to be nuanced to the individual’s setting (e.g., home vs congregate setting) given that there may be variability in supports in a shared space, availability of supports (e.g., lives alone, family/staff availability) and/or financial resources.
3. The impact of aphasia on functional activities, participation and quality of life, including the impact on relationships, vocation and leisure, should be assessed and addressed across the continuum of care.