A consortium of global experts released proposed updated diagnostic criteria for vascular cognitive impairment and dementia (VCID).

The proposed update would revise criteria first released in 2014 by the International Society for Vascular Behavioral and Cognitive Disorders (VasCog). The proposal for the second iteration also provides guidance on neuroimaging and fluid biomarkers and has already been endorsed by the World Stroke Organization (WSO), earning it the name VasCog-2-WSO.

“Considering subsequent advances in the field, a revision was needed,” Perminder Sachdev, MD, PhD, Center for Healthy Brain Aging at the University of New South Wales Sydney, Sydney, Australia, and colleagues wrote.

The update “should provide an international standard for VCID diagnosis, facilitating diagnostic consistency among clinicians and researchers,” they added.

Deborah Blacker, MD, one of the consortium authors and professor of psychiatry and epidemiology at Harvard Medical School, Boston, noted the importance of addressing vascular contributions to dementia, and how to deal with it in the clinic, especially when it comes to developing interventions.

“There’s a broader understanding these days about just how multifactorial dementia is, especially in older individuals. And I think [this project] is about people figuring out the best way to address these issues,” Blacker told Medscape Medical News.

The proposed criteria were published online on September 16 in JAMA Neurology.

Consensus Achieved

Although Alzheimer’s disease (AD) is the most common form of dementia, vascular dementia is the second most prevalent, accounting for roughly 15%-20% of cases, the authors reported. In addition, up to 75% of individuals with dementia may experience cognitive and functional decline related to cerebrovascular disease.

However, a major obstacle to advancing research in this area “is the absence of universally recognized and clearly operationalizable diagnostic criteria, reducing the validity and interpretability of clinical outcomes and research findings,” the authors wrote.

A 2019 study showed that the original VasCog-1 criteria were comparable to those of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the Vascular Impairment of Cognition Classification Consensus Study.

“But technology is accelerating,” which is why updated criteria will be helpful, Blacker said.

The VasCog-2-WSO was developed using a Delphi process that included at least three rounds of online surveys, sent in 2023 to 70 experts. Each round required a minimum of 75% agreement among participants.

Among the experts, 77% were neurologists, psychiatrists, epidemiologists, or geriatricians. Geographically, 78% were from Europe, North America, or Australia, 9% from Asia, 4% from Brazil, and 2% from the Caribbean.

Agreement was reached by 49-54 experts on the diagnostic criteria for preclinical, mild, and major levels of VCID, as well as on research guidelines.

‘Practical Guidance’

Using “VCID” to refer to the overall cognitive construct for all forms of vascular cognitive deficits, “vascular MCI” for a mild level, and “vascular dementia” for a major level achieved 84% consensus among the Consortium.

Other key revisions include:

• Updated VasCog neuroimaging and clinical criteria
• Additional biomarker criteria for AD and other neurodegenerative conditions
• A new preclinical/at-risk category

The investigators also noted that VasCog-2-WSO offers “practical guidance” for applying all of the criteria.

“This is designed to assist with decision-making in both clinical and research settings and remain sufficiently broad and flexible to facilitate clinical judgment,” the authors wrote.

They noted that the new criteria now need validation in longitudinal studies and assessment of their clinical utility.

“The criteria remain to be tested in the field, and their validation is an important future goal to build on previous efforts involving VasCog-1 and other criteria,” the authors wrote.

‘A Step in the Right Direction’

In an accompanying editorial, David S. Knopman, MD, Mayo Clinic, Rochester, Minnesota, noted that input from such a wide group of clinicians “that captured points of agreement but also acknowledged gaps in consensus” was a major strength of the new criteria.

Although Knopman participated in the Delphi process, he noted a few concerns with VasCog-2-WSO.

The new criteria continued to accept that, even without a history of stroke, the presence of physical signs consistent with a stroke can serve as a core criterion.

However, the impact “is mooted by the addition of an alternative core clinical criteria that allows any cognitive syndrome to fulfill a core criteria to improve sensitivity,” Knopman wrote.

On the other hand, “a step in the right direction” is the reliance on cardiovascular (CVD) imaging features in order to achieve specificity.

Overall, VasCog-2-WSO “have advanced a practical clinical approach to the categorical diagnosis of vascular cognitive impairment. However, the causal contribution of CVD to later life cognitive impairment is broader than the cases captured by the categorical diagnosis,” Knopman wrote.

“A probabilistic approach to explicate the role of atherosclerotic and arteriolosclerotic CVD would represent the broader clinical-biological construct more accurately,” he added.

This paper was funded by a long list of organizations, including the University of New South Wales, the National Institutes of Health, the National Heart Foundation of Australia, the National Medical Research Council of Singapore, and the French Department of Health Direction Générale de l’Offre Des Soins. Sachdev reported receiving advisory board fees from Eisai, Roche Australia, and Eli Lilly Australia outside the submitted work. Blacker reported no relevant financial relationships. A full list of conflicts for Knopman and other members of the Consortium are provided in the original articles.