Neuropsychological assessment plays a central role in diagnosing vascular cognitive impairment and dementia (VCID), yet clinical approaches have varied widely for nearly two decades.

Newly updated, consensus-harmonized guidelines from the International Society for Vascular Behavioral and Cognitive Disorders (VasCog) aim to clarify which cognitive domains matter most, how testing can be structured efficiently, and how assessments can be adapted to modern clinical settings.

Developed by an international panel of experts, the VasCog neuropsychological (VasCog-NP) guidelines update and expand on the National Institute for Neurological Disorders and Stroke-Canadian Stroke Network (NINDS-CSN) recommendations published in 2006.

The authors describe the new guidance as offering a more comprehensive and flexible framework for VCID assessment, designed to support consistency while accommodating different clinical contexts.

The development of the guidelines was led by Adam Bentvelzen, PhD, of the Center for Healthy Brain Aging at the University of New South Wales, and published online on December 9 in JAMA Network Open.

Why Now?

VCID arising from cerebrovascular disease is the second most common form of dementia after Alzheimer’s disease (AD), accounting for approximately 17%-30% of all cases, reflecting the large burden of cerebrovascular disease worldwide. It is a heterogeneous disorder with multiple etiologies, making the characterization of distinct patterns of associated cognitive deficits challenging.

“Recent developments in disease-modifying treatments in the AD field and emphasis on preventive approaches for dementia in general, particularly for VCID, have amplified the importance of accurately identifying clinical patterns to disentangle heterogeneity in dementia,” the guideline authors noted. Along with emerging biomarkers, standardization of neuropsychological assessments is necessary to achieve this objective, they added.

The 2006 NINDS-CSN test battery has been widely adopted and validated in different languages. However,advancements in the field since 2006 warrant a reassessment of harmonized guidance for assessment of VCID.

“Neuropsychological batteries are not immutable and need to be reviewed as new developments occur in the field, such as increasing adoption of digitized methods and automation, increased attention to culture-sensitive test adaptations (variants of tests in diverse languages, and telehealth and remote assessment methods,” Bentvelzen told Medscape Medical News.

In addition, the role of multiple comorbid pathologies, frequently including cerebrovascular disease, in accelerating cognitive and brain aging has become well-established.

“There is now greater emphasis on small vessel disease as a major, and possibly the most significant, contributor to VCID, with supporting research to delineate its neuropsychological profile,” Bentvelzen said.

“Taken together, it was unclear whether the existing NINDS-CSN standards remained sufficient to accommodate the assessment of VCID in current times and many in the field felt a review was needed,” he noted.

How Was the Update Conducted?

The update used a formal Delphi consensus process involving 44 international experts who participated in three survey rounds. The NINDS-CSN and other relevant published harmonized neuropsychological batteries, aided by literature review of recent developments in VCID, were used as reference points for the three survey rounds.

“Previous guidance such as the NINDS-CSN was obtained via workshops and meetings, while our work and its constituent processes are entirely formalized and objectively reported by our use of the Delphi method,” Bentvelzen told Medscape Medical News.

“The Delphi method is well-established as the gold standard approach to determining agreement on standardized guidance, including in the medical field. As a result, clinicians and researchers can have greater confidence that our guidance is well accepted by the expert community, and future researchers can replicate the results as all aspects of the study are objectively reported,” he noted.

Using this approach, 31 experts reached consensus on a core assessment battery of neuropsychological tests based on key cognitive domains, and on additional guidelines for comprehensive testing, cognitive screening, telehealth and computerized assessment methods and assessments of diverse populations.

What’s New?

A major achievement highlighted by the authors was the establishment of consensus on a general framework for neuropsychological assessment, including a core (~45 min), comprehensive (60 to ≥ 180 min), and brief cognitive screening (5-10 min) test battery, suitable for research, specialized clinical, and primary care settings.

Another major achievement in the VasCog-NP was establishing executive function and attention and processing speed as core cognitive domains in VCID,with guidance that shorter test batteries (if required) should prioritize the domains of attention and processing speed, executive function, learning, memory, and mood.

With the VasCog-NP, there is now a “greater choice of neuropsychological tests and clearer guidance on when and how to use particular measures,” Bentvelzen told Medscape Medical News.

“The list of core (most highly preferred measures) of the VasCog-NP battery mostly overlaps the NINDS-CSN — with the exception of more detailed assessment of attention and processing speed, and an alternative core measure for mood,” he explained.

“However, the main benefit of our battery is the addition of many acceptable alternative tests, and crucially, more clear guidance on when and how the alternatives could or should take precedence over the core measures; for example, if a clinician wishes to minimize motoric and/or linguistic demands,” Bentvelzen added.

“This recognizes that in clinical practice, flexibility is the key and a single one-stop shop of aspirational measures will not always suffice in the real world, nor in many research contexts,” he said.

For cognitive screening, for example, the Montreal Cognitive Assessment (MoCA) was endorsed as the highest-ranked option.

“Preferred” verbal memory tests designed to permit dissociation of an encoding vs a retrieval pattern of memory failure — key to distinguishing VCID from AD — include the California Verbal Learning Test, Rey Auditory Verbal Learning Test, and Hopkins Verbal Learning Test Revised.

Importantly, the cognitive domains of VasCog-NP align with the consensus VasCog-2 World Stroke Organization diagnostic criteria for VCID.

How Will the New Guidance Change Practice?

Bentvelzen said the updated guidance could alter clinical practice in several ways.

“Particularly relevant for medical practitioners, we hope there is greater attention to using cognitive screening tools such as the MoCA that include items measuring the cognitive domains attention, processing speed and executive function, as these domains are central to the most common cognitive profile of VCID,” he said.

“Some commonly used screening tests such as the Mini Mental State Examination, almost entirely neglect these central domains hence are particularly insensitive to detecting the types of cognitive changes that occur in the early stages of VCID,” he noted.

“For clinicians such as neurologists, geriatricians, and neuropsychologists that may perform longer, more comprehensive assessments, we hope the importance of including assessment of premorbid functioning is clearer when considering the type and extent of cognitive changes, along with assessment of mood and behavior change as this is a common symptom comorbid with cognitive changes but may also represent a potential differential diagnosis (i.e., clinical depression),” Bentvelzen said.

In addition, the guidelines outline several practical considerations for individuals with VCID, including the potential impact of stroke-related symptoms — such as aphasia or apraxia — and cultural and linguistic diversity on assessment, as well as strategies for managing these challenges.

The updated guidance also provides more flexible options for assessment.

“Overall, the group agreed upon telehealth methods including the use of established instruments via videoconference and accepted telephone cognitive screening, but did not recommend remote self-administered methods without supervision, or comprehensive neuropsychological assessment via the phone,” Bentvelzen said.

There was also consensus support for including copyright-free alternatives and for forming a working group to identify region-specific normative datasets, including low- and middle-income countries.

“We strongly recommend using the highest quality standardization sources (normative data) and neutral score descriptors that avoid stigmatizing terms (for example, ‘exceptionally low score’ in place of ‘severe impairment’),” Bentvelzen added.

This research had no commercial funding. Bentvelzen had no relevant disclosures.