Statement of Principles concerning vascular neurocognitive disorder (Balance of Probabilities) (No. 10 of 2023)

The instrument pivots on four core legal‑medical concepts: (1) the RMA's role and legal basis; (2) the clinical definition of the disease; (3) the enumerated qualifying factors; and (4) the relationship of those factors to "relevant service."

1. RMA role and legal basis. The SoP is made under subsection 196B(3) of the VEA (s 3). Section 8 records the RMA's considered view based on available medical‑scientific evidence that vascular neurocognitive disorder can, on balance of probabilities, be related to relevant service. The SoP therefore sets evidentiary presumptions or thresholds to be used in adjudicating claims under the VEA/MRCA frameworks specified in s 5.

2. Clinical definition. "Vascular neurocognitive disorder" is defined in s 7(2) by reference to DSM‑5‑TR‑derived clinical diagnostic criteria. The criteria require: evidence of major or mild neurocognitive disorder (Criterion A); features consistent with a vascular aetiology , either temporally related onset to documented cerebrovascular events or a pattern of decline prominent in complex attention and frontal‑executive function (Criterion B); evidence of cerebrovascular disease by history, examination and/or neuroimaging sufficient to account for the deficits (Criterion C); a non‑exhaustive list of included subtypes (Binswanger, multi‑infarct dementia, post‑stroke dementia, strategic infarct dementia, subcortical ischaemic vascular dementia, vascular MND/MILD due to vascular disease including atherosclerosis, and vascular mild cognitive impairment without dementia) (Criterion D); and explicit exclusions listing delirium, other mental disorders and a range of non‑vascular neurological/systemic conditions (Criterion E). The Schedule clarifies the DSM‑5‑TR definitions that feed into these criteria (Schedule 1: "major neurocognitive disorder", "mild neurocognitive disorder", "DSM‑5‑TR").

3. Enumerated qualifying factors. Section 9 lists 27 discrete factors. The list is structured to cover two situations: things that can precede the clinical onset (s 9(1)-(13)) and things that can precede clinical worsening or otherwise materially contribute/aggravate an existing disorder (s 9(14)-(27)). The factors comprise documented cerebrovascular events (including subarachnoid haemorrhage), specified cerebral vessel diseases combined with neuroimaging evidence of white matter lesions/haemorrhage/infarction, long‑standing hypertension (≥5 years), arrhythmias such as atrial fibrillation/flutter and sick sinus syndrome at the time of onset/worsening, carotid artery disease/ischaemic heart disease/heart failure, cardiac surgery within 12 months, diabetes of ≥5 years' duration, quantified tobacco exposure (≥20 pack‑years with initiation ≥5 years before onset and cessation not more than 20 years prior), prolonged physical inactivity against a 3 METs threshold, depressive disorder of ≥5 years' duration, chronic kidney disease per Schedule thresholds, ambient PM2.5 exposure exceeding 25 μg/m3 for at least 2,000 hours within 5 years, moderate to severe traumatic brain injury at least 5 years before onset/worsening, and inability to obtain appropriate clinical management (see s 9 and Schedule 1 definitions for pack‑years, MET, chronic kidney disease, PM2.5 threshold and others).

4. Relationship to service. Section 10 prescribes two constraints. First, any factor relied upon must be related to the person's "relevant service" as defined in the Schedule (s 10(1); Schedule 1). Second, the later group of factors (s 9(14)-(27)) are restricted to material contribution or aggravation where the disorder was suffered/contracted before or during but did not arise out of the person's relevant service (s 10(2)). Put simply, the SoP distinguishes between establishing causation for a disease that began outside service and establishing aggravation or material contribution during service, and it requires a service relationship in either case.

Other key conceptual features: the instrument expressly displaces reliance on ICD‑10‑AM codes for the definition , although it notes the disorder attracts ICD‑10‑AM code F01, the legal meaning for the RMA is the DSM‑derived definition in s 7(2) (s 7(3)-(4)). The Schedule also sets precise numeric thresholds for exposures and disease severity (for example one pack‑year definition, PM2.5 annual average >25 μg/m3, CKD definitions), converting clinical and environmental concepts into measurable legal criteria.

Primary affected persons

• Veteran and current/former members of the Australian Defence Force who lodge claims under the VEA or MRCA frameworks specified in s 5. The instrument applies to claims to which section 120B of the VEA or section 339 of the MRCA applies (s 5). The Schedule defines "relevant service" as eligible war service (other than operational service) under the VEA, defence service (other than hazardous service and British nuclear test defence service) under the VEA, and peacetime service under the MRCA (Schedule 1: "relevant service"). Thus, the SoP’s scope is explicitly tied to the statutory definitions that determine which kinds of service are “relevant” for entitlements.

Decision‑makers and administrators

• The Repatriation Medical Authority uses this SoP to inform medical assessments used in adjudicating claims under the VEA and MRCA (s 3, s 8). The instrument itself does not name administrative agencies for payments, but by operation of the VEA/MRCA regime the SoP will be used by claims assessors and medical panels when deciding whether a disease is connected with service. The instrument therefore affects DVA decision processes and medical practitioners who provide evidence for claims (for example by producing neuroimaging reports, documenting chronic diseases, or providing smoking history and activity limitations). The instrument also implicitly affects clinicians engaged by claimants to prepare medico‑legal reports that address the SoP criteria.

Indirectly affected groups

• Family members and dependants of claimants. The SoP extends to "death from vascular neurocognitive disorder" where the disorder contributed to a terminal event (s 7(5) and Schedule 1 definition of "terminal event"), so it can affect survivor entitlements and death‑benefit claims to the extent those exist under VEA/MRCA constructs.
• Medical experts and forensic evaluators. The SoP prescribes clinical thresholds and evidence types claimants and decision‑makers will rely on (for example DSM‑5‑TR diagnoses, neuroimaging showing white matter lesions, PM2.5 exposure quantification, pack‑year calculations, MET‑based assessments). Those preparing reports must address these definitional thresholds.
• Regulatory and environmental agencies only to the extent environmental exposure evidence is needed. The PM2.5 threshold (annual average >25 μg/m3 and specified exposure hours) requires environmental exposure data which may come from public monitoring networks or specialist exposure assessments; this creates dependencies on external data sources.

Who does not gain or change rights under this instrument

• The instrument does not itself create new categories of benefit or prescribe payments; it is diagnostic/evidentiary. It does not directly alter the statutory entitlements found in the VEA or MRCA; rather it sets the RMA's principles to be applied when determining service connection for claims that invoke those statutes (ss 3, 5, 8). If a claimant cannot establish at least one qualifying factor related to relevant service as set out in s 9, the SoP provides no basis for a finding of service connection under this particular medical principle.

Practical exposure of affected persons

• Claimants must document clinical timing (onset vs worsening), measurable durations (for example ≥5 years for hypertension, diabetes, depressive disorder), quantified exposures (pack‑years, PM2.5 hours), and objective clinical findings (neuroimaging showing white matter lesions/haemorrhage/infarction). The Schedule provides precise operational definitions (for example one pack‑year calculation, CKD criteria, MET). Those who cannot produce this evidence may face difficulty satisfying the SoP criteria.

This SoP creates medical‑evidentiary duties and rights within the VEA/MRCA claims process rather than statutory duties with criminal sanctions. The instrument prescribes what the RMA will regard as satisfactory medical evidence for a finding of service connection for vascular neurocognitive disorder and death from it. Key duties and rights, as derived from the instrument, are:

Claimant duties (evidentiary)

• Establish at least one factor in s 9 as existing in the person's history and that it is related to the person's relevant service (s 9; s 10(1)). The claimant must therefore adduce medical records, diagnostic imaging, documented clinical events (for example cerebrovascular accidents), and other evidence sufficient to show the factor existed in the timeframe required (for example hypertension at least 5 years before onset).
• Where the claimant relies on a factor that is an injury or disease covered by another SoP, they must comply with the terms of that other SoP because s 11 mandates that those other SoP factors "apply in accordance with the terms of that Statement of Principles as in force from time to time." Practically, this means the claimant may need to establish matters set out in multiple SoPs.
• For factors requiring measured exposures or durations (pack‑years, PM2.5 hours, MET thresholds, CKD criteria), the claimant must provide evidence that the Schedule’s numerical thresholds are met. The SoP defines these thresholds (Schedule 1), so evidence must be tailored to those definitions.

Decision‑maker rights and duties

• The RMA, and by extension the decision‑makers applying the SoP to claims, have the duty to apply the SoP's medical criteria when determining whether, on the balance of probabilities, vascular neurocognitive disorder is connected with relevant service (s 8). The SoP expresses the RMA's medical view on probability and factual factors to consider.
• Decision‑makers may rely on other SoPs when overlapping injuries or diseases are implicated, per s 11. The SoP gives decision‑makers an explicit cross‑reference mechanism to incorporate the terms of other SoPs.

Burden and standard of proof

• The SoP adopts "balance of probabilities" standard as its operative threshold (title and s 8). It states the RMA is of the view that, on that standard, the disease "can be related" to relevant service given the sound medical‑scientific evidence available. The instrument does not change the statutory legal standard of the tribunal or court adjudicating entitlement under the VEA/MRCA, but it sets the medical presumption RMA will apply in adjudicative processes.

Temporal duties

• The instrument distinguishes onset versus clinical worsening; for many factors there is a requirement that the risk factor preceded the clinical onset (s 9(1)-(13)) or preceded clinical worsening (s 9(14)-(27)). For factors applicable to worsening, s 10(2) limits their application to disorders that were suffered or contracted before or during (but did not arise out of) relevant service, applying only to material contribution or aggravation.

Rights to rely on definitions and thresholds

• Claimants and decision‑makers can and should rely on the instrument’s explicit definitions (Schedule 1) when framing evidence. For example, "one pack‑year" is defined and must be used in calculating smoking exposure; "chronic kidney disease" is defined by clear clinical tests or transplant history; "ambient, chronically polluted air as specified" is defined by PM2.5 annual averages exceeding 25 μg/m3 and a 2,000‑hour exposure threshold within five years. Using these definitions provides a clear evidentiary roadmap for both claimants and assessors.

Limitations of the instrument

• The SoP does not impose statutory sanctions, fines, or criminal penalties. It does not itself award benefits; it informs determination of service connection under the VEA/MRCA regime. It does not remove the need for claimants to establish the service relationship required by the VEA/MRCA frameworks; s 10(1) expressly requires the factor be related to relevant service.

The instrument contains no penalty provisions and does not itself create enforcement mechanisms. Its legal role is evidentiary and determinative within the VEA/MRCA decision framework rather than punitive. The control mechanisms embedded in the instrument are administrative and evidentiary:

• Determination function. The SoP provides the RMA’s medical criteria for deciding whether, on the balance of probabilities, vascular neurocognitive disorder or death from it is connected with relevant service (s 8). That determination is used in claims adjudication processes under the VEA and MRCA (s 5). The administrative outcomes of such determinations (for example grant or denial of entitlements) will follow the procedures and remedies provided in the VEA/MRCA statutory frameworks; the SoP does not itself set or modify those remedies.
• Repeal and replacement mechanism. The instrument repeals a prior RMA SoP (No. 79 of 2014) and thus acts as the operative statement of medical principles for vascular neurocognitive disorder from its commencement date (s 4; ss 1-2). This type of instrument is enforced by being the standard applied in subsequent claim decisions.
• Evidentiary enforcement. The SoP sets mandatory criteria for what the RMA regards as sufficient medical evidence (s 7-9, Schedule 1). The "enforcement" effect is that claimants who cannot meet these criteria by the evidence available risk an adverse determination; conversely, compliant evidence aligning with the SoP supports a finding of service connection. The SoP therefore enforces standards via administrative decision‑making rather than criminal sanctions.

Practical enforcement pathways (implicit, not detailed in instrument)

• Administrative review and merits review processes that exist under the VEA and MRCA regimes will apply to decisions that use this SoP; however, the instrument itself does not specify appeal routes, judicial review, or any penalty for non‑compliance by parties. Remedies and enforcement of benefits or decisions flow from the parent statutes (VEA/MRCA) rather than from the SoP text.
• Reliance on external data. Some factors require environmental or clinical data (PM2.5 levels, neuroimaging showing white matter disease/infarction/haemorrhage, GFR measures for CKD). Enforcement in practice will depend on admissibility and availability of this evidence. The SoP defines the evidentiary expectations; absence of such evidence will undermine claims.

Limitations as an enforcement instrument

• The SoP is not self‑executing in the sense of imposing sanctions; it is an evidentiary standard. It does not impose investigatory powers, compulsory evidence production mechanisms, or penalties for failing to supply evidence. The administrative machinery applying the SoP must operate under the VEA/MRCA processes and the associated review and appeal regimes, which are beyond the SoP's text.

The instrument is embedded into a broader statutory and clinical classification ecosystem. Explicit cross‑references and dependencies indicate how the SoP will interact with other legal instruments and non‑statutory standards:

1. Relationship with the VEA and MRCA. The SoP is made under subsection 196B(3) of the VEA (s 3) and expressly applies to claims to which section 120B of the VEA or section 339 of the MRCA applies (s 5). It therefore operates as a medical principle supplementing the statutory frameworks that govern entitlement and compensation. The SoP does not itself amend or displace the statutory rules concerning benefits, review rights, or procedural rules in the VEA/MRCA; it provides the medical criteria the RMA will apply when considering causation or contribution issues in claims under those statutes.

2. Interaction with other Statements of Principles. Section 11 provides that if a factor in s 9 refers to an injury or disease covered by another SoP, then the terms of that other SoP apply as in force from time to time. This creates a system of inter‑SoP reliance: a single claim may require application of multiple SoPs, and the operative terms for injuries listed in other SoPs are those other instruments' current provisions. Practically, this requires claimants and decision‑makers to consult multiple SoPs to determine qualifying factors, thresholds, and timing.

3. Use of international clinical classifications and external publications. The instrument references DSM‑5‑TR for the diagnostic framework (s 7(2); Schedule 1 defines DSM‑5‑TR). It also notes that while vascular neurocognitive disorder attracts ICD‑10‑AM code F01, the legal meaning for the SoP is the DSM‑derived clinical definition in s 7(2) (s 7(3)). The SoP explicitly cites the ICD‑10‑AM Tenth Edition (effective 1 July 2017) as the source of the code but disclaims substituting code definitions for the s 7(2) definition (s 7(3)-(4)). These references mean adjudicators and experts will need to reconcile clinical diagnostic categories across DSM and ICD frameworks when preparing or assessing evidence.

4. Dependence on clinical and public health measurement systems. Several Schedule definitions depend on clinical or environmental measurement systems external to the RMA: chronic kidney disease defined by GFR or albuminuria (Schedule 1), ambient PM2.5 threshold defined by an annual average >25 μg/m3 and a 2,000‑hour exposure threshold over five years (Schedule 1), pack‑year calculations based on cigarettes per day and years smoked (Schedule 1), and METs for physical exertion (Schedule 1: 1 MET quantified). These measures require that clinical laboratories, imaging services, environmental monitoring networks, or occupational/environmental exposure assessors provide admissible data. The SoP therefore interacts functionally with environmental laws, public health monitoring, clinical laboratory standards, and imaging practice standards insofar as it requires those outputs as admissible evidence.

5. Potential overlaps with medico‑legal rules of evidence. The SoP sets standards for medical factors that must be established (s 9). Admissibility of expert evidence, hearsay issues, or evidentiary weight will continue to be governed by the procedural and evidentiary rules applicable to decision makers and review bodies under VEA/MRCA and administrative law. The SoP does not displace those evidentiary procedures; it informs the content of expert opinion and documentary evidence to be assessed under those procedures.

6. No express interaction with criminal law or other civil statutes. The instrument neither creates nor modifies criminal offences, nor does it purport to alter civil liabilities outside the VEA/MRCA decision frameworks. Its effect is limited to the administrative adjudication of service connection under VEA/MRCA claims.

The instrument provides a succinct internal amendment history limited to its own creation and immediate predecessor:

• New instrument: Statement of Principles concerning vascular neurocognitive disorder (Balance of Probabilities) (No. 10 of 2023), dated 27 February 2023, commenced 27 March 2023 (ss 1-2).
• Repeal of prior SoP: The Statement of Principles concerning vascular dementia No. 79 of 2014 (Federal Register of Legislation No. F2014L01141) made under subsection 196B(3) of the VEA is expressly repealed by s 4 of this instrument.

No further amendment entries are contained within the instrument. There is no schedule of prior amendments to this instrument because it is the replacement instrument. The SoP’s text also incorporates external documents which may change independently (for example, DSM‑5‑TR updates or new ICD revisions), but such external updates do not automatically amend this instrument; the SoP refers specifically to DSM‑5‑TR and to ICD‑10‑AM Tenth Edition (effective 1 July 2017) for the ICD code reference (s 7(3)-(4), Schedule 1). Section 11 contemplates that the terms of other SoPs "as in force from time to time" will apply where relevant factors cross‑refer to other SoPs, meaning the operative content of cross‑referenced SoPs can change independently.

For practitioners tracking changes, the concrete amendment trail from the instrument itself is:

• 2014: Prior SoP (No. 79 of 2014) in force (now repealed).
• 2023: Repatriation Medical Authority issues replacement SoP (No. 10 of 2023), dated 27 Feb 2023, commencing 27 Mar 2023; prior SoP repealed (s 4).

Absent any additional documentation linked in this instrument (such as a legislative instrument register entry beyond the repeal notation or a published explanatory memorandum), there is no further amendment record within the text to disclose. Users requiring the full administrative history should consult the Federal Register of Legislation and the RMA's records for any subsequent modification, revocation, or replacement after the commencement date.

The instrument contains no litigation history. It is a determinative administrative medical instrument and the text does not record any court or tribunal decisions that have interpreted or challenged it. It does not cite any cases. The RMA’s determination is a medical statement which will be applied in statutory claim decision‑making, and any litigation or merits review arising from decisions that apply this SoP would be recorded in the decisions or in public court or tribunal records, but such records are not part of this instrument's text.

For practitioners: because the instrument itself does not list litigation, users must search administrative law judgments, Veterans' Review Board decisions, or federal court cases to identify whether or how courts or tribunals have interpreted this SoP in practice. The SoP will interact with claims decided under the VEA and MRCA, and any judicial or tribunal commentary on the application of RMA SoPs generally, or on issues arising from specific elements of this SoP (for example timing of neuroimaging, PM2.5 exposure evidence, or the application of s 10(2) to aggravation claims), would be found in those external decisions rather than in the instrument.

The instrument sets clear thresholds but also contains several application points that create potential evidentiary or interpretive pitfalls for claimants, medical experts, and decision‑makers. These "gotchas" are drawn from the text and definitions in the SoP and Schedule.

1. Timing mismatch regarding neuroimaging. Section 9(2) and 9(15) require "having a specified disease of the cerebral vessels, in the presence of neuroimaging (magnetic resonance imaging or computed tomography) findings of cerebral white matter lesions, haemorrhage or infarction, before the clinical onset [or before clinical worsening] of vascular neurocognitive disorder." The Schedule, however, defines "neuroimaging (magnetic resonance imaging or computed tomography) findings" as "an image of an interior of a body obtained by medical techniques, that is usually obtained at a date after the clinical onset of the disease." Practically, this creates an evidentiary tension: the SoP asks for neuroimaging findings present before onset, while acknowledging that neuroimaging is usually obtained after clinical onset. This tension may result in contested interpretations as to what evidence suffices to satisfy the "before onset" requirement, and could require expert opinion on whether imaging findings represent pre‑existing pathology even if the scan occurred after onset.

2. The service relationship requirement. Section 10(1) requires that any factor in s 9 "must be related to the relevant service rendered by the person." Claimants must therefore show not merely the existence of a factor (for example history of hypertension) but also that that history is related to their relevant service as defined in Schedule 1. The Schedule’s definition of "relevant service" excludes certain categories (for example hazardous service under the VEA) which can be a determinative issue in eligibility.

3. Distinction between disease onset and aggravation. Section 10(2) narrows the application of s 9(14)-(27) to material contribution or aggravation only where the disorder was "suffered or contracted before or during (but did not arise out of) the person's relevant service." This means that for disorders that "arose out of" service, some later factors will not be available to support a separate aggravation finding. Understanding whether a disorder "arose out of" service or was only "suffered or contracted" before/during service is likely to be a focal dispute.

4. Quantified exposure thresholds create specific evidentiary hurdles. Several factors set numerical thresholds:

• Smoking: at least 20 pack‑years, commencing at least 5 years before onset, with a cessation window of 20 years if stopped (s 9(8), (21); Schedule 1 defines pack‑year). Claimants must produce reliable smoking histories and compute pack‑years per the Schedule's method.
• Physical inactivity: inability to undertake >3 METs for at least 5 years within the previous 20 years (s 9(9), (22); Schedule defines MET). Clinicians and occupational assessors must translate functional history into MET metrics, which may require retrospective clinical judgment.
• PM2.5 exposure: ambient PM2.5 annual average >25 μg/m3 and at least 2,000 hours within the 5 years before onset/worsening (s 9(12), (25); Schedule defines threshold). Quantifying an individual's hours exposed to ambient PM2.5 at specific concentrations can be complex and dependent on environmental monitoring data and assumptions about individual location and activity.
• Chronic kidney disease: defined by GFR <60 for at least 3 months, albuminuria ≥3 mg/mmol for ≥3 months, biopsy/imaging/urinary sediment abnormalities, or kidney transplant (Schedule 1). Claimants must have longitudinal renal function records.

The requirement for these precise pieces of evidence will impose data collection and expert reporting burdens.

5. "Inability to obtain appropriate clinical management" is undefined. Factor s 9(27) lists "inability to obtain appropriate clinical management for vascular neurocognitive disorder" but the Schedule provides no definition of "appropriate clinical management" or standards for proving inability to obtain it. This creates interpretive uncertainty and potential for dispute on causation or aggravation when care access issues are alleged.

6. Differential diagnosis and exclusions. The DSM‑derived criteria in s 7(2)(E) list numerous exclusions (delirium; other mental disorders; inherited white matter disease; mitochondrial disorders; neurodegenerative disease such as Alzheimer disease, Parkinson’s disease, Huntington’s chorea; brain tumour; subdural haematoma; effects of substance; systemic disorders such as hypothyroidism, B12 deficiency, niacin deficiency, hypercalcaemia, neurosyphilis, HIV). Claimants must therefore provide evidence that the cognitive deficits are not "primarily due to" these listed causes. This increases the requirement for comprehensive clinical assessment and appropriate laboratory or imaging work‑ups to exclude these alternative causes.

7. ICD code reference is explicitly subordinated. Section 7(3) notes vascular neurocognitive disorder attracts ICD‑10‑AM code F01 but the legal meaning for the SoP is the DSM‑derived definition in s 7(2). Practitioners relying solely on ICD coding in clinical records risk misaligning with the SoP's diagnostic standard.

8. Death cases require linking terminal events to the disorder. Section 7(5) extends the disorder to "death from a terminal event or condition that was contributed to by the person's vascular neurocognitive disorder," and the Schedule defines "terminal event" broadly (pneumonia, respiratory failure, cardiac arrest, circulatory failure, cessation of brain function). In practice, medical record linkage and cause‑of‑death evidence will be required to show the disorder contributed materially to the terminal event.

9. Cross‑SoP interaction may multiply evidentiary requirements. Section 11 imports other SoPs' terms when a factor refers to another injury/disease. This may require claimants to satisfy multiple SoP thresholds across different instruments, compounding complexity.

10. Neuroimaging content requirements. The SoP requires imaging demonstrating "cerebral white matter lesions, haemorrhage or infarction" in the presence of a specified disease of cerebral vessels. Because imaging is often interpreted with variable descriptive language, precise radiological reporting is needed. Ambiguous radiology reports may be insufficient to satisfy the SoP unless clarified by expert opinion.

Taken together, these points identify where claim preparation and medical evidence strategy must be tightly aligned to the SoP’s defined thresholds and timing rules; otherwise, claimants risk failing to meet the RMA’s articulated criteria.

Compliance here means assembling and presenting the medical and factual evidence that aligns with the SoP’s definitions and thresholds so that a decision maker applying the RMA’s principles can find, on the balance of probabilities, that vascular neurocognitive disorder or death from it is connected with relevant service. Practical steps based on the instrument’s text:

1. Establish the DSM‑5‑TR‑derived diagnosis required by s 7(2). Prepare clinical documentation that directly addresses the SoP’s diagnostic criteria:

• Criterion A: Document evidence of major or mild neurocognitive disorder per DSM‑5‑TR definitions. Use standardised neuropsychological testing or qualified clinical assessments to show either “substantial impairment” (major) or “modest impairment” (mild), and link testing to the cognitive domains listed (complex attention, executive function, learning and memory, language, perceptual‑motor, social cognition). See Schedule 1 definitions for "major neurocognitive disorder" and "mild neurocognitive disorder".
• Criterion B: Provide evidence of a vascular pattern (either documented cerebrovascular events temporally related to onset, or a neurocognitive profile with prominence in complex attention and frontal‑executive function).
• Criterion C: Provide history, physical examination findings, and neuroimaging evidence sufficient to account for deficits; ensure reports address the explanatory link between vascular pathology and cognitive deficits.
• Criterion E: Rule out listed alternative causes. Obtain relevant tests,endocrine (thyroid), B12/folate, infectious (syphilis, HIV as clinically indicated), imaging to exclude tumour or subdural haematoma, substance histories,so records demonstrate deficits are not primarily due to excluded conditions.

2. For the s 9 qualifying factors, gather objective evidence aligned with the exact thresholds:

• Cerebrovascular events (s 9(1), (14)): Provide hospital records, CT/MRI images, discharge summaries, stroke unit notes with dates showing events occurred before clinical onset/worsening.
• Specified disease of cerebral vessels with neuroimaging findings (s 9(2), (15)): Obtain neuroimaging demonstrating white matter lesions, haemorrhage or infarction together with documentation of the specified disease (Schedule 1 lists antiphospholipid syndrome, cerebral amyloid angiopathy, cerebral arteriolosclerosis, etc.). Where imaging occurred after onset, engage a neuroradiologist or neurologist to opine whether findings are consistent with pre‑existing pathology sufficient to satisfy the "before" requirement; note the tension between the timing requirement and the Schedule’s note that imaging is "usually obtained" after onset.
• Hypertension and diabetes (s 9(3), (7), (16), (20)): Provide serial primary care or specialist records to show diagnosis dates and sustained durations (≥5 years before onset/worsening).
• Cardiac conditions and surgery (s 9(4)-(6), (17)-(19)): Produce cardiology records for arrhythmias (diagnosis/timing), echocardiograms, angiography, and operative records for cardiac surgery (with dates showing occurrence within 12 months where required).
• Smoking history (s 9(8), (21)): Calculate pack‑years per the Schedule’s method and provide corroborating records (medical notes, occupational health records, statements) to show initiation dates and cessation dates if relevant. Use the Schedule’s example calculation and the equivalence measures for tobacco types.
• Physical activity limitation (s 9(9), (22)): Obtain clinical assessments or functional capacity evaluations that document inability to undertake activities >3 METs for the specified duration. Where available, use occupational therapy reports, exercise tests, or clinician statements mapping activities to MET values (Schedule defines MET).
• Depressive disorder (s 9(10), (23)): Provide psychiatric or general practice records showing diagnosis and duration of at least 5 years prior to onset/worsening.
• Chronic kidney disease (s 9(11), (24)): Supply lab data demonstrating GFR <60 ml/min/1.73 m2 for ≥3 months, albuminuria ≥3 mg/mmol for ≥3 months, kidney imaging or biopsy results, urinary sediment findings, or transplant records as per Schedule definition.
• PM2.5 exposure (s 9(12), (25)): Assemble environmental exposure evidence showing average annual PM2.5 concentrations >25 μg/m3 in relevant locations and estimate the person’s exposure hours (≥2,000 hours within the five years before onset/worsening). Use public environmental monitoring data, employment or residential histories, and, if necessary, occupational hygienist assessments.
• Traumatic brain injury (s 9(13), (26)): Provide hospital/ED records, neuroimaging, and classification of TBI severity (moderate to severe) with dates at least five years prior to onset/worsening.
• Inability to obtain appropriate clinical management (s 9(27)): Because "appropriate clinical management" is not defined in the Schedule, document attempts to access care (referrals, wait times, specialist availability), reasoned clinical opinions linking lack of care to disease progression, and contemporaneous records that show barriers to treatment.

3. Demonstrate the relationship to relevant service (s 10(1)). For each factor relied upon, present a cogent factual link between the factor’s occurrence and the person's defined relevant service (Schedule 1). This may include service medical records, deployment records, military health records that show onset or exposures during service, and administrative evidence confirming the characterisation of the person's service as "relevant service" under the Schedule’s categories.

4. Address aggravation rules (s 10(2)). If relying on s 9(14)-(27) for material contribution or aggravation, ensure the primary disease predated or was contracted before/during service but did not arise out of it. Document the pre‑service or in‑service chronology carefully to avoid misapplication of the aggravation factor.

5. Engage experts who will structure opinions around the SoP. Medical experts should be asked to:

• Apply the DSM‑5‑TR criteria as set in s 7(2) and Schedule 1 definitions;
• Explicitly opine whether the claimant meets at least one of the s 9 factors with reference to the Schedule's definitions and numerical thresholds;
• Discuss timing (onset/worsening) and whether factors are related to relevant service;
• Where imaging occurred after onset, explain whether imaging demonstrates pathology that pre‑dates clinical onset or is sufficient to account for deficits nonetheless, addressing the "neuroimaging usually after onset" Schedule note.

6. Collate supporting non‑medical records. Employment, residential, and service location histories to substantiate PM2.5 exposure; smoking histories corroborated by records or third‑party statements for pack‑year calculations; cardiology and surgical records; renal function longitudinal data; and psychiatric histories to support depressive disorder duration.

7. Reconcile overlapping SoPs. If a s 9 factor refers to an injury/disease covered by another SoP, obtain and satisfy the requirements of that SoP as well (s 11). This may require meeting multiple SoP thresholds and providing a consistent package of medical and expert evidence.

8. Anticipate evidentiary objections. Because the SoP defines precise thresholds, expect adjudicators to challenge vague or incomplete documentation. Avoid unsupported lay assertions of durations or exposures; wherever possible, secure contemporaneous medical records, imaging, or expert reconstructions.

9. Prepare for death claims. For claims alleging death from a terminal event contributed to by vascular neurocognitive disorder (s 7(5)), obtain cause of death documentation, hospital records around the terminal event, autopsy reports if available, and medical opinions tying the disorder to the fatal sequence (for example aspiration pneumonia resulting from cognitive decline).

10. Procedural diligence. Ensure that timeframes, dates, and causal chains are clearly documented and that experts’ reports state opinions on causation "on the balance of probabilities" in terms that align with the RMA's expressed standard (s 8).

In short, compliance requires translating the SoP’s medical thresholds into a structured evidence package showing diagnosis, the existence of at least one qualifying factor per s 9 with Schedule‑level detail, and a clear factual link between that factor and the person's relevant service as defined in the Schedule.