vascular dementia
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Etiology
- ischemic stroke(s)
- multi-infarct dementia
- strategic infarcts
- small vessel disorders
- embolic stroke
- hemorrhagic stroke(s)
- cerebral amyloid angiopathy
- primary CNS angiitis
- hypertension
- coronary artery disease before age 45 years[16]
- also see risk factors & protective factors
Epidemiology
- 10-20% of patients with dementia (USA); 50% in Japan
- prevalence 1.2-4.2% of individuals > 65 years of age[6]
- most patients also have Alzheimer's disease (AD)[1]
- more common in men
- may disproportionately affect African-Americans[6]
- pure vascular cognitive impairment is not rare[15]
Pathology
- multi-infarct dementia
- anterior, middle &/or posterior cerebral artery territory
- cortical vessels & subcortical arterioles
- macroinfarcts frontal lobe white matter are the main neuropathologies associated with cognitive decline in pure vascular cognitive impairment[15]
- angular gyrus syndrome
- posterior branch of middle cerebral artery
- severity of dementia in patients who also have AD correlates with neurofibrillary tangle pathology rather than vascular pathology[1]
Clinical manifestations
- sudden onset of cognitive decline
- patchy deficits, stepwise deterioration
- focal neurologic deficits may be present
- early change may include gait disorder with frequent falls
- affective & psychotic manifestations are common
- delusions
- apathy
- disinhibition
- personality or mood changes may be early manifestation
- emotional incontinence (abrupt crying, laughter)
- mental slowing
- impairment in processing speed & executive dysfunction, processes generally associated with white matter tracts & subcortical gray matter[8]
- impaired organizational skills
- motor disturbances or gait instability
- magnetic gait described in 80 year old
- frontal-subcortical pattern predominates[6]
- strokes in the non-dominant hemisphere
- visual-spatial function may be compromised
- patient may get lost or wander
- poor insight & safety awareness
- pseudobulbar palsy & emotional incontinence in later stages
- urinary incontinence &/or fecal incontinence
- frequent co-morbid conditions
- see Hachinski ischemic scale
- also see diagnostic criteria for vascular dementia
Radiology
- ischemic changes on brain imaging
Complications
- neuropsychiatric symptoms are associated with institutionalization, mortality & cognitive deterioration*[14]
* associations depend on severity of dementia
Differential diagnosis
Management
manage cardiovascular risk factors & reduce risk of stroke
- blood pressure control
- aspirin or other antiplatelet agent for ischemic stroke(s)
- control of hyperlipidemia
- cholinesterase inhibitors
- SSRI for depression
- Ginkgo biloba is possibly useful[4]
- nurse-led intervention to decrease cardiovascular risk factors did not diminish incidence of dementia vs standard care[11]
More general terms
More specific terms
Additional terms
- diagnostic criteria for vascular dementia
- lacunar infarct
- leukoaraiosis
- risk factors & protective factors for vascular dementia
- stroke; cerebrovascular accident (CVA)
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Role of cholinergic therapy in treatment of Alzheimer's disease & other dementias, Farlow, M et al, 2001
- ↑ Miller B, UCSF Memory & Aging Center, 2001
- ↑ 4.0 4.1 4.2 Prescriber's Letter 9(3):17 2002
- ↑ McPherson SE & Cummings JL, Vascular Dementia, Clinical Assessment, Neuropsychologic Features, and Treatment. in: Handbook of Neuropsychology & Aging, Plenum Press, New York, 1997
- ↑ 6.0 6.1 6.2 6.3 Kristi Wagner Steh, West Los Angeles VA, GRECC, Dec 2003
Cummings JL, The Neuropsychiatry of Alzheimer's Disease and Related Dementias, Martine Dunitz LTD, Taylor & Francis Group, London (2003)
Mendez MF & Cummings JL, Dementia: A Clinical Approach, Butterworth & Heinemann, Philadelphia (2003) - ↑ van Oijen M et al, Atherosclerosis and risk for dementia. Ann Neurol 2007, 61:403 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17328068
- ↑ 8.0 8.1 Rawlings AM et al. Diabetes in midlife and cognitive change over 20 years: A cohort study. Ann Intern Med 2014 Dec 2; 161:785 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25437406 <Internet> http://annals.org/article.aspx?articleid=1983393
- ↑ 9.0 9.1 Purandare N et al. Association of cerebral emboli with accelerated cognitive deterioration in Alzheimer's disease and vascular dementia. Am J Psychiatry 2012 Mar 1; 169:300. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22193532
Doraiswamy PM. Silent cerebrovascular events and Alzheimer's disease: An overlooked opportunity for prevention? Am J Psychiatry 2012 Mar 1; 169:251. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22407112 - ↑ Gorelick PB, Scuteri A, Black SE et al Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association. Stroke. 2011 Sep;42(9):2672-713 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21778438
- ↑ 11.0 11.1 Moll van Charante EP, Richard E, Eurelings LS et al. Effectiveness of a 6-year multidomain vascular care intervention to prevent dementia (preDIVA): A cluster- randomised controlled trial. Lancet 2016 Jul 26; PMID: https://www.ncbi.nlm.nih.gov/pubmed/27474376
- ↑ 12.0 12.1 Friberg L, Rosenqvist M. Less dementia with oral anticoagulation in atrial fibrillation. European Heart Journal. Oct 24, 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29077849 https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehx579
Styles S Cutting Dementia Risk in Atrial Fibrillation: Does Rhythm Control Strategy Matter? Medscape. April 29, 2022 https://www.medscape.com/viewarticle/972967 - ↑ Ritter A, Pillai JA. Treatment of Vascular Cognitive Impairment. Curr Treat Options Neurol. 2015 Aug;17(8):367. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26094078
- ↑ 14.0 14.1 Sep YCP, Leeuwis AE, Exalto AE et al NEUROPSYCHIATRIC SYMPTOMS AS PREDICTOR OF POOR CLINICAL OUTCOME IN PATIENTS WITH VASCULAR COGNITIVE IMPAIRMENT. Am J Geriatr Psychiatry. 2022 Jan 2:S1064-7481(21)00577-7.. PMID: https://www.ncbi.nlm.nih.gov/pubmed/3508208 https://www.sciencedirect.com/science/article/pii/S1064748121005777
- ↑ 15.0 15.1 15.2 Oveisgharan S et al. Frequency and underlying pathology of pure vascular cognitive impairment. JAMA Neurol 2022 Oct 24; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36279115 https://jamanetwork.com/journals/jamaneurology/fullarticle/2797275
- ↑ 16.0 16.1 George J Coronary Heart Disease by Age 45 Linked With Subsequent Dementia. All-cause dementia, Alzheimer's disease, and vascular dementia risks elevated. MedPage Today November 29, 2023 https://www.medpagetoday.com/neurology/dementia/107594
Lang J, Li C, Gao D et al Association Between Onset Age of Coronary Heart Disease and Incident Dementia: A Prospective Cohort Study. J Am Heart Assoc. 2023;0:e031407 PMID: https://www.ncbi.nlm.nih.gov/pubmed/38018492 https://www.ahajournals.org/doi/full/10.1161/JAHA.123.031407