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Vascular Dementia

Vascular dementia is a condition arising secondarily to cerebrovascular disease. It is characterized by executive dysfunction and difficulty in performing activities of daily living. It must be differentiated from other causes of dementia, primarily Alzheimer's disease.


Presentation

Vascular dementia (VaD) is the second most common cause of dementia and its prevalence increases after the sixth decade of life [1] [2]. It is defined as a condition characterized by features of stroke or subclinical vascular brain injury which involves malfunction of at least two cognitive domains leading to a decrease in the ability to perform activities of daily living [3]. The cognitive features of VaD depend on the anatomical location of the vascular injury and this has led to the classification of VaD into different subtypes: small, large, or mixed vessel disease [4] [5]. Patients with small vessel disease present with a higher incidence of executive dysfunction whereas dysfunctional language and visuospatial perception are noticed more often in patients with large vessel VaD [6]. Clinical presentation of VaD in cortical injury includes speech abnormalities and neglect while a subcortical injury is associated with cognitive, emotional and behavioral difficulties, psychomotor retardation, pseudobulbar palsy, and gait dysfunction [1] [3]. Other features of VaD are restlessness, agitation, aggressive behavior, hallucinations, delusions, paranoia, circadian mood disturbances (sundowning), disorientation, and depression. As the brain injury is variable in VaD, memory disturbances may also be variable or may be completely absent [1]. The intellectual decline in VaD is classically described as "step-wise" (multi-infarct dementia) but can be continuous (lacunar infarcts) too.

Clinical presentation of VaD may resemble that of Alzheimer's disease (AD) although the following features help to differentiate between the two conditions:

  • major depression is more commonly seen in patients with VaD
  • apathy is seen in the early stages of VaD while it occurs in the late stages of AD
  • VaD patients have diminished language fluency compared to AD patients
  • Long-term memory deficits are more prevalent in AD patients
Memory Impairment
  • impairment and other deficits to meet operationalized criteria for dementia, and (3) the use of limited test batteries whose psychometric properties are incompletely understood.[ncbi.nlm.nih.gov]
  • We found that all patients had amnesia, especially in the AN group, six of the eight patients had scores of 1 on the CDR Memory scale, and all but one disclosed the CASI domain Recent memory impairment.[ncbi.nlm.nih.gov]
  • The development of multiple cognitive deficits manifested by both: Memory impairment (impaired ability to learn new information or to recall previously learned information) One or more of the following cognitive disturbances: (a) aphasia (language disturbance[strokecenter.org]
  • Symptoms of vascular dementia include the following: Memory impairment Impairment in at least 1 other cognitive domain (eg, orientation, language, praxis, executive functions, visuospatial abilities) Worsening of cognitive abnormalities Impact on activities[emedicine.com]
Aphasia
  • Transcortical sensory and motor aphasia was observed in four patients with thalamic hemorrhages and infarcts. In these patients SPECT detected hypoperfusion in adjacent cortical areas.[ncbi.nlm.nih.gov]
  • Exclusion criteria : cases with disturbance of consciousness, delirium, psychosis, severe aphasia, or major sensorimotor impairment precluding neuropsychological testing.[strokecenter.org]
  • The development of multiple cognitive deficits manifested by both: Memory impairment (impaired ability to learn new information or to recall previously learned information) One or more of the following cognitive disturbances: (a) aphasia (language disturbance[strokecenter.org]
  • MedlinePlus reports that language problems are common in this disease, and can result in difficulties with problem solving and word finding (also called aphasia).[livestrong.com]
  • Those symptoms include confusion; memory loss; struggles with word recall, or aphasia; difficulty paying attention, or following a conversation; impaired motor skills, and vision loss.[lcbseniorliving.com]
Apraxia
  • Visual constructive apraxia is very common in dementia and impairment in these abilities can provide clinical information for differential diagnosis.[ncbi.nlm.nih.gov]
  • […] of multiple cognitive deficits manifested by both: Memory impairment (impaired ability to learn new information or to recall previously learned information) One or more of the following cognitive disturbances: (a) aphasia (language disturbance) (b) apraxia[strokecenter.org]
  • […] dementia uncertain or unlikely include (a) early onset of of memory deficit and progressive worsening of memory deficit and progressive worsening of memory and other cognitive functions such as language (transcortical sensory aphasia), motor skills (apraxia[strokecenter.org]
  • In addition, the person must have one or more of the following symptoms: Aphasia - A deterioration of language abilities Apraxia - Difficulty executing motor activities Agnosia - An impaired ability to recognize or identify objects Problems with executive[mentalhelp.net]
  • Apraxia: It is an inability to carry out simple or complex movements. Attention Deficit: Moderate or severe distraction. Fluctuating course: The person with vascular dementia does not remain stable throughout.[blog.cognifit.com]
Amnesia
  • CASE REPORT We report a 51-year-old right-handed man with no medical history, who presented an acute onset vascular dementia associated with an antero-retrograde amnesia, a word-finding difficulty, and a dysexecutive syndrome.[ncbi.nlm.nih.gov]
  • We found that all patients had amnesia, especially in the AN group, six of the eight patients had scores of 1 on the CDR Memory scale, and all but one disclosed the CASI domain Recent memory impairment.[ncbi.nlm.nih.gov]
  • In 2012, he developed gait disturbance and mild amnesia. One year later, his gait disturbance worsened, and he developed urinary incontinence.[ncbi.nlm.nih.gov]
  • Her last neuropsychological testing revealed a stable pattern of amnesia. Figure 1. MRI showing bilateral thalamic infarctions.[web.archive.org]
Neglect
  • Clinical presentation of VaD in cortical injury includes speech abnormalities and neglect while a subcortical injury is associated with cognitive, emotional and behavioral difficulties, psychomotor retardation, pseudobulbar palsy, and gait dysfunction[symptoma.com]
  • Common dementia signs and symptoms include: Memory loss Impaired judgement Difficulties with abstract thinking Faulty reasoning Inappropriate behavior Loss of communication skills Disorientation to time and place Gait, motor, and balance problems Neglect[helpguide.org]
  • […] cardioembolism, vasculitis Chronic: atherosclerosis, CADASIL Hemorrhage Hypertension Vascular malformation: AVM, aneurysm Cerebral amyloid angiopathy: sporadic, hereditary Treatment of established symptoms (Tertiary amelioration) Cognitive: amnesia, aphasia, neglect[web.archive.org]
  • Common dementia signs and symptoms Memory loss Impaired judgement Difficulties with abstract thinking Faulty reasoning Inappropriate behavior Loss of communication skills Disorientation to time and place Gait, motor, and balance problems Neglect of personal[helpguide.org]

Workup

A physician should suspect VaD in a patient with cognitive dysfunction which follows a neurologic episode/deficit. The workup should commence with a detailed history eliciting onset and progression of cognitive and neuropsychiatric symptoms as well as a history of atherosclerotic conditions like angina pectoris. A detailed neurological and psychiatric assessment is essential. The Mini-Mental Status Exam (MMSE) is likely to reveal patchy cognitive deficits in VaD compared to global deficits in AD [7]. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria provide the guidelines to help in the diagnosis of VaD [8].

Laboratory tests are performed to exclude other etiologies of dementia. They include a complete blood count (CBC), erythrocyte sedimentation rate (ESR), blood glucose levels, thyroid, liver, and kidney function tests, vitamin B12 levels, and Venereal Disease Research Laboratory (VDRL) test for syphilis. In addition, other tests like human immunodeficiency virus (HIV) testing, and tests to rule out autoimmune diseases should be ordered.

Neuroimaging with computed tomography (CT) and magnetic resonance imaging (MRI) help to confirm the diagnosis with MRI being considered the gold standard. A vascular cause of dementia mainly can be excluded if CT and MRI do not demonstrate any cerebrovascular pathology. MRI findings in VaD include multiple white matter infarcts or lesions in the periventricular white matter, lacunar infarcts, and atrophy of the hippocampal or entorhinal cortical areas. Positron emission tomography (PET) helps in the identification of VaD and differentiates it from AD [9]. Cerebral angiography is only indicated prior to carotid endarterectomy and is likely to show beading of the cortical blood vessels. Other tests which may be performed include an electrocardiogram, echocardiography, Holter monitoring, and carotid Doppler studies.

Treatment

  • There are no pharmacological agents with a regulatory approval for its treatment or prevention.[ncbi.nlm.nih.gov]
  • The post-treatment levels for all measurements in the treatment group were better than the levels measured in the control group (P 0.05).[ncbi.nlm.nih.gov]
  • The median OQS based on the STRICTA guideline was 12 (minimum 8, maximum 14), with "extent to which treatment was varied (1c)," "number of needle insertions per subject per session (2a)," and "setting and context of treatment (4b)" having a positive rate[ncbi.nlm.nih.gov]
  • However, unlike Alzheimer's disease, there are no licensed treatments for vascular dementia.[ncbi.nlm.nih.gov]
  • The most effective, evidence-based treatments were donepezil and galantamine.[ncbi.nlm.nih.gov]

Prognosis

  • Similarly, no single prognosis can be given, being largely dependent on the underlying cause and the degree to which successful treatment can be initiated. Promoted articles (advertising)[radiopaedia.org]
  • Prognosis for People With Vascular Dementia If the conditions that cause vascular dementia go untreated, the prognosis is not good.[webmd.com]

Etiology

  • There are a variety of etiologies that contribute to the development of vascular cognitive impairment and VaD, and these are often associated with other dementia-related pathologies such as Alzheimer disease.[ncbi.nlm.nih.gov]
  • Multiple etiology dementia with both VCI and AD is the single most common cause of later life dementia.[ncbi.nlm.nih.gov]
  • PURPOSE: Dementia has several different etiologies, and vascular dementia (VaD) is considered the second leading cause of dementia after Alzheimer disease (AD).[ncbi.nlm.nih.gov]
  • Major diagnostic difficulties ensue from the very frequent cases with white matter lesions, since their etiology and classification remain widely unknown.[ncbi.nlm.nih.gov]
  • Vascular cognitive impairment comprises a heterogeneous group of cognitive disorders of various severity and types that share a presumed vascular etiology.[ncbi.nlm.nih.gov]

Epidemiology

  • Author information 1 Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands. m.a.ikram@erasmusmc.nl. 2 Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands. m.a.ikram@erasmusmc.nl. 3 Department of Neurology,[ncbi.nlm.nih.gov]
  • Epidemiologic evaluations based on complete autopsy studies need to be correlated with compliance of therapy, appropriate diagnosis of hypertension, and its long-term effects on the nervous system.[ncbi.nlm.nih.gov]
  • Our review supports the use of the HIS in epidemiological studies on dementia.[ncbi.nlm.nih.gov]
  • Fergus.doubal@ed.ac.uk. 2 VISTA and VICCTA Coordinator, Institutes of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK. 3 Reader in Epidemiology, Department of Epidemiology & Public Health, University College London, London, UK.[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • CONCLUSIONS: An imbalance in pro-oxidant and anti-oxidant defenses is apparently involved in the pathophysiology of the AD and MD groups.[ncbi.nlm.nih.gov]
  • We discuss the pathophysiology of these cases.[ncbi.nlm.nih.gov]
  • Electronic address: limeizhang1313@126.com. 9 Department of Pathophysiology, School of Basic Medical Sciences, Harbin Medical University, Heilongjiang, China.[ncbi.nlm.nih.gov]
  • Sometimes, they are difficult to distinguish due to overlaps in symptomatology, pathophysiology, and comorbidity.[ncbi.nlm.nih.gov]
  • The pathophysiology of ischemic stroke is complex and recent molecular, cellular, and animal models and postmortem brain studies have revealed that multiple cellular changes have been implicated, including oxidative stress/mitochondrial dysfunction, inflammatory[ncbi.nlm.nih.gov]

Prevention

  • Similarly, the effects of lipids and lipid-lowering therapy on preventing or treating dementia remain unclear; the few trials that have assessed lipid-lowering therapy for preventing (two trials) or treating (four trials) dementia found no evidence to[ncbi.nlm.nih.gov]
  • It describes the difficulty of making a firm diagnosis and the importance of stroke prevention.[web.archive.org]
  • Pharma Consultancy, Wien, Austria. 11 Centre for Dementia Prevention, University of Edinburgh, Edinburgh, UK. 12 ICHOM International Consortium for Health Outcomes Measurement, Hamilton House, Mabledon Place, London, WC1H 9BB, UK. 13 Marjorie MacBeath[ncbi.nlm.nih.gov]
  • How can I prevent vascular dementia? The best way to prevent vascular dementia is to lower the risk of stroke.[web.archive.org]
  • This update describes the subtypes of VaD, with details of their complex presentation, associated pathological lesions, and issues with diagnosis, prevention, and treatment. The Author(s) 2016.[ncbi.nlm.nih.gov]

References

Article

  1. Ramos AR, Dib SI, Wright CB. Vascular Dementia. Curr Transl Geriatr Exp Gerontol Rep. 2013;2(3): 188-195.
  2. Kalaria RN. Cerebrovascular disease and mechanisms of cognitive impairment: evidence from clinicopathological studies in humans. Stroke. 2012;43:2526–2534.
  3. 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;42:2672–2713.
  4. van Straaten ECW, Scheltens P, Knol DL, et al. Operational definitions for the NINDS-AIREN criteria for vascular dementia: an interobserver study. Stroke. 2003;34:1907–1912.
  5. Jellinger KA. Morphologic diagnosis of “vascular dementia” – a critical update. J Neurol Sci. 2008;270:1–12
  6. Ying H, Jianping C, Jianquing Y, et al. Cognitive variations among vascular dementia subtypes caused by small, large or mixed vessel disease. Arch Med Sci. 2016;12(4):747-753.
  7. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.
  8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders (5th ed.). Washington, DC. American Psychiatric Association; 2013.
  9. Nagata K, Maruya H, Yuya H, et al. Can PET data differentiate Alzheimer's disease from vascular dementia?. Ann N Y Acad Sci. 2000;903:252-261.

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Last updated: 2018-06-22 07:15