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.
Vascular dementia (VaD) is the second most common cause of dementia and its prevalence increases after the sixth decade of life  . 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 . 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  . 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 . 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  . 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 . 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:
- 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]
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.medscape.com]
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]
[…] neurologic deficits often develop: Exaggeration of deep tendon reflexes Extensor plantar response Gait abnormalities Weakness of an extremity Hemiplegias Pseudobulbar palsy with pathologic laughing and crying Other signs of extrapyramidal dysfunction Aphasias [merckmanuals.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]
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]
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]
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]
Caring for people with dementia is stressful and demanding, and caregivers may become depressed and exhausted, often neglecting their own mental and physical health. [msdmanuals.com]
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]
[…] 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]
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]
‘Severe amnesia’ was previously an exclusion criteria for bvFTD; however, 10% of pathologically confirmed cases have reported memory symptoms at the time of the initial clinical evaluation, with some showing severe amnesia. [doi.org]
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 . Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria provide the guidelines to help in the diagnosis of VaD .
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 . 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.
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