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

• Weakness

  We present a case report of a 50-year-old man with migraines associated with left-sided weakness since age 34 years, a stroke at age 43 years, followed by progressive dementia. [ncbi.nlm.nih.gov]

  Symptoms can include problems with memory and concentration, confusion, changes in personality and behavior, loss of speech and language skills, and sometimes physical symptoms such as weakness or tremors. [urmc.rochester.edu]

  They will likely advise you to call if symptoms become worse (such as obvious changes in behavior, personality, memory, or speech) or if new symptoms appear, such as sudden weakness or confusion. [hopkinsmedicine.org]

  While overt strokes have recognizable symptoms such as weakness and speech difficulties, covert strokes are subtler and can occur silently without any visible symptoms. [alzheimer.ca]

• Crying

  Symptoms include confusion or problems with short-term memory; wandering, or getting lost in familiar places; walking with rapid, shuffling steps; losing bladder or bowel control; laughing or crying inappropriately; having difficulty following instructions [ninds.nih.gov]

  Symptoms include confusion, problems with recent memory, wandering or getting lost in familiar places, loss of bladder or bowel control ( incontinence ), emotional problems such as laughing or crying inappropriately, difficulty following instructions, [medicinenet.com]

  They may include: Problems with short-term memory Wandering or getting lost in familiar surroundings Laughing or crying at inappropriate times Trouble concentrating, planning, or following through on activities Problem managing money Inability to follow [putnamridge.com]

  Those with the disease may also display inappropriate emotions to a situation: they may break into laughter or suddenly start crying without being provoked. [livestrong.com]

• Fatigue

  Causes of memory problems other than dementia include: Malnutrition Dehydration Fatigue Depression Adverse reaction to medication Thyroid disease Metabolic disorder Head injuries Benign brain tumors Viral or bacterial infections Parkinson’s disease What [web.archive.org]

  There is often a marked feeling of mental fatigue when mental tasks are attempted, and new learning is found to be subjectively difficult even when objectively successful. [apps.who.int]

  I’ve had to learn how to control it and try not to let myself get upset and frustrated At first, she put her symptoms down to stress, age and fatigue. “My tiredness was through the roof and I couldn’t concentrate on anything at all,” she says. [bhf.org.uk]

  Medical conditions that may present symptoms similar to depression (fatigue, irritability, insomnia, decreased appetite, anxiety) caused by vascular disease should first be ruled out. [caregiver.org]

• Dysphagia

  Pill Properties that Cause Dysphagia and Treatment Failure. Current therapeutic research, clinical and experimental. 2015;77:79–82. Epub 2015/11/07. pmid:26543509 View Article PubMed/NCBI Google Scholar 53. [journals.plos.org]

• Hypertension

  Although persistent poorly controlled hypertension is known to damage the brain both acutely and chronically, the effects of intermittent hypertension remain to be defined. [ncbi.nlm.nih.gov]

  Hypertension, diabetes mellitus, and smoking have been associated with vascular disease but also with AD. [web.archive.org]

  It is primarily seen in patients with atherosclerosis and chronic hypertension and results from the accumulation of multiple white matter lesions or cortical infarcts, although cerebral hemorrhages can be variably included 4. [radiopaedia.org]

• Hypotension

  Among 133 consecutive patients with the clinical diagnosis of vascular dementia there were 6 patients (4.5%) in whom dementia was judged to be associated with cerebral hypoperfusion due to cardiac arrhythmias and systemic hypotension. [ncbi.nlm.nih.gov]

  Results from death of neurones as a result in disruption of blood flow Blood flow disruption can result from haemorrhage, clot, and watershed infarcts due to hypotensive episodes Diseased blood vessels greatly pre-disposes to vascular dementia T2DM HTN [oxfordmedicaleducation.com]

  This may result from heart failures, hypotension, or carotid artery occlusion. There is no cure for vascular dementia but prevention by controlling vascular risk factors, such as high blood pressures, can be effective. [youtube.com]

  Other causes of vascular dementia include vasculitis, an inflammation of the blood vessel system; profound hypotension (low blood pressure); and lesions caused by brain hemorrhage. [stanfordhealthcare.org]

  […] disease (e.g., aspirin, dipyridamole, clopidragril, carotid endarterectomy), cardiac embolic events (e.g. anticoagulation, spirin), small-vessel disease (e.g. antiplatelet therapy as in large vessel disease), and hemodynamic mechanisms (e.g. control of hypotension [encyclopedia.com]

• Thrombosis

  If blood vessels in the brain burst (cerebral haemorrhage), if arteries blocked by plaque formation or clots (thrombosis or embolism), or if there is insufficient blood flow to parts of the brain (ischaemia) brain tissue will die. [zarcrom.com]

  This may be explained in part by the fact that many different vascular pathologies may lead to cognitive impairment, including cerebral thrombosis, cardiac embolism, and hemorrhage. [web.archive.org]

  In contrast, the subcortical regions include small vessel thrombosis and embolism leading to brain parenchyma or chronic ongoing atherosclerosis. [frontiersin.org]

  At the point when a vein is block, the term utilized is cerebral Sino venous thrombosis (CSVT). In the 3rd shape, hemorrhagic neurology (HS), the vein crack as opposed to being blocked. [coalesceresearchgroup.com]

  Brain tissue supplied by stiff and thickened arterioles may be at increased risk of ischaemia and damaged arteriolar walls may be more likely to precipitate secondary thrombosis [ 14 ]. [clinsci.org]

• Psychomotor Retardation

  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]

  retardation and abnormal executive function. [strokecenter.org]

  Features of pseudobulbar palsy Emotional problems - eg, emotional lability, psychomotor retardation or depression. For objective evidence, carry out a test of cognitive functioning (see under 'Diagnosis', below). [patient.info]

  Depression, psychomotor retardation and abulia are believed to be more characteristic of patients with VaD than AD, even when matched for dementia severity. [doi.org]

• Behavior Disorder

  Haloperidol has been used with acceptable side effects in the management of behavior disorders of dementia. [aafp.org]

  The prevalence of cerebrovascular diseases, hemiplegia, depression, delirium, behavioral disorders due to alcohol, schizophrenia, and psychotic disorders were >3-times higher in the cases than in controls. [journals.plos.org]

  disorder Decline in personal hygiene and grooming Mental rigidity and inflexibility Distractibility and impersistence Hyperorality and dietary changes Perseverative and stereotyped behavior Utilization behavior Speech and language Altered speech output [indianjpsychiatry.org]

• Abnormal Behavior

  Possible symptoms of vascular dementia include: Memory problems; forgetfulness Slurred speech Language problems Abnormal behavior Dizziness Leg or arm weakness Lack of concentration Wandering or getting lost in familiar surroundings Moving with rapid, [web.archive.org]

• Stroke

  Report of the WHO Task Force on Stroke and other Cerebrovascular Disorders. Stroke 1989;20:1407–1431. [oadoi.org]

  (eMedicine.com) Living With Stroke—Memory and Problem Solving – Tips on how to improve attention span and problem solving abilities following a stroke, along with how to distinguish between types of memory deficits. [web.archive.org]

• Mild Cognitive Impairment

  KEYWORDS: dementia; mild cognitive impairment; stroke; vascular dementia [ncbi.nlm.nih.gov]

  Just as mild cognitive disorder often precedes full blown Alzheimer’s dementia, there is a vascular mild cognitive impairment that precedes vascular dementia. [brightfocus.org]

• Memory Impairment

  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]

  Moreover, contrary to the early memory impairment that characterizes AD, the memory deficit in pure LBD usually appears later in the disease course. [doi.org]

  impaired in episodic memory, and more severely impaired on tests of attentional/executive function, semantic memory, and visuospatial skills. [jnnp.bmj.com]

  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]

• Cognitive Disorder

  The cognitive disorders observed in CKD patients are probably explained by the common susceptibility of brain tissue to vascular injury. [jasn.asnjournals.org]

  Sachdev P (1999) Vascular cognitive disorder. Int J Geriatr Psychiatry 14:402–403 CrossRef PubMed Google Scholar 7. O’Brien JT, Erkinjuntti T, Reisberg B et al (2003) Vascular cognitive impairment. [oadoi.org]

  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]

• 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]

  […] 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]

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.

There are no pharmacological agents with a regulatory approval for its treatment or prevention. [ncbi.nlm.nih.gov]

Multi-Infarct Dementia Information Page (2009) This Web page provides an overview of multi-infarct dementia, including its symptoms, treatment, prognosis, and related research. [web.archive.org]

Prognosis The prognosis for individuals with MID is generally poor. The symptoms of the disorder may begin suddenly, often in a step-wise pattern after each small stroke. [ninds.nih.gov]

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]

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]

[…] and multiple body system manifestations due to the underlying etiology. [icd10data.com]

SIDAM: a structured interview for the diagnosis of dementia of the Alzheimer type, multi-infarct dementia and dementias of other etiology according to ICD-10 and DSM III-R. Psychol Med. 1991 ; 21 :225-236. [dx.doi.org]

Author information 1 Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands. [email protected] 2 Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands. [email protected] 3 Department of Neurology, [ncbi.nlm.nih.gov]

Clinical presentations and epidemiology of vascular dementia. Clin Sci. 2017;131(11):1059-1068. doi:10.1042/CS20160607 Saito S, Yamamoto Y, Ihara M. Development of a Multicomponent Intervention to Prevent Alzheimer's Disease. [verywellhealth.com]

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]

It describes the difficulty of making a firm diagnosis and the importance of stroke prevention. [web.archive.org]

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]

Because lipid-lowering agents are key in preventing cardiovascular disease, they are of interest for prevention of VaD. [uspharmacist.com]

The best treatment for MID is prevention early in life – eating a healthy diet, exercising, not smoking, moderately using alcohol, and maintaining a healthy weight. [ninds.nih.gov]

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8. American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders (5th ed.). Washington, DC. American Psychiatric Association; 2013.
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