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Vascular Dementia

Basics

  • Cognitive impairment caused by cerebrovascular disease sequelae.
  • Affects memory, thinking, learning, language, behavior, judgment, and executive function.
  • Also called vascular cognitive impairment (VCI), vascular cognitive disorder (VCD), or Binswanger disease.
  • DSM-5 categorizes as mild or major vascular cognitive disorder.

Epidemiology

  • Common cause of dementia in elderly, often coexists with Alzheimer dementia.
  • Incidence: 6 to 12 per 1,000 persons aged >70 years.
  • Prevalence: 1.2-4.2% in people aged >65 years.
  • 14-32% prevalence of dementia post-stroke.

Etiology and Pathophysiology

  • No strict pathologic criteria like Alzheimer disease.
  • Large vessel disease: cognitive impairment following stroke.
  • Small vessel disease: white matter changes, subcortical infarcts, lacunar infarcts.
  • Risk factors: TIA/stroke, hypertension, peripheral vascular disease (PVD), atrial fibrillation, hyperlipidemia, diabetes.
  • Genetic: CADASIL (NOTCH3 gene mutation), ApoE4 allele, APP gene mutation causing cerebral hemorrhage with amyloidosis.

Risk Factors

  • Age (risk doubles every 5 years)
  • Prior stroke or TIA
  • Tobacco use
  • Diabetes (especially with frequent hypoglycemia)
  • Hypertension, atherosclerotic heart disease, atrial fibrillation, PVD
  • Hyperlipidemia
  • Metabolic syndrome
  • Low socioeconomic status

General Prevention

  • Aggressive treatment of vascular risk factors: HTN, diabetes, hyperlipidemia.
  • Smoking cessation.
  • Lifestyle modifications: weight loss, physical activity.
  • Correction of hearing loss.
  • Address depression and social isolation.
  • Cognitive stimulation activities.
  • Medications: aspirin, statins, antihypertensives for vascular risk reduction.

Commonly Associated Conditions

  • CADASIL
  • Cerebral amyloid angiopathy (CAA) causing ischemic white matter damage.

Diagnosis

History

  • Gradual, stepwise cognitive decline typical in multi-infarct dementia.
  • Assess cognitive domains affected, vascular risk factors, medication compliance.
  • Symptoms may include urinary incontinence and gait disturbances.
  • History of stroke, coronary artery disease, atrial fibrillation, hyperlipidemia, or PVD.

Physical Exam

  • Check for hypertension, carotid and abdominal bruits.
  • Cardiac exam for arrhythmias, especially atrial fibrillation.
  • Assess gait: initiation, speed, balance.
  • Look for focal neurologic deficits.

Differential Diagnosis

  • Alzheimer dementia
  • Depression
  • Delirium
  • CNS tumors
  • Thyroid dysfunction
  • Vitamin B12 deficiency

Diagnostic Tests

  • Cognitive tests: SLUMS exam, Montreal Cognitive Assessment (MoCA).
  • Neuropsychological testing for domain-specific deficits.
  • Labs: CBC, metabolic panel, lipid profile, TSH, HbA1c, vitamin B12.
  • MRI brain: gold standard imaging for white matter changes, infarcts.
  • Neuroimaging findings may not correlate perfectly with clinical deficits.

Treatment

Prevention

  • Control hypertension, diabetes, and hyperlipidemia.
  • Smoking cessation.
  • Healthy diet and exercise.

Medications

  • Limited evidence for cholinesterase inhibitors and memantine; may help in mixed dementias.
  • SSRIs for agitation and psychosis.

Additional Therapies

  • Limit alcohol intake.
  • Aspirin and antiplatelet agents to prevent recurrent stroke if no contraindications.

Surgery

  • Carotid endarterectomy for symptomatic carotid artery stenosis.
  • Preferred over stenting in patients >70 years if perioperative risk is low (<6%).

Complementary Medicine

  • Avoid Ginkgo biloba due to bleeding risk.

Inpatient/Nursing Considerations

  • Functional assessment and prevention of pressure ulcers post-stroke.
  • Minimize Foley catheter use.
  • Nonpharmacologic behavioral management preferred before medications.
  • Provide orientation cues and family involvement to prevent delirium.
  • Recognize and treat depression which can mimic dementia.

Ongoing Care

  • Regular visits for vascular risk factor optimization.
  • Early discussions on advance directives and caregiver support.

Follow-Up Recommendations

  • Monitor cognitive function and cardiovascular risk.
  • Encourage physical and mental exercises.

Diet

  • American Heart Association or DASH diet.
  • Low-fat, reduced simple carbohydrates especially for metabolic syndrome.

Patient Education

  • Importance of vascular risk modification (smoking cessation, diet, exercise).
  • Home monitoring of blood pressure and glucose if applicable.

Prognosis

  • Shortened life expectancy; worse prognosis after stroke.
  • Cognitive deficits post-stroke rarely improve.
  • Predictors of progression: age, premorbid cognition, depression, polypharmacy.

Complications

  • Behavioral problems: delusions, hallucinations.
  • Depression, falls, frequent hospitalizations.
  • Aspiration pneumonia.
  • Physical disability due to stroke.
  • Severe cognitive impairment.
  • Caregiver stress and burnout.

ICD10 Codes:
- F01.50 Vascular dementia without behavioral disturbance
- F01.51 Vascular dementia with behavioral disturbance

Clinical Pearls:

  • Early executive dysfunction and gait abnormalities distinguish vascular dementia from Alzheimer dementia.
  • Memory relatively preserved early in vascular dementia.
  • Stepwise progression is characteristic; obtain detailed history from caregiver.
  • Mixed Alzheimer and vascular dementia common in clinical practice.