1st February 2024

Vascular Dementia

It is the second most common type of dementia. It is a progressive neurodegenerative cognitive decline that constitutes approximately around 20% of all cases of dementia.

It occurs mainly due to reduced blood supply to the brain. This hypoperfusion could be due to damaged or diseased blood vessels, TIA, or mini TIA’s. This hypoperfusion deprives the oxygen and nutrients supply to the brain and can affect cognition and day-to-day living.

Background

Epidemiology

• Unlike Alzheimer’s dementia, the incidence of vascular dementia is higher in males.
• It is common in people more than 65 years of age.
• It constitutes 20% of dementias

Risk factors

• Age- As age increases, risk increases. People above 65 are at higher risk
• Sex- More in males compared to females
• Ethnicity- South Asian and African-Caribbean
• Physical health problems- Cardiovascular risk factors, Arterial disease, Hypertension, Stroke, Diabetes Mellitus, Hyperlipidaemia, Obesity
• Smoking, excess alcohol intake
• Social isolation
• Physical inactivity
• Head injury

Types of Vascular Dementia

1. Mild Vascular cognitive impairment
2. Multi-infarct dementia- the commonest form. It is caused by a series of small strokes or TIAs. It is a cortical type of vascular dementia. The white matter of the cerebral hemisphere and the deep grey nuclei, including the striatum and thalamus, are affected more, causing cognitive decline. It mainly affects the area associated with memory, learning and language skills. Though it can be temporary, multiple episodes can lead to permanent damage.
3. Vascular dementia due to a strategic single infarct
4. Vascular dementia due to lacunar lesions- small cavities or lacunas are formed in the brain parenchyma due to occluding vessels.
5. Vascular dementia due to haemorrhagic lesions
6. Binswanger disease- affects small blood vessels in the white matter
7. Subcortical Vascular dementia
8. Mixed dementia (Alzheimer’s dementia plus Vascular dementia)

Clinical features

1. A classic history of stepwise progression is suggestive of vascular dementia but is not always seen. The onset of illness and cognitive problems could be related to cerebrovascular disease.
2. General symptoms as seen in Alzheimer’s disease may be noted
3. Specific features include:
   • Mild to severe Depression
   • Weakness of limbs and movement difficulties
   • Bladder and bowel control can be lost
   • Speech and language difficulties
4. Behavioural problems:
   • Anger, agitation
   • Psychotic symptoms
   • Laughing, crying inappropriately
   • Problems following instructions, handling money
5. Mood and behavioural changes are more prominent in small vessel diseases like Binswanger’s, lacunar disease

Differential Diagnosis

• Other types of dementias
• Parkinson’s disease dementia
• Depression
• HIV-associated neurocognitive disorder
• Huntington’s disease dementia

Evaluation

• Very similar to Alzheimer’s dementia.
• Specific tests and investigations
  1. Physical health assessment
  2. Special tests- serology (VDRL, HIV) in specific situations
• Neuroimaging- CT, MRI 

Management

There is no specific treatment as such. These treatment options can reduce the progress of vascular dementia. A biopsychosocial approach is taken, like the management of other dementias. 

Bio

• Mainstay is managing medical illnesses such as high blood pressure, high cholesterol, diabetes Mellitus and heart conditions
• Anti-dementia medications are not as effective as in Alzheimer’s dementia
  • Anti-dementia medications can be considered only if there is associated Alzheimer’s dementia, Parkinson’s Disease dementia, Dementia with Lewy Bodies
  • Consider antipsychotics for behavioural and psychological symptoms of dementia, weighing the pros and cons of antipsychotics and physical health.

Psycho

• Apart from the ones mentioned in Alzheimer’s dementia, CBT for anxiety and depression.

Social

• Apart from the ones mentioned in Alzheimer’s dementia, patients should be educated on a healthy lifestyle: smoking cessation, reducing alcohol excess, increasing exercise and maintaining a healthy diet. 
• Physiotherapy and Occupational therapy input
• Speech and Language therapy
• Carer support, Respite care

Prognosis

Vascular dementia has a higher mortality rate compared to Alzheimer’s dementia. People with a diagnosis live for approximately 5 years following the diagnosis. This could be due to multiple physical health risk factors.

References

• Stewart, R. (2020). Vascular and mixed dementia. Oxford Textbook of Old Age Psychiatry, [online] pp.479–494. doi:https://doi.org/10.1093/med/9780198807292.003.0031.
• bestpractice.bmj.com. (n.d.). Vascular dementia – Symptoms, diagnosis and treatment | BMJ Best Practice. [online] Available at: https://bestpractice.bmj.com/topics/en-gb/319
• Wolters, F.J. and Ikram, M.A. (2019). Epidemiology of Vascular Dementia. Arteriosclerosis, Thrombosis, and Vascular Biology, 39(8), pp.1542–1549. doi:https://doi.org/10.1161/atvbaha.119.311908.
• Series, H. and Esiri, M. (2012). Vascular dementia: a pragmatic review. Advances in Psychiatric Treatment, 18(5), pp.372–380. doi:https://doi.org/10.1192/apt.bp.110.008888.
• Series, H. and Esiri, M. (2020). Vascular Dementia. [online] Cambridge University Press. Available at: https://www.cambridge.org/core/books/abs/clinical-topics-in-old-age-psychiatry/vascular-dementia/EA86DA225E0DDA48E03FCAA884EE685A [Accessed 21 Feb. 2023].