Vacular Dementia

Epidemiology

• A common cause of dementia (15% of cases).
• More common with age and males.
• Higher mortality than alzheimer’s (a diagnosis of dementia after a stroke is an independent predictor of mortality (usually around 5 years).

Subtypes and clinical features

• Vascular dementia usually has a classical ‘step-wise’ progression although there is a degree of gradual decline caused by small vessel disease.
  • Multi-infarct dementia (MID)– Multiple mini-strokes lead to the step-wise cognitive decline.  Between strokes there may be complete stability.  Cardiovascular risk factors/ disease are usually present.
  • Strategic infarct dementia– This is a single stroke event that has managed to cause cognitive decline either due to its location or size (often midbrain/lacunar strokes).  The cognitive impairment may partially or completely recover after the event.
  • Small Vessel disease (Binswanger disease)- Multiple microvascular infarcts of perforating vessels leads to preogressive lacunae and white matter leukoariosis on MRI.  (Subcortical dementia- gradual intellectual decline; generalised slowing and motor problems).
  • Hypoperfusion injury
  • Haemorrhagic
  • Other

Clinical Features/Diagnosis

• Onset may follow a CVA and is more acute than Alzheimers.  The Hatchinski score may help to support the diagnosis of vascular dementia:

• Emotional and personality changes may be early, followed by cognitive defects.
• Depression and affective lability and confusions are not uncommon, especially at night.
• Behavioural slowing is common too.
• Executive function will usually be lost at some stage (goal formation, initiation, planning etc).
• Memory impairment is less severe than in AD.
• Psychomotor problems are common.

Management

• Establish and treat any causative factors e.g. hypertension.  Aspirin might help if started early.
• Whilst anticholinesterase drugs e.g. donezapil/galantamine are unlicensed for vascular dementia, they may be beneficial