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

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