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vascular dementia

Etiology: 1) ischemic stroke(s) a) multi-infarct dementia b) strategic infarcts 1] angular gyrus syndrome 2] caudate infarction 3] globus pallidus infarction 4] thalamic infarction c) small vessel disorders 1] small vessel ischemic disease (50%) - lacunar infarcts 2] leukoaraiosis 3] Binswanger's disease d) embolic stroke - high incidence of cerebral emboli (not from carotids) [9] - atrial fibrillation [12] 2) hemorrhagic stroke(s) 3) cerebral amyloid angiopathy 4) primary CNS angiitis 5) hypertension 6) coronary artery disease before age 45 years [16] 6) also see risk factors & protective factors Epidemiology: 1) 10-20% of patients with dementia (USA); 50% in Japan 2) prevalence 1.2-4.2% of individuals > 65 years of age [6] 3) most patients also have Alzheimer's disease (AD) [1] 4) more common in men 5) may disproportionately affect African-Americans [6] 6) pure vascular cognitive impairment is not rare [15] Pathology: 1) multi-infarct dementia a) anterior, middle &/or posterior cerebral artery territory b) cortical vessels & subcortical arterioles c) macroinfarcts frontal lobe white matter are the main neuropathologies associated with cognitive decline in pure vascular cognitive impairment [15] 2) angular gyrus syndrome - posterior branch of middle cerebral artery 3) severity of dementia in patients who also have AD correlates with neurofibrillary tangle pathology rather than vascular pathology [1] Clinical manifestations: 1) sudden onset of cognitive decline 2) patchy deficits, stepwise deterioration 3) focal neurologic deficits may be present - early change may include gait disorder with frequent falls 4) affective & psychotic manifestations are common a) delusions b) apathy c) disinhibition d) personality or mood changes may be early manifestation e) emotional incontinence (abrupt crying, laughter) 5) mental slowing - impairment in processing speed & executive dysfunction, - generally associated with lesions in white matter tracts & subcortical gray matter [8] - visual spatial skills impaired - attention deficit [17] 6) impaired organizational skills 7) motor disturbances or gait instability - slowing of motor performance [18] - magnetic gait described in 80 year old 8) frontal-subcortical pattern predominates [6] 9) strokes in the non-dominant hemisphere a) visual-spatial function may be compromised b) patient may get lost or wander c) poor insight & safety awareness 10) pseudobulbar palsy & emotional incontinence in later stages 11) urinary incontinence &/or fecal incontinence 12) frequent co-morbid conditions a) hypertension b) coronary artery disease 13) see Hachinski ischemic scale 14) also see diagnostic criteria for vascular dementia Radiology: - ischemic changes on brain imaging a) computed tomography (CT) b) magnetic resonance imaging (MRI), more sensitive 1] white matter hyperintensity (leukoaraiosis) - confluent periventricular & temporal lobe white matter hyperintensities 2] infarcts Complications: - neuropsychiatric symptoms are associated with institutionalization, mortality & cognitive deterioration* [14] * associations depend on severity of dementia Differential diagnosis: Alzheimer's disease Management: manage cardiovascular risk factors & reduce risk of stroke 1) blood pressure control 2) aspirin or other antiplatelet agent for ischemic stroke(s) 3) control of hyperlipidemia 4) cholinesterase inhibitors - not FDA-approved, but suggested to be useful [1,4] - endorsed by MKSAP19 [1] 5) SSRI for depression 6) Ginkgo biloba is possibly useful [4] 7) nurse-led intervention to decrease cardiovascular risk factors did not diminish incidence of dementia vs standard care [11]

Interactions

disease interactions

Related

diagnostic criteria for vascular dementia lacunar infarct leukoaraiosis risk factors & protective factors for vascular dementia stroke; cerebrovascular accident (CVA)

Specific

angular gyrus syndrome multi-infarct dementia

General

cerebrovascular disease/disorder dementia; Alzheimer's disease & related dementias (ADRD)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2009, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Role of cholinergic therapy in treatment of Alzheimer's disease & other dementias, Farlow, M et al, 2001
  3. Miller B, UCSF Memory & Aging Center, 2001
  4. Prescriber's Letter 9(3):17 2002
  5. McPherson SE & Cummings JL, Vascular Dementia, Clinical Assessment, Neuropsychologic Features, and Treatment. in: Handbook of Neuropsychology & Aging, Plenum Press, New York, 1997
  6. Kristi Wagner Steh, West Los Angeles VA, GRECC, Dec 2003 - Cummings JL, The Neuropsychiatry of Alzheimer's Disease and Related Dementias, Martine Dunitz LTD, Taylor & Francis Group, London (2003) - Mendez MF & Cummings JL, Dementia: A Clinical Approach, Butterworth & Heinemann, Philadelphia (2003)
  7. van Oijen M et al, Atherosclerosis and risk for dementia. Ann Neurol 2007, 61:403 PMID: 17328068
  8. Rawlings AM et al. Diabetes in midlife and cognitive change over 20 years: A cohort study. Ann Intern Med 2014 Dec 2; 161:785 PMID: 25437406 http://annals.org/article.aspx?articleid=1983393
  9. Purandare N et al. Association of cerebral emboli with accelerated cognitive deterioration in Alzheimer's disease and vascular dementia. Am J Psychiatry 2012 Mar 1; 169:300. PMID: 22193532 - Doraiswamy PM. Silent cerebrovascular events and Alzheimer's disease: An overlooked opportunity for prevention? Am J Psychiatry 2012 Mar 1; 169:251. PMID: 22407112
  10. Gorelick PB, Scuteri A, Black SE et al Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association. Stroke. 2011 Sep;42(9):2672-713 PMID: 21778438
  11. Moll van Charante EP, Richard E, Eurelings LS et al. Effectiveness of a 6-year multidomain vascular care intervention to prevent dementia (preDIVA): A cluster- randomised controlled trial. Lancet 2016 Jul 26; PMID: 27474376
  12. Friberg L, Rosenqvist M. Less dementia with oral anticoagulation in atrial fibrillation. European Heart Journal. Oct 24, 2017 PMID: 29077849 https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehx579 - Styles S Cutting Dementia Risk in Atrial Fibrillation: Does Rhythm Control Strategy Matter? Medscape. April 29, 2022 https://www.medscape.com/viewarticle/972967
  13. Ritter A, Pillai JA. Treatment of Vascular Cognitive Impairment. Curr Treat Options Neurol. 2015 Aug;17(8):367. PMID: 26094078
  14. Sep YCP, Leeuwis AE, Exalto AE et al NEUROPSYCHIATRIC SYMPTOMS AS PREDICTOR OF POOR CLINICAL OUTCOME IN PATIENTS WITH VASCULAR COGNITIVE IMPAIRMENT. Am J Geriatr Psychiatry. 2022 Jan 2:S1064-7481(21)00577-7.. PMID: 3508208 https://www.sciencedirect.com/science/article/pii/S1064748121005777
  15. Oveisgharan S et al. Frequency and underlying pathology of pure vascular cognitive impairment. JAMA Neurol 2022 Oct 24; [e-pub]. PMID: 36279115 https://jamanetwork.com/journals/jamaneurology/fullarticle/2797275
  16. George J Coronary Heart Disease by Age 45 Linked With Subsequent Dementia. All-cause dementia, Alzheimer's disease, and vascular dementia risks elevated. MedPage Today November 29, 2023 https://www.medpagetoday.com/neurology/dementia/107594 - Lang J, Li C, Gao D et al Association Between Onset Age of Coronary Heart Disease and Incident Dementia: A Prospective Cohort Study. J Am Heart Assoc. 2023;0:e031407 PMID: 38018492 https://www.ahajournals.org/doi/full/10.1161/JAHA.123.031407
  17. Iadecola C, Duering M, Hachinski V Vascular Cognitive Impairment and Dementia: JACC Scientific Expert Panel. J Am Coll Cardiol. 2019 Jul 2;73(25):3326-3344. PMID: 31248555 PMCID: PMC6719789 Free PMC article. Review
  18. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022