Vascular Dementia


Continuing Education Activity

Dementia is a syndrome of chronic progressive cognitive decline resulting in functional impairment. In the Diagnostic Manual of Mental Disorders, Fifth Edition (DSM-V), cognitive decline is quantified as deficits in one or more domains (e.g., memory, executive function, visuospatial, language, attention). Second only to Alzheimer disease, vascular dementia is one of the most common causes of dementia affecting the elderly (aged greater than 65 years), with a variable presentation and unpredictable disease progression. The diagnosis of vascular dementia is obtained by a thorough history and physical examination, including a measure of cognitive performance. Vascular dementia is diagnostically challenging and not precise given the many causes of dementia, including the potential for a mixed dementia syndrome. This activity reviews the cause and pathophysiology of vascular dementia and highlights the interprofessional team's role in its management.

Objectives:

  • Identify the etiology of vascular dementia.
  • Review the presentation of a patient with vascular dementia.
  • Outline the treatment and management options available for vascular dementia.
  • Discuss interprofessional team strategies for improving care coordination and communication to advance the treatment of vascular dementia and improve outcomes.

Introduction

Dementia is a syndrome of chronic progressive cognitive decline resulting in functional impairment.[1] In the Diagnostic Manual of Mental Disorders, Fifth Edition (DSM-V), cognitive decline is quantified as deficits in one or more domains (e.g., memory, executive function, visuospatial, language, attention). Second only to Alzheimer disease, vascular dementia is one of the most common causes of dementia affecting the elderly (aged greater than 65 years), with a variable presentation and unpredictable disease progression.[2][3][4] The diagnosis of vascular dementia is obtained by a thorough history and physical examination, including a measure of cognitive performance.[5] Vascular dementia is diagnostically challenging and not precise given the many causes of dementia, including the potential for a mixed dementia syndrome.[3]

Etiology

Vascular dementia is distinguished from other forms of dementia in that it results from brain ischemia, although the temporal relationship to the ischemic event may be subtle or go unnoticed. There are various subtypes and multiple terms to describe the vascular pathology and affected brain tissue, such as multi-infarct dementia, small vessel disease or Binswanger disease, strategic infarct dementia, hypoperfusion dementia, hemorrhagic dementia, hereditary vascular dementia, and Alzheimer disease with cardiovascular disease.[3][4]

Epidemiology

Approximately 15% to 17% of all dementia syndromes are vascular in etiology.[2][4] The incidence of vascular dementia increases with age, with the risk doubling approximately every five years.[4] Risk factors for the development of vascular dementia include hyperlipidemia, hypertension, diabetes mellitus, and tobacco use.[2][3]

Pathophysiology

Vascular dementia occurs as a result of cerebral tissue ischemia causing gliosis and demyelination. Ischemia may occur as a result of atherosclerosis, thrombosis, or vasculopathy.[2][3][4] There are several subtypes of vascular dementia, including the following:

  • Binswanger disease
  • Mild vascular cognitive impairment
  • Mixed dementia (a combination of Alzheimer disease and vascular dementia)
  • Multi-infarct dementia
  • Subcortical vascular dementia
  • Vascular dementia due to a localized single infarct
  • Vascular dementia due to lacunar lesions
  • Vascular dementia due to hemorrhagic lesions

History and Physical

A thorough history should be obtained from the patient, focusing on cognitive and functional deficits, onset, and symptomatic progression. Interviewing family members and caregivers is important as patients with cognitive decline rarely have insight into their cognitive and functional limitations. Caregivers may report an abrupt or stepwise onset of cognitive decline, or the appearance of symptoms may be subtle without connection to an ischemic event. The functional assessment should evaluate for impairments in instrumental activities of daily living (IADLs), such as cooking, driving, and financial and medication management, and basic activities of daily living (ADLs), such as dressing, bathing, and toileting. Additionally, the patient's past medical history, current medications, and surgical history should be obtained. Regarding physical examination, one should assess patients for focal neurologic deficits.[5]

Evaluation

If there is a suspicion of vascular dementia, then patients should undergo cognitive testing. A variety of cognitive performance tests enable the practitioner to assess for cognitive domain deficits. Rule-out secondary etiologies of cognitive decline, including depression, thyroid disorder, medications (e.g., benzodiazepines or anticholinergics), alcohol abuse, or infectious causes (e.g., neurosyphilis or human immunodeficiency virus-associated dementia). Recommended laboratory studies include complete blood count, complete metabolic panel, thyroid-stimulating hormone level, rapid plasma regain (RPR), and vitamin B12. For depression assessment, practitioners can utilize the Geriatric Depression Scale (validated in mild dementia) or PHQ-9. If warranted, practitioners should obtain imaging studies. For example, if the patient demonstrates focal neurologic deficits, then MRI without contrast would be the preferred imaging modality.[5]

Today vascular dementia also is diagnosed using the DSM 5 criteria,  the International Classification of Diseases, Tenth Edition criteria, the Alzheimer's Disease Diagnostic and Treatment criteria, the National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche at L'Enseignement en Neurosciences (NINDS-AIREN) criteria and the Hachinski ischemic score.

Treatment / Management

There are no present curative treatments for vascular dementia. Treatment of vascular dementia includes two approaches: (1) management of progression and behaviors and (2) prevention by modifying risk factors. Cholinesterase inhibitors have been shown to slow the progression of cognitive decline.[6] The side effect profile is significant, including gastrointestinal distress, symptomatic bradycardia, and agitation. Memantine, an NMDA antagonist, is FDA approved for moderate to severe dementia and has been shown to improve patient functional levels and lessen care dependency.[3] Whether to offer these medications takes a careful conversation with patients and caregivers, weighing the benefits and side effects individualized to their health condition and goals of care.

Medication management includes the elimination of medications that are unnecessary or have the potential to exacerbate symptoms (e.g., anticholinergics). Identification and optimization of comorbidities, such as hypertension, diabetes mellitus, and hyperlipidemia, will assist in lowering patient vascular risk factors but have not demonstrated an impact on cognitive function.[4] Additionally, providers should encourage smoking cessation in tobacco users, advise a decrease in alcohol use, and assess other potential geriatric syndromes such as falls, depression, and urinary incontinence.[5][7][8][9]

Prevention

Vascular dementia is preventable by modifying the risk factors like diabetes, hypertension, smoking, and hyperlipidemia. The one crucial risk factor that should be modified is hypertension. Countless studies show that the use of antihypertensive medications can reduce the risk of vascular dementia. The patient’s coronary artery disease, atrial fibrillation, and ischemic heart disease must be appropriately managed.[10][11]

In patients who show early impairment in cognition or have MRI or CT evidence of stroke or carotid artery disease, data show that secondary prevention with stroke preventive treatments like carotid endarterectomy, antiplatelet agents, warfarin, or physical exercise can slow down the progression of the disease.

Differential Diagnosis

  • Vascular dementia
  • Delirium
  • Alzheimer dementia

Prognosis

Mortality/Morbidity

Overall, patients with vascular dementia have a shortened life expectancy. Those who have already had a cerebrovascular accident have the highest mortality, with a 5-year survival of only 39%. Patients with vascular dementia also have coexisting atherosclerotic disease, and death from cardiovascular causes is common.

Complications

Besides death, other complications of vascular dementia include the following:

  • Abnormal behavior, such as delusion, paranoia, or hallucinations
  • Aspiration pneumonia
  • Depression
  • Falls
  • Gait difficulties
  • Pressure sores and ulcers
  • Repeated hospitalizations
  • Stress on caregivers

Deterrence and Patient Education

Diagnosis of vascular dementia allows physicians to provide patients and caregivers with valuable counseling regarding secondary prevention, safety, advance care planning, and caregiver burden. Secondary prevention discussions may focus on a healthy diet, exercise, cognitive stimulation, and socialization. As healthcare providers, our goal is to ensure safety while optimizing independence.

Enhancing Healthcare Team Outcomes

There are no present curative treatments for vascular dementia. Management of vascular dementia requires the efforts of an interprofessional healthcare team, consisting of clinicians (including NPs and PAs), specialists, nurses, and pharmacists, all coordinating their efforts and sharing information to achieve optimal patient outcomes. [Level 5]

Treatment of vascular dementia includes two approaches: (1) management of progression and behaviors and (2) prevention by modifying risk factors. Cholinesterase inhibitors have been shown to slow the progression of cognitive decline.[6] The side effect profile is significant, including gastrointestinal distress, symptomatic bradycardia, and agitation. Memantine, an NMDA antagonist, is FDA approved for moderate to severe dementia and has been shown to improve patient functional levels and lessen care dependency.[3] Whether to offer these medications takes a careful conversation with patients and caregivers, weighing the benefits and side effects individualized to their health condition and goal.

Issues of driving, medication management, financial management, and cooking are some issues that should be evaluated. Advanced-care planning should explore the patient’s values as they relate to interventions, quality of life, and longevity. Lastly, provide caregivers with support and education, which may consist of support groups or respite care to manage caregiver burden.


Article Details

Article Author

Omici Uwagbai

Article Editor:

Virginia Kalish

Updated:

1/26/2021 10:48:38 AM

PubMed Link:

Vascular Dementia

References

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