Vascular dementia

Different entities under this term

  • Multi infarct dementia
  • Small vessel dementia (white matter disease)
  • CADASIL
  • Strategic infarct dementia (in basal ganglia)
  • Hypoperfusion dementia (watershed infarct)
  • Hemorrhagic dementia (associated with amyloid angiopathy)
  • Alzheimer with CV disease

RF

  • Smoking, elderly, stroke, vascular diseases
  • Presence of Alzheimer disease **
    – There are common vascular risk factors (DM, hypertension, IHD, dyslipidemia) between Alzheimer and vascular dementia

Clinical features

  • Inattention
  • Apraxia
  • Dementia
  • Much more variable and depend on the neural substrates affected by the underlying vascular pathology

Brain imaging

  • White mater lesion in >70 is probably due to vascular dementia
    – Predictive of cognitive and functional impairments over the next 3 years
  • Atrophy (generalized and hippocampal eg in Alziheimer) is strongly associated with the extent of vascular pathology.


Small multiple white mater lesion in vascular dementia

Management

  • No standard drugs for therapy
  • Use of Alzheimer drugs (cholinesterase inhibitors i.e. rivastigmine, donepezil, galantamine & NMDA antagonist eg memantine) is due to evidence showing neuropathological and neurochemical overlaps between 2 diseases
    – But they do not show an improvement in global functions (compared to vast improvement in Alzheimer) so guidelines do not support routine use of these drugs in vascular dementia.
  • Drugs for underlying risk factors
    – Antihypertensive drugs, antiplatelets, statins, OADs
    – Note that these drugs DO NOT treat vascular dementia (no trials have shown to have cognitive improvement, and most trials that studied antihypertensives in cardiovascular & cerebrovascular outcomes did not study cognition improvement as the primary endpoint)

Reference:

  • John T O’Brien, Alan Thomas. Vascular Dementia. Lancet 2015;386:1698-706
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