Introduction

Vascular dementia (VD) is the second most common form of dementia after Alzheimer disease. It is not a single disease but a group of syndromes of cognitive impairment caused by different mechanisms causing ischaemia or haemorrhage secondary to cerebrovascular disease. Vascular dementia has been increasingly recognised as the most severe form of the spectrum of deficits encompassed by the term vascular cognitive impairment (VCI). Early detection and an accurate diagnosis are important in the prevention of vascular dementia.

Classification

The main subtypes of VD:
  • Stroke-related VD – multi-infarct or single-infarct dementia
  • Subcortical VD – caused by small vessel disease
  • Mixed dementia – the presence of both VD and Alzheimer’s disease

Epidemiology

  • Incidence: 70.00 cases per 100,000 person-years
  • Peak incidence: 70+ years
  • Sex ratio: 1:1
Condition Relative
incidence
Vascular dementia1
Frontotemporal lobar degeneration0.04
<1 1-5 6+ 16+ 30+ 40+ 50+ 60+ 70+ 80+

Aetiology

Risk factors
  • History of stroke or transient ischaemic attack (TIA)
  • Atrial fibrillation
  • Hypertension
  • Diabetes mellitus
  • Hyperlipidaemia
  • Smoking
  • Obesity
  • Coronary heart disease
  • A family history of stroke or cardiovascular

Rarely, VD can be inherited as in the case of CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.

Clinical features

Patients with VD typically presents with
  • Several months or several years of a history of a sudden or stepwise deterioration of cognitive function.

Symptoms and the speed of progression vary but may include:
  • Focal neurological abnormalities e.g. visual disturbance, sensory or motor symptoms
  • The difficulty with attention and concentration
  • Seizures
  • Memory disturbance
  • Gait disturbance
  • Speech disturbance
  • Emotional disturbance

Diagnosis

Diagnosis is made based on:
  • A comprehensive history and physical examination
  • Formal screen for cognitive impairment
  • Medical review to exclude medication cause of cognitive decline
  • MRI scan – may show infarcts and extensive white matter changes

National Institute for health and care excellence (NICE) recommends that diagnosis be made using the NINDS-AIREN criteria for probable vascular dementia
Presence of cognitive decline that interferes with activities of daily living, not due to secondary effects of the cerebrovascular event
  • established using clinical examination and neuropsychological testing
Cerebrovascular disease
  • defined by neurological signs and/or brain imaging
A relationship between the above two disorders inferred by:
  • the onset of dementia within three months following a recognised stroke
  • an abrupt deterioration in cognitive functions
  • fluctuating, stepwise progression of cognitive deficits

Management

General management
  • Treatment is mainly symptomatic with the aim to address individual problems and provide support to the patient and carers
  • Important to detect and address cardiovascular risk factors – for slowing down the progression

Non-pharmacological management
  • Tailored to the individual
  • Include: cognitive stimulation programmes, multisensory stimulation, music and art therapy, animal-assisted therapy
  • Managing challenging behaviours e.g. address pain, avoid overcrowding, clear communication

Pharmacological management
  • There is no specific pharmacological treatment approved for cognitive symptoms
  • Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid Alzheimer’s disease, Parkinson’s disease dementia or dementia with Lewy bodies.
  • There is no evidence that aspirin is effective in treating patients with a diagnosis of vascular dementia.
  • No randomized trials found evaluating statins for vascular dementia