What is Vascular Dementia?
Vascular dementia is one of the main causes of a serious cognitive condition, mostly affecting older adults (over 65). It is the primary cause of dementia not related to the deterioration of the brain. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, groups all diseases causing dementia under the term major neurocognitive disorder, or MND for short. MND involves a noticeable decrease in cognitive skills including attention, memory, decision-making, language, or visual-spatial ability, resulting in a loss of self-sufficiency.
Risks related to heart health — like smoking, high blood pressure, high cholesterol, diabetes, and irregular heartbeat — often contribute to vascular dementia. Diagnosing this condition involves a detailed review of the patient’s medical history and physical/neurological evaluation, including testing mental cognition. Brain imaging can provide a more accurate diagnosis. As there are currently no approved medications that can halt or reverse vascular dementia, treatment mainly focuses on managing symptoms and providing support.
What Causes Vascular Dementia?
Vascular dementia is a type of brain disease that comes as a result of reduced blood flow (ischemia) or bleeding (hemorrhage) in the brain, not from other diseases that damage brain proteins. However, the link between the events that cause reduced blood flow or bleeding and loss in cognitive skills might be subtle and might sometimes go unnoticed. Here’s how we understand vascular dementia’s development: factors that increase the risk of blood vessel diseases lead to brain blood vessel diseases. These diseases then cause brain injury which disrupts the networks in the brain responsible for cognitive skills, resulting in vascular dementia.
Recent studies in the fields of brain pathology and cognitive psychology suggest that vascular dementia and Alzheimer’s disease often occur together, making pure cases of either disease quite rare. Indeed, problems with blood vessels in the brain can make Alzheimer’s disease worse, and changes caused by Alzheimer’s disease can also cause problems with blood vessels.
Risk Factors and Frequency for Vascular Dementia
In the past, it was believed that the risk of vascular dementia, a type of memory loss caused by damaged blood vessels in the brain, increased steadily as people got older. However, recent research suggests this may not be accurate. One study that followed over 1.4 million people for a period of time found that old age doesn’t necessarily make people more prone to vascular dementia.
- Vascular dementia is typically ranked as the second most common cause of dementia, after Alzheimer’s disease, in North America and Europe. It accounts for about 15 to 20% of clinically diagnosed cases of major neurocognitive disorder (MND)
- However, it might be even more prevalent in Asia and some developing countries.
- The exact numbers are hard to pin down because many people suffer from a mix of different types of dementia. Very often, vascular dementia occurs alongside Alzheimer’s disease.
- When we look at the results from studies examining brain tissue, less than 15% of cases are found to be caused entirely by vascular issues.
Signs and Symptoms of Vascular Dementia
When diagnosing vascular dementia, doctors need to conduct thorough medical and neurological exams, including an evaluation of mental status. It’s also important to gather as much information as possible about the patient’s history and current functioning. Sometimes, this information is obtained from the person directly responsible for their day-to-day care. However, just relying on this individual isn’t sufficient; the patient’s own perspective on their condition is also vital.
The doctor will need to review if the patient has any vascular risk factors, how serious they are, how long they’ve been present and how well they respond to medication or changes in lifestyle. They will carefully check the patient’s history for previous heart surgeries or procedures undertaken for peripheral vascular disease.
The doctor will also ask for specific details about the patient’s cognitive problems, especially any issues regarding the execution of tasks or maintaining attention. They’ll look for the link between changes in cognitive or functional abilities and any ischemic or hemorrhagic incidents. They will also ask for descriptions regarding the progression of the symptoms; slow progression could hint at subcortical vascular disease or possible Alzheimer disease/mixed pathology, while step-wise progression may indicate possible underlying lacunar or territorial infarctions.
The doctor will also tap into the patient’s social and family history. They will review past or current tobacco use, obesity, physical activity habits, social networks, and familial history of dementia, especially those thought to be linked with cerebrovascular disease. An assessment of medications the patient is currently taking is also essential, especially those that modify vascular risk factors.
Mood evaluation is necessary to check for anxiety or depression symptoms, as depression at mid-life can act as a risk factor for later-life dementia. The doctor will also assess the patient’s ability to carry out daily tasks, whether they’re basic or complicated instrumental tasks.
The physical examination will check for signs of cardiovascular disease. The doctor will take the pulse and blood pressure at every visit. They will look for signs of peripheral vascular disease, like colder skin temperature, frail/shiny skin on the legs and feet, and weak pulses in the legs and feet. An examination of the retina might reveal signs of hypertensive retinopathy.
The doctor will also perform a cardiopulmonary examination to check for irregular rhythmic activity that signifies atrial fibrillation, possible atherosclerosis, and fluids overload symptoms on pulmonary examination. The neurological examination aims to unearth signs of focal neurological deficit.
The Vascular Impairment of Cognition Classification Consensus Study identifies four main categories of vascular dementia, namely: Subcortical ischemic vascular dementia; Poststroke dementia; Multi-infarct dementia; and Mixed dementia.
The diagnosis also includes a formal cognitive assessment. Nowadays, professionals tend to prefer the Montreal Cognitive Assessment over the Mini-Mental State Examination since it assesses executive function better.
Testing for Vascular Dementia
For individuals with suspected vascular dementia, a series of measures are taken to determine a diagnosis. This usually involves a complete evaluation involving brain imaging, laboratory tests, and often cognitive ability tests.
A common first step is to run some basic lab tests, like a complete blood count and comprehensive metabolic panel. Unless your doctor has a specific reason to suspect certain conditions (based on your medical history), you usually won’t need to be tested for issues such as C-reactive protein, HIV, or antibodies related to syphilis. Additionally, your doctor may also suggest testing your levels of Vitamin B12 and homocysteine. Higher homocysteine levels, for instance, have been linked with a higher risk of developing vascular dementia.
Brain imaging, or neuroimaging, is crucial in making a detailed diagnosis. Magnetic Resonance Imaging (MRI) is typically the chosen method as it provides a detailed view of the brain in different ways – all of which help assess cognitive impairment. For most patients, a contrast dye isn’t needed unless there’s a risk of bleeding or infection.
An MRI can capture images in different ways – or sequences. The main ones used include:
1. T1-weighted sequence: This is to study the structure of the brain anatomy and areas of shrinkage or atrophy, which helps to determine the probability of mixed Alzheimer’s and vascular dementia.
2. FLAIR (fluid-attenuated inversion recovery) sequence: This sequence helps in identifying white matter changes typically due to reduced or blocked blood supply and small stroke areas. These changes can be measured using a tool called the Fazekas scale.
3. Several other sequences like Gradient echo (GRE) and susceptibility-weighted imaging (SWI) sequence are useful in detecting tiny brain bleeds. Diffusion-weighted imaging (DWI) is also important in identifying any recent stroke.
Neuropsychological testing is also very useful as it helps understand the extent of cognitive and behavioral changes, adding valuable context to other test results. These measures can also be used to distinguish between vascular dementia and Alzheimer’s disease, although in many cases, these assessments need to be done over a period of time to get an accurate diagnosis.
These tests are also crucial in identifying any behavioral or psychosocial effects related to dementia management. It’s important to remember that the specific symptoms and effects experienced can often vary greatly across different types of dementia – which is why a need for more specific and thorough research into these areas is felt.
At present, other types of brain imaging methods like PET scans aren’t routinely used in the clinical evaluation of vascular dementia – these tools are typically reserved for research settings. Similarly, the use of ‘biomarkers’ (specific chemical indicators in the blood or spinal fluid) for diagnosing vascular dementia lags behind their use for Alzheimer’s disease. However, as new treatments for Alzheimer’s disease emerge, these tools may become more accessible in a clinical setting.
Treatment Options for Vascular Dementia
Preventing and managing risk factors for vascular problems is the main strategy for dealing with vascular dementia. To this point, we don’t have a direct medication to cure vascular dementia, so treatment typically includes both medication- and lifestyle-based strategies.
In general, the main goal is to control risk factors that can be changed. To note, aspirin, a common medication that was previously suggested for initial prevention, is now only recommended for ongoing treatment. There’s also no clear winner among blood pressure medications for preventing dementia in older adults. Some studies suggest that water pills, or diuretics, might help, but the results are not consistent. And, we don’t have enough information on people younger than 65 to make informed decisions.
Recent studies have shown that maintaining low LDL-C levels (a type of cholesterol) can significantly slow down cognitive decline. Even though there have been concerns about memory problems linked to the use of cholesterol-lowering drugs known as statins, there’s no solid scientific evidence to support this concern. Therefore, statins are currently considered beneficial because they help lower cholesterol levels and protect the heart, especially in ongoing treatment plans.
Lifestyle changes are also being heavily investigated for their potential to prevent some types of dementia. These changes include healthy eating, regular physical activity and staying socially active. A study analyzing long-term data from Korean individuals found that regular exercise was connected to a lower chance of developing dementia, particularly after having a stroke. It’s also important to look out for potential issues in older adults like falls, malnutrition, abuse, and urinary incontinence, and to take steps to manage these effectively. Another critical point is addressing safety concerns, particularly if the patient lives alone, drives regularly, or has access to guns.
At this stage, no medication has received explicit approval from the FDA for vascular dementia treatment. However, drugs that increase the availability of a brain chemical called acetylcholine might be used. These drugs, known as cholinesterase inhibitors, often form the foundation of Alzheimer’s disease treatment and may also help improve blood flow in the brain. They could slow down cognitive decline in some patients with vascular dementia, but they come with potential side-effects including digestive upset, slow heart rate, sleep problems, and weight loss.
Another drug called memantine, which blocks a chemical receptor in the brain, may be used for off-label treatment of vascular dementia. Common side effects include dizziness and headaches.
There are newer drugs, like aducanumab, lecanemab, and potentially donanemab, that are approved for early Alzheimer’s treatment, but their benefits and side effects are still under debate, and they are not recommended for vascular dementia.
Non-medication approaches, while they’ve been less studied than drug-based treatments, still have the potential to be beneficial. These strategies include working with dietitians, social workers, rehabilitation therapists, audiologists, and geriatric case managers to ensure quality care for the patient. Ensuring proper financial and healthcare decision-making capacity is also essential. Proactive care planning can be helpful. If vascular dementia has progressed to its later stages, palliative care or hospice services may be considered.
What else can Vascular Dementia be?
When trying to diagnose vascular dementia, a doctor would also need to consider other conditions which might present similarly. Some of these include:
- Alzheimer’s Disease
- Mixed dementia presentations
- Normal pressure hydrocephalus
- Excessive alcohol consumption
- Emergence or worsening of bipolar and other mood disorders
- Metabolic imbalances, especially related to B12 and homocysteine levels
These considerations would help the doctor to reach a more accurate diagnosis. Understanding the symptoms of each of these conditions is crucial in diagnosing the real cause.
What to expect with Vascular Dementia
Like all Motor Neuron Diseases (MND), vascular dementia is ultimately a disease that can’t be cured and will eventially lead to death. It seems to have a worse outlook than Alzheimer’s disease.
In one study of patients with MND, those who sadly passed away quickly were slightly older when they were diagnosed, had lower scores on the Mini-Mental State Examination (MMSE, a test for cognitive functions like memory and attention), showed more signs of depression, and had a higher presence of factors that increase the risk of heart disease. These factors were all statistically significant, which means they were not due to chance.
The study found that while Alzheimer’s disease was most common among individuals who passed away quickly, it was less common among the group that lived longer. For people passing away quickly, vascular dementia, frontotemporal dementia (affecting the frontal and temporal lobes of the brain), and Creutzfeldt-Jakob disease (a rare and fatal brain disorder) occurred more often than Alzheimer’s disease.
For vascular dementia, research has shown a life expectancy range of 3 to 5 years after diagnosis.
Possible Complications When Diagnosed with Vascular Dementia
As vascular dementia worsens from mild to moderate, difficult behaviours often become more frequent. This can lead to increased stress for the person caring for the patient. These difficult behaviours could include delusions, seeing things that aren’t there (visual hallucinations), and feelings of suspicion without any reasonable cause (paranoia), among other symptoms. During such times, counseling for the caregiver is crucial. It can be very helpful for the caregivers to learn methods of diverting the patient’s attention and implementing calming strategies. It’s important to note that there isn’t a single pill or mix of medications that can eliminate all of these challenging behaviours.
As patients move into the final stages of vascular dementia, it is often not the mental aspects that become the main issue but physical problems. These can include issues with walking (gait), risks of choking (aspiration), falls, bed sores or ulcers, and repeated hospital stays.
Common Progression Symptoms:
- Increased frequency of difficult behaviours
- Delusions
- Visual hallucinations
- Paranoia
- Problems with walking (gait)
- Risks of choking (aspiration)
- Falls
- Bed sores or ulcers
- Repeated hospital stays
Preventing Vascular Dementia
If a patient is diagnosed with vascular dementia, which is a decline in thinking skills caused by conditions blocking or reducing blood flow to the brain, doctors can provide valuable advice to patients and their loved ones. This advice can help to prevent worsening of the condition, promote safety, prepare for future care needs, and manage the strain on those providing care.
Discussions on preventing further health decline should include adopting a healthy diet, incorporating physical exercise, participating in activities that stimulate the brain, and maintaining social connections. The main objective is to keep the patient safe while empowering them to maintain as much independence as possible and providing support to the individual who is assisting with their care.
