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Vascular Dementia

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Overview

Vascular dementia is the second most common cause of dementia and describes chronic progressive cognitive impairment caused by different pathologies causing ischaemia or haemorrhage damaging grey and white matter.

There is a large degree of overlap with Alzheimer’s disease and many people have both.

Epidemiology

  • 2nd most common cause of dementia
  • Strokes double the risk of developing dementia

Risk Factors

Presentation

The progression of vascular dementia is stepwise, where there may be sudden or gradual deteriorations with intermittent plateaus.

  • Features of dementia.
  • Onset of symptoms after a stroke
  • Difficulty concentrating and paying attention
  • Focal neurological deficits:
    • Visual problems
    • Dysphasia
    • Hemiparesis
    • Extrapyramidal signs e.g. Parkinsonian features
  • Gait disturbances
  • Seizures
  • Depression
  • Anxiety
  • Bladder incontinence
  • Features of pseudobulbar palsy – inability to control facial movements:
    • Problems speaking
    • Problems with chewing
  • Emotional lability

Differential Diagnoses

Delirium

  • Onset much more acute
  • Difficulty paying attention and fluctuating consciousness
  • Reversible causes may be present
  • Symptoms themselves fluctuate and often are worse at night
  • Short-term and varying hallucinations

Normal pressure hydrocephalus

  • Gait disturbance
  • Incontinence
  • Cognitive impairment
  • No stepwise progression

Alzheimer’s disease

  • No stepwise progression
  • Gradual course
  • A stroke may change Alzheimer’s disease into vascular dementia

Dementia with Lewy bodies

  • No stepwise progression
  • Parkinsonian features e.g. tremor, shuffling gait, falls, and bradykinesia
  • Fluctuating cognition
  • Vivid hallucinations

Frontotemporal dementia

  • Onset at 50-60 years usually
  • No stepwise progression
  • Decreased inhibition and socially inappropriate behaviour
  • Impulsive

Parkinson’s disease dementia

Depression

  • Low mood and anhedonia
  • Memory loss may be present but is not the main presenting complaint
  • Low self-esteem

Assessment

Screening tools

Cognitive assessment tools in a non-specialist setting include:

  • 10-point Cognitive Screener (10-CS)
  • 6-item Cognitive Impairment Test (6-CIT)
  • 6-item Screener
  • Memory Impairment Screen (MIS)
  • Mini-Cog
  • Test Your Memory (TYM)

Dementia should not be ruled out solely based on a normal cognitive assessment test.

Investigations

Initial investigations in primary care

Initial investigations are to rule out possible reversible causes of symptoms:

Other investigations may need to be considered if appropriate:

  • Chest x-ray
  • Urine microscopy and culture
  • Urine toxicology panel for opiates, cocaine, benzodiazepine and cannabinoids
  • Syphilis serology
  • HIV testing

Referral to secondary care

If the person is severely disturbed, arrange admission to hospital. Detention under the Mental Health Act (1983) may be needed.

If dementia is suspected in people with learning disabilities arrange a specialist referral for assessment and treatment.

People with MCI are followed up regularly and referred to secondary care if their symptoms deteriorate.

All other patients should be referred to a memory assessment service for specialist assessment and management.

Investigations in secondary care

Specialist investigations may include:

Management

Management involves addressing cardiovascular risk factors to slow progression and treating symptoms.

Addressing cardiovascular risk factors is done by prescribing aspirin or clopidogrel, lifestyle changes, statins, controlling blood pressure, controlling diabetes, and carotid endarterectomy if indicated etc.

Donepezil, rivastigmine, galantamine, and memantine is only indicated if there is concomitant Alzheimer’s disease.

Monitoring

  • Patients should be followed up every 6 months to look for functional or cognitive declines. Home safety risks should also be assessed at these visits.

Patient Advice

  • Discussions regarding future care i.e. lasting power of attorney, advance decisions, place of death, and wills should take place with the patient and their family and carers at an early stage.
  • Patients should stop smoking, reduce alcohol consumption, and eat a healthy balanced diet to reduce the risk of dementia or further decline, and to reduce the risk of frailty
  • When communicating with patients with Alzheimer’s disease, family and carers etc. should use short and simple sentences and provide response choices to avoid confusion
  • Coping techniques should also be discussed with family and carers etc. of the patient.
  • Legal information surrounding driving should be given.

Complications

  • Behavioural problems such as poor judgement, delusions, hallucinations, wandering
  • Depression
  • Falls
  • Gait disturbance
  • Aspiration pneumonia
    • Patients may have dysphagia to solids and liquids
    • Recurrent pneumonia may indicate terminal states of vascular dementia and is often the cause of death
  • Pressure ulcers
  • Caregiver burden and stress
  • Elder abuse

Prognosis

The prognosis is worse than Alzheimer’s disease and has an average life expectancy of 3-5 years

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