Vascular Dementia: A Complete Guide

Overview

Dementia is an umbrella term used to describe several different conditions. Dementia can often be confused with disorders such as delirium, and certain types of dementia may be mistaken for Alzheimer’s disease, the most common type. The confusion is understandable, as vascular dementia falls into a cluster of disorders which are part of the Alzheimer’s family. Vascular dementia is the second most common type of dementia after Alzheimer’s disease. Research has led to greater knowledge and understanding of the disease as well as earlier detection.

1. What is Vascular Dementia?
2. How Does Vascular Dememtia Differ from Alzheimer’s Disease?
3. Who is at Risk of Developing Vascular Dementia?
4. What are the Symptoms of Vascular Dementia?
5. Diagnosing Vascular Dementia
6. Treatment and Outcomes for Vascular Dementia
7. Prevention of Vascular Dementia
8. Caring for Someone with Vascular Dementia
9. The Future of Vascular Dementia

What is Vascular Dementia?

Vascular dementia (VD) was previously referred to as “Multi-Infarct” or “Post-Stroke” dementia. Research has revealed that vascular dementia has a strong correlation with abnormalities in blood flow within the brain. Inadequate blood flow can occur anywhere in the body, but the brain is especially vulnerable. This highlights the vascular aspect of the disease and is the initial reason VD was once considered to be a post-stroke side effect. Today, vascular dementia is defined as a decline in cognitive function caused by conditions that block or reduce blood flow to the brain, depriving brain cells of vital oxygen and nutrients.

There are 8 Subtypes of Vascular Dementia:

• Mild Vascular Cognitive Impairment
• Multi-Infract Dementia
• Vascular Dementia due to a Single Infarct
• Vascular Dementia due to Lacunar Lesions
• Vascular Dementia due to Hemorrhagic Lesions
• Binswanger Disease
• Subcortical Vascular Dementia
• Mixed Dementia (a combination of Alzheimer’s disease and Vascular Dementia)

Vascular dementia may also be classified as Cortical or Subcortical Dementia in correlation with the areas of the brain that may be impacted.

People with vascular dementia can experience either focal or diffused effects on the brain. This means that the damage may be focused in one area, or it may spread throughout the brain. Mild Vascular Cognitive Impairment can occur in older adults as a result of multiple infarcts or tissue death due to aging. The greater the breadth of vascular damage, the larger the impact on the brain. Focal vascular diseases usually occur after another type of event in the body, such as an embolic or thrombotic clot. Hypertension or high blood pressure that is left untreated is often the cause of this type of vascular disease.

Small Vessel Disease occurs when all small vessels within a specific area are compromised, again mostly in the brain. Small vessel disease implies damage to arterial walls; this damage and the events that follow are what lead to vascular dementia.

Lacunar Disease is another disease of small vessels; in this instance the vessels become occluded, or clogged. In the absence of adequate treatment, blood flow is inhibited, thus resulting in tissue damage and death. With lacunar disease, the lack of blood flow causes some people to develop lesions within the brain, called lacunae.

Binswanger Disease is a disease that causes diffused, or widespread damage to the white matter in the brain. This damage impairs the blood flow within the brain, resulting in vascular dementia.

The common theme throughout the different causes of vascular dementia is an event in the body that results in decreased blood flow to the brain. This may be from hereditary conditions or other types of underlying diseases.

How Does Vascular Dementia Differ from Alzheimer’s Disease?

There are certainly similarities between vascular dementia and Alzheimer’s disease, and in fact, mixed dementia is a type of disorder in which individuals have a combination of both vascular dementia and Alzheimer’s disease. Alzheimer’s disease is more common, as it is estimated that 60-80% of people with dementia have Alzheimer’s disease.

While many of the presenting symptoms are the same, major differences consist of onset and predisposing factors including different types of illness. Alzheimer’s disease generally has a slower onset, and people report symptoms such as memory difficulties, particularly in regard to recent activities or conversations. Vascular dementia, on the other hand, primarily affects judgment or ability to make decisions, as opposed to memory.

Vascular dementia occurs most often from blockage of blood vessels or damage that leads to tissue death in the brain (for example, stroke). The location and size of this damage determines the extent of disease a person will experience, and the type of treatment.

Who is at Risk of Developing Vascular Dementia?

Vascular dementia is the second most common type of dementia in the United States, affecting between 15-20% of people with dementia. The prevalence rate increases by 9 times in people who have suffered from a stroke; 25% of people appear to show signs of new-onset dementia within a year of stroke. Men have a higher risk of developing vascular dementia than women. Aging is also a risk factor, so elderly individuals are more likely to develop vascular and other types of dementia.

Many of the risk factors and treatments for vascular dementia are like those of heart disease, due to the relationship between vascular dementia and the occlusion of blood vessels. Those with diagnosed heart conditions may be at greater risk for VD (for example, atrial fibrillation that does not undergo treatment). People with high blood pressure and high cholesterol that is left untreated are also at greater risk. Heart conditions, Diabetes, high blood pressure, and high cholesterol increase damage to blood vessels, increasing the likelihood of ischemic damage. Those who have previously suffered strokes or transient ischemic attacks (TIAs) are at the greatest risk.

What are the Symptoms of Vascular Dementia?

Symptoms of vascular dementia vary across individuals because the symptoms are dependent on the area and the extent of the brain damage. For example, some individuals may experience memory loss if vascular damage occurs in the temporal lobe; others may not experience as much memory loss, but may struggle more with an inability to make decisions and poor judgment if there is damage to the frontal lobe of the brain. Thus, the main symptom of Alzheimer’s — memory loss — may or may not occur in someone with vascular dementia.

Vascular dementia symptoms are most obvious if they occur relatively soon after a stroke. Sudden post-stroke symptoms may include confusion, disorientation, difficulty speaking or understanding speech, or vision loss. These symptoms make diagnosis and treatment challenging as they often mimic stroke symptoms, and may also occur at the same time a stroke is occurring. Following one or more strokes, vascular dementia may also be characterized by physical symptoms such as problems with vision or speech and weakness in limbs, but these symptoms might improve with rehabilitation.

If a person has suffered multiple strokes over a period of time, the changes may be more gradual. This happens because the damage spreads more slowly across the brain. The person may begin to demonstrate impaired planning and judgment, uncontrolled laughing or crying, inability to pay attention, impaired social ability, and have difficulty finding the right words.

Vascular dementia may progress in an irregular pattern, where the person appears better for a period of time, only to have their health worsen again.

Diagnosis and Treatment Options

Diagnosis can be difficult if the person develops symptoms gradually. Family members may be the first to notice and comment on changes in the person’s personality or demeanor.

The most effective diagnosis and subsequent treatment involves professional screening which will include a thorough analysis of medical history, noting any family history of dementia. In addition, an evaluation of independent function and daily activities is required to identify what areas the person has difficulty with. Family members are consulted to determine any changes they have noticed, and laboratory tests are performed to detect underlying medical issues. Brain imaging may also be necessary to see where damage has occurred.

The most useful test in determining the presence of dementia is a neurological examination or neuropsychological assessment. These tests will look at behavioral factors such as mood, temper, etc., but more importantly, they will focus on a person’s decision making abilities. Simple tests can assess a person’s executive functioning skills (i.e. their ability to solve problems and make decisions). These tests can provide the health care team and family members with an idea of the stage and severity of the disease, and will allow for the development of treatment strategies to assist the person.

In 2011, the American Stroke Association and the American Heart Association identified the following Three Criteria that indicate the greatest likelihood that mild cognitive impairment is the result of vascular changes:

1. The diagnosis of dementia or mild cognitive impairment as confirmed by neurocognitive testing, which involves several hours of written or computerized tests that provide detailed evaluation of specific thinking skills such as judgment, planning, problem solving, reasoning, and memory.
2. Brain imaging, usually with magnetic resonance imaging (MRI), may show evidence of either:
3. A recent stroke
4. Other brain vessel changes for which the severity and pattern of affected tissue are consistent with the types of impairment documented in neurocognitive testing.
5. There is no evidence that factors other than vascular changes contribute significantly to memory loss or cognitive decline.

Treatment and Outcomes

At this time, there are no approved drugs for the treatment of vascular dementia. There is, however, some clinical trial evidence that certain drugs used to treat the symptoms of Alzheimer’s disease may present a small benefit to those living with vascular dementia. The most important treatment factor is controlling the risk factors that caused the dementia in the first place, e.g. blood pressure or cholesterol levels.

Vascular dementia does shorten lifespan; this is especially true if the dementia follows on the heels of an event such as a stroke. On average, individuals with vascular dementia typically live for about 5 years after their symptoms begin. This is shorter than the typical duration of Alzheimer’s disease.

Prevention of Vascular Dementia

The most effective way to prevent the development of vascular dementia is to make sure you address any cardiovascular risk factors you may have. Research shows that the same things that are good for the heart and arteries seem to be good for the brain.

Some things you can do to reduce your risk:

• Don’t smoke – or quit if you do
• Maintain your blood pressure, cholesterol and blood sugar within recommended limits
• Sustain a healthy diet, such as the Mediterranean diet
• Limit alcohol consumption
• Exercise frequently
• Manage your stress levels
• Stay socially engaged and active
• Identify and treat depression

Caring for Someone with Vascular Dementia

Living with vascular dementia can be very difficult, both for people who are diagnosed and their family members.

Fiona is a middle-aged woman living in England who details her experience after her mother’s vascular dementia diagnosis:

The first sign of the dementia setting in was when my mother wouldn’t recognize where she was as she was driving; she would have to pull over to re-orientate herself, and she found this confusing and very frightening. After this, there was quite a rapid progression with her having episodes that would cause her to blank out and then sleep. She also became very argumentative and aggressive, attacking me physically by pushing, shoving, and throwing water over me. She also gave my husband a clip round the ear when she thought he’d been cheeky!

Marie is a 47-year-old woman from Ireland who shares her frustrations obtaining a diagnosis for her mother:

Seven years ago, we received the diagnosis that my mum had vascular dementia. There is still confusion over the difference between vascular dementia and Alzheimer’s: there are over 200 causes of dementia, and Alzheimer’s disease is only one of them.

Dementia itself is a collection of symptoms that can surface slowly over time, or suddenly with a health setback such as a stroke. Seven years before my mum was diagnosed, she had two heart attacks which I think attributed to her dementia.

My parents lived in London most of their adult lives but are from Ireland. When I was in my twenties, they moved back to Belfast, mother’s home town. I stayed in London and met my husband, married and had my children there.

It’s been a long journey and it’s so true, I once heard: ‘Dementia is the longest goodbye’ and that is so true. The most difficult aspect for me still is that although she is here, she is no longer the same person and has forgotten who I am.

Margaret is a middle aged woman from Canada who discusses her family’s experience when her mother began showing signs of vascular dementia:

My mother was independent, intelligent and very private. She had strict boundaries and questions about her health, and her finances were off limits. My father died after a brief illness when my mom was 52. He was 6 years away from retirement, and her world was shattered. I’m not an expert on dementia. I only know my mom’s case. We knew she’d had mini strokes over the years. In her case:

• Her short term memory was awful
• She repeated herself constantly (told the same stories and asked the same question)
• She had trouble with context and wasn’t able to string information together and come to logical conclusions
• She couldn’t remember dates and was confused by numbers
• She would acknowledge that she had challenges but believed she could live independently
• She had no ability to manage her medication or meals. She was always extremely well groomed and looked great, though

In 2001, after several odd incidents involving my mother, I decided it was time to contact her doctor and express my concerns about my mother’s memory. My mother was 67. The doctor was surprised that I thought my mom had dementia. We made an appointment and the doctor asked my mom a few questions, designed for those with memory loss. The doctor agreed that there might be some sort of vascular dementia. The situation was difficult because I had young kids, and my mother lived 3 hours away. My sister and I tried hard to support her but her illness was confusing. She could seem normal and well. It became hard to know if we were overreacting.

In 2002, she blacked out outside of her condo. She fell down and was completely disoriented. A neighbor saw her and thought she was drunk. She had been on her way to a wedding with my aunt, and they ended up going to the wedding anyway. However, people kept asking my aunt what was wrong with my mother because she wasn’t able to follow conversations.

As is clear from these first hand accounts, caring for someone with vascular dementia can be hard. Seek help, ask for advice, and learn from others who have had similar experiences. You should also talk to your doctor about treatment approaches – both pharmacological and non-pharmacological.

The Future of Vascular Dementia

Presently, there are some clinical trials examining potential drugs that may slow the progression of vascular dementia, but there are currently no medications that prevent or stop its development. Other studies are focused on the lifestyle risk factors which cause vascular dementia, including quickly recognizing the signs and symptoms of stroke to prevent its development in the first place.

Since there is currently no cure or effective medication to treat the disease, the focus is typically on preventing vascular dementia. The best hopes for preventing the disease come from modifying unhealthy behaviors that put you at greater risk. However, should you find yourself or a family member dealing with a vascular dementia diagnosis, there are resources, support groups, and caregivers that can be immensely helpful.

References

• The Alzheimer’s Society www.alz.org 2016 Alzheimer’s facts and figures
• The American Heart Association www.heart.org
• The Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/vascular-dementia/basics/coping-support/con-20029330
• Patients Canada www.patientscanada.ca
• Medscape: www.emedicine.medscape.com
• University of California Memory and Aging Centre www.memory.ucsf.edu
• University of California San Francisco Health www.ucsfhealth.org

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