From the Guidelines
Vascular Dementia Definition and Management
Vascular dementia is a progressive cognitive disorder characterized by impaired memory, attention, and executive function, resulting from reduced blood flow to the brain 1. It is also known as vascular cognitive impairment (VCI), which can occur alone or in association with Alzheimer's disease (AD) 1. The diagnosis of VCI requires the presence of both cognitive impairment and cerebrovascular pathology, and should include three main components: understanding cognitive abilities through validated cognitive screens and assessments, identifying cerebrovascular pathology through neuroimaging, and determining functional impact through historical individual and collateral information 1.
Key Features and Management
The management of vascular dementia involves controlling risk factors, such as:
- Hypertension: Treatment should be considered for average diastolic blood pressure readings ≥90 mmHg and for average systolic blood pressure readings ≥140 mmHg 1.
- Diabetes: Management through lifestyle modifications and pharmacological interventions.
- Hyperlipidemia: Treatment with statins like atorvastatin (10-80 mg daily) 1. Additionally, cholinesterase inhibitors like donepezil (5-10 mg daily) and memantine (5-20 mg daily) may be used to slow cognitive decline, with treatment durations typically ranging from 6 to 12 months or longer, depending on individual response and tolerability 1.
Diagnosis and Treatment Approach
The diagnosis of vascular dementia should be based on standardized criteria, such as the Vascular Behavioral and Cognitive Disorders (VAS-COG) Society criteria, Diagnostic and Statistical Manual of Mental Disorders (DSM5), Vascular Impairment of Cognition Classification Consensus Study, or the American Heart Association consensus statement 1. Magnetic resonance imaging (MRI) is recommended over computed tomography (CT) for investigating vascular cognitive impairment 1.
Important Considerations
It is essential to assess, diagnose, and treat hypertension according to guidelines from Hypertension Canada 1. For patients with cognitive disorders in which a vascular contribution is known or suspected, antihypertensive therapy should be strongly considered 1. The use of aspirin is not recommended for patients with mild cognitive impairment (MCI) or dementia who have brain imaging evidence of covert white matter lesions of presumed vascular origin without history of stroke or brain infarcts 1.
Treatment Goals
The primary goal of treatment is to slow cognitive decline, improve symptoms, and prevent further vascular events. Treatment should be individualized, and the choice of pharmacologic agents should be based on tolerability, adverse effect profile, ease of use, and cost of medication 1.
From the Research
Definition and Overview of Vascular Dementia
- Vascular dementia is an umbrella term that encompasses the pathological changes in the brain due to cerebrovascular disease, resulting in dementia 2.
- It is the second most common form of dementia after Alzheimer's disease, and its diagnosis is often complicated by the presence of Alzheimer's pathology in some individuals 2.
- Vascular dementia is preventable and treatable, with established primary and secondary prevention measures for the causative cerebrovascular diseases, such as vascular risk factor intervention, antiplatelet therapy, and anticoagulation 2.
Causes and Risk Factors
- Major stroke and cerebral small vessel disease (cSVD) are the major risk factors for vascular dementia, leading to blood-brain barrier deregulation, neurovascular coupling dysfunction, and inflammation 3.
- Vascular risk factors, such as hypertension, obesity, and diabetes, exacerbate neurovascular impairments and increase the prevalence of vascular dementia 3.
- Air pollution is an underestimated risk factor that triggers vascular dysfunction via inflammation and oxidative stress, contributing to the development of vascular dementia 3.
Symptoms and Diagnosis
- Vascular dementia is characterized by a decline in cognitive functions, including executive functions, associated with structural and functional alterations in the cerebral vasculature 3.
- The diagnosis of vascular dementia is based on a thorough clinical evaluation and neuroimaging, with the most recent diagnostic criteria breaking down the diagnosis into four phenotypic categories: subcortical ischemic vascular dementia, poststroke dementia, multi-infarct dementia, and mixed dementia 4.
Treatment and Management
- Cholinesterase inhibitors, such as donepezil, may be a rational treatment for vascular dementia, as they have been shown to improve cognitive function, clinical global impression, and activities of daily living in patients with mild to moderate vascular cognitive impairment 5, 6.
- However, the evidence for the effectiveness of cholinesterase inhibitors in vascular dementia is limited, and further research is needed to establish their efficacy and safety in this population 5, 6.
- Rehabilitation and physical and cognitive exercise may be beneficial for patients with vascular dementia, but more research is needed to confirm their effectiveness 2.