What is the management of vascular dementia?

Management of Vascular Dementia

The management of vascular dementia should primarily focus on aggressive vascular risk factor control, particularly hypertension management with a target systolic BP <120 mmHg, combined with cholinesterase inhibitors in selected patients. 1, 2

Diagnostic Approach

• MRI is recommended over CT for investigating vascular cognitive impairment 2
• Use standardized criteria for diagnosis (VAS-COG, DSM5, or American Heart Association consensus) 2
• Evaluate for strategic infarct locations (left frontal, left temporal, left thalamus, right parietal) that are highly likely to impair cognition 2

Vascular Risk Factor Management

Hypertension Control

• Antihypertensive therapy should be strongly considered for patients with:
  • Diastolic BP ≥90 mmHg
  • Systolic BP ≥140 mmHg 2, 1
• Target systolic BP <120 mmHg in middle-aged and older persons with vascular risk factors 2
  • This intensive BP control reduces risk of developing mild cognitive impairment by approximately 0.4-0.7% per year 2

Other Vascular Risk Factors

• Implement guideline-recommended treatments to prevent first-ever or recurrent stroke 2
• Address modifiable risk factors:
  • Diabetes management
  • Lipid control
  • Atrial fibrillation screening and management
  • Sleep disorder evaluation
  • Lifestyle modifications (diet, exercise, weight management) 1

Antiplatelet Therapy

• Aspirin is NOT recommended for patients with MCI or dementia who have white matter lesions without history of stroke 2
• For patients with covert brain infarcts without stroke history, aspirin may be considered, though benefit remains unclear 2, 1

Pharmacological Management

Cholinesterase Inhibitors

• Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) may be considered for selected patients with vascular cognitive impairment 2
• In network meta-analysis, 10 mg donepezil ranked first for cognitive improvement but had most side effects, followed by galantamine 2

NMDA Receptor Antagonist

• Memantine may be considered for vascular cognitive impairment in selected patients 2
• Associated with small improvements in cognitive function 2, 1

Management of Neuropsychiatric Symptoms

• For depression and anxiety:

  • Cognitive behavioral therapy improves mood, increases depression remission, and improves ADL performance 2
  • Physical activity reduces depressive symptoms in people with MCI 2
  • Serotonergic antidepressants can improve overall neuropsychiatric symptoms, agitation, and depression 2

• For agitation and behavioral disturbances:

  • Non-pharmacological approaches first: simulated presence therapy, massage therapy, animal-assisted interventions, personally tailored interventions 2
  • Antipsychotics should be used with extreme caution due to increased mortality risk, likely from cardiac toxicities 2

Non-Pharmacological Interventions

• Implement cognitive scaffolding (checklists, specific approaches to cognitive tasks) 1
• Establish structured routines and modify environment to support function 1
• Provide communication and memory aids 1
• Evaluate driving capacity, as 70% of drivers with mild vascular cognitive impairment fail on-road driving tests 1

Ongoing Assessment and Support

• Regular assessment of cognitive status, functional abilities, and behavioral symptoms (every 6 months) 1
• Assess caregiver needs and provide appropriate education and support 1
• Educate patients and families about expected clinical course and impact on cognition and function 1

Common Pitfalls to Avoid

• Delaying diagnosis and treatment initiation
• Using antipsychotics without proper indication
• Overlooking treatable causes of cognitive decline
• Neglecting caregiver needs and burden
• Failing to periodically reassess medication efficacy and side effects 1