What is the treatment for vascular dementia?

Treatment of Vascular Dementia

The treatment of vascular dementia requires aggressive management of vascular risk factors, particularly hypertension, combined with cholinesterase inhibitors for cognitive symptoms, with donepezil 10mg showing the greatest cognitive benefit among pharmacological options. 1

Risk Factor Management

Hypertension Control

• Intensive blood pressure control is crucial, with a target systolic BP <120 mmHg for individuals over 50 with BP >130 mmHg to reduce mortality, cardiovascular risk, and cognitive impairment 1
• Antihypertensive therapy should be strongly considered for individuals with average diastolic BP ≥90 mmHg or systolic BP ≥140 mmHg 1
• There is a linear relationship between lower blood pressure and lower vascular cognitive impairment risk, with evidence showing an absolute risk reduction of 0.4-0.7% per year 1

Other Vascular Risk Factors

• All patients with vascular cognitive impairment should receive guideline-recommended treatments to prevent first-ever or recurrent stroke 1
• Management of diabetes, dyslipidemia, and smoking cessation is essential as these midlife risk factors are associated with a 20-40% increased risk of vascular cognitive impairment 1
• Antiplatelet or antithrombotic therapy should be guided by existing primary and secondary stroke prevention guidelines 1
• For patients with covert brain infarcts without history of stroke, aspirin may be considered, though the benefit remains unclear 1

Pharmacological Management for Cognitive Symptoms

Cholinesterase Inhibitors

• Cholinesterase inhibitors may be considered for individuals with vascular or mixed dementia based on randomized trials showing small magnitude benefits in cognitive outcomes 1
• In a network meta-analysis of seven trials, donepezil 10mg ranked first for cognitive benefit but had the most side effects 1
• Galantamine ranked second in both efficacy and side effects 1
• Rivastigmine showed the lowest impact in terms of both positive effects and side effects 1

NMDA Receptor Antagonist

• Memantine has been associated with small improvements in cognitive function in individuals with vascular dementia 1
• It can be considered as an alternative or adjunct to cholinesterase inhibitors 1

Management of Neuropsychiatric Symptoms

Non-Pharmacological Approaches

• Psychological interventions such as cognitive behavioral therapies improve mood, increase depression remission rates, and enhance activities of daily living performance 1
• Physical activity reduces depressive symptoms in people with mild cognitive impairment 1
• For behavioral disturbances in severe vascular dementia, consider:
  • Simulated presence therapy using audio/video recordings of family members 1
  • Massage therapy, animal-assisted interventions, and personally tailored interventions 1

Pharmacological Management of Mood and Behavior

• Healthcare providers should monitor for changes in mood and behavior throughout the disease trajectory 1
• Serotonergic antidepressants (SSRIs) significantly improve overall neuropsychiatric symptoms, agitation, and depression in individuals with vascular cognitive impairment 1
• Antipsychotics should be used with extreme caution due to increased risk of death, primarily from cardiac toxicities 1
• SSRIs are considered first-line treatments for agitation in vascular dementia 1

Diagnostic Considerations

Neuroimaging

• MRI is recommended over CT for investigating vascular cognitive impairment 1
• When MRI is not available or contraindicated, CT is a reasonable alternative 1
• White matter hyperintensities should be reported using a validated visual rating scale such as the Fazekas scale 1
• Beginning confluent or confluent subcortical white matter hyperintensities on the Fazekas scale are often sufficient to cause clinical cognitive impairment 1

Clinical Pearls and Pitfalls

• Vascular dementia is the second most common cause of dementia after Alzheimer's disease, comprising 15-20% of clinically diagnosed dementia in North America and Europe 1, 2
• Mixed vascular and Alzheimer pathology has a prevalence of up to 38% in some neuropathologic studies, with the probability increasing with age 1
• Unlike Alzheimer's disease where memory impairment is prominent, vascular dementia often presents with executive dysfunction while memory impairment may be mild or absent 3
• The left frontal, left temporal, left thalamus, and right parietal regions are strategic locations where infarcts are highly likely to impair cognition 1
• Avoid using antipsychotics when possible due to increased mortality risk; when necessary, use the lowest effective dose for the shortest duration 1