What is the treatment for vascular dementia?

Treatment of Vascular Dementia

The treatment of vascular dementia should focus on aggressive vascular risk factor management, particularly intensive blood pressure control with a target systolic BP <120 mmHg, combined with cholinesterase inhibitors or memantine for cognitive symptoms. 1

Vascular Risk Factor Management

• 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 patients with average diastolic BP ≥90 mmHg or systolic BP ≥140 mmHg 2, 1
• All patients with cognitive symptoms or impairment should receive guideline-recommended treatments to prevent first-ever or recurrent stroke 2
• 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

Pharmacological Management for Cognitive Symptoms

• Cholinesterase inhibitors (donepezil, galantamine, rivastigmine) may be considered for the treatment of vascular cognitive impairment in selected patients 2, 1
• Donepezil 10mg has shown the best results for cognitive benefit but has more side effects 1
• Memantine (NMDA receptor antagonist) is associated with small improvements in cognitive function in individuals with vascular dementia 1, 3
• FDA studies show that memantine treatment was statistically significantly superior to placebo in patients with vascular dementia, particularly in day-to-day function and overall clinical effect 3
• The recommended dosing for memantine starts at 5 mg once daily, with increases in 5 mg increments to a target dose of 20 mg/day (5 mL twice daily) 3

Management of Neuropsychiatric Symptoms

• Psychological interventions such as cognitive behavioral therapies improve mood, increase depression remission rates, and enhance activities of daily living performance 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, 4

Aspirin and Antiplatelet Therapy

• The use of aspirin is not recommended for patients with MCI or dementia who have brain imaging evidence of covert white matter lesions of presumed vascular origin without history of stroke or brain infarcts 2
• For patients with covert brain infarcts detected on neuroimaging without history of stroke, aspirin use is reasonable, but the benefit is unclear 2
• Antiplatelet or antithrombotic therapy should be guided by existing primary and secondary stroke prevention guidelines 1

Diagnostic Considerations

• Magnetic resonance imaging (MRI) is recommended over computed tomography (CT) for investigating vascular cognitive impairment 2, 1
• Use of standardized criteria (VAS-COG Society criteria, DSM5, Vascular Impairment of Cognition Classification Consensus Study, or the American Heart Association consensus statement) is recommended for diagnosis 2
• White matter hyperintensities should be reported using a validated visual rating scale such as the Fazekas scale 1

Special Considerations

• For patients with severe renal impairment (creatinine clearance of 5-29 mL/min), a reduced memantine target dose of 5 mg twice daily is recommended 3
• Memantine should be administered with caution to patients with severe hepatic impairment 3
• Unlike Alzheimer's disease, executive dysfunction is commonly seen in vascular dementia, while memory impairment may be mild or absent 5
• Mixed dementia (AD with VaD) has been underestimated as a prevalent cause in the older population and may benefit from similar treatment approaches 6