What is the treatment for vascular dementia?

Treatment of Vascular Dementia

The treatment of vascular dementia centers on aggressive vascular risk factor control—particularly achieving systolic blood pressure <120 mmHg—combined with consideration of cholinesterase inhibitors or memantine for cognitive symptoms, while avoiding aspirin in patients without prior stroke. 1

Vascular Risk Factor Management (Primary Treatment Strategy)

Blood Pressure Control

• Target systolic BP <120 mmHg for individuals over 50 years with BP >130 mmHg, as this reduces mortality, cardiovascular risk, and cognitive impairment 1
• Antihypertensive therapy is mandatory for diastolic BP ≥90 mmHg or systolic BP ≥140 mmHg, with absolute risk reduction of 0.4-0.7% per year 1
• There is a linear relationship between lower blood pressure and reduced vascular cognitive impairment risk 1
• Hypertensive angiopathy is the major causative factor for vascular dementia 2

Other Cardiovascular Risk Factors

• Aggressively manage diabetes, as it more than doubles the risk of vascular dementia 1
• Control dyslipidemia and implement smoking cessation, which can reduce vascular cognitive impairment risk by 20-40% 1
• Medication for hypertension, diabetes, and hypercholesterolemia is recommended 2

Pharmacological Management for Cognitive Symptoms

Cholinesterase Inhibitors

• Cholinesterase inhibitors (donepezil, rivastigmine, galantamine) may be considered in patients with vascular or mixed dementia, showing small magnitude benefits in cognitive outcomes 3, 1
• Donepezil 10mg ranked first for cognitive benefit but has the most side effects 1
• Galantamine has shown benefit in possible Alzheimer's disease with cerebrovascular disease 4

Memantine

• Memantine (NMDA receptor antagonist) is associated with small improvements in cognitive function in people with vascular dementia 3, 1
• Consider memantine in selected patients with vascular cognitive impairment 5

Important Caveat on Antiplatelet Therapy

• Do NOT use aspirin for patients with cognitive impairment who have white matter lesions of presumed vascular origin without history of stroke or brain infarcts 3, 5

Management of Neuropsychiatric Symptoms

Antidepressants (First-Line for Behavioral Symptoms)

• Serotonergic antidepressants (SSRIs) significantly improve overall neuropsychiatric symptoms, agitation, and depression in people with vascular cognitive impairment 3, 1
• Treating comorbid depression can improve cognition 2

Antipsychotics (Use with Extreme Caution)

• All antipsychotics increase the risk of death in elderly patients with dementia, primarily due to cardiac toxicity 3
• Use antipsychotics only when absolutely necessary and with extreme caution 3

Non-Pharmacological Interventions

Physical Activity

• Physical activity interventions of at least moderate intensity are strongly recommended to improve cognitive outcomes 1
• Aerobic exercise and/or resistance training of at least moderate intensity improves cognition 1
• Physical activity reduces the risk of vascular dementia by 41% (OR = 0.59) 1

Dietary Modifications

• Adherence to a Mediterranean diet decreases risk of cognitive decline, with high consumption of mono- and polyunsaturated fatty acids and low saturated fat intake 1
• Alcohol reduction is recommended 2

Cognitive and Social Engagement

• Encourage cognitive and physical activity, social engagement, and mentally stimulating activities 1, 2

Diagnostic Imaging Considerations

• MRI is recommended over CT for investigating vascular cognitive impairment 3, 1
• Report white matter hyperintensities using validated visual rating scales such as the Fazekas scale 1
• FDG-PET provides greater sensitivity in identifying frontotemporal dementia cases that remain undetected by MRI 3

Safety and Environmental Modifications

• Install safety items such as grab rails, sensor night lights, electronic bracelets, and tele-assistance support centers, which can reduce falls by 50% (RR = 0.50) 1
• Assess driving fitness, as approximately 70% of drivers with very mild to mild vascular cognitive impairment fail on-road driving tests 1

Personalized Management and Follow-Up

• Create a personalized management plan using a person-centered approach with shared decision-making and culturally appropriate goals 1
• Educate the individual, family, and caregivers at multiple points about the expected clinical course 1
• Encourage advanced care planning early in the disease course 1
• Revisit the management plan regularly as vascular cognitive impairment evolves 1

Common Pitfalls to Avoid

• Do not prescribe aspirin for primary prevention in patients with white matter lesions without stroke history 3, 5
• Avoid antipsychotics unless absolutely necessary due to increased mortality risk 3
• Do not neglect aggressive blood pressure control—this is the cornerstone of treatment 1
• Remember that vascular dementia typically shows stepwise deterioration with periods of partial recovery, unlike the gradual decline of Alzheimer's disease 2