What is the management of vascular dementia?

Management of Vascular Dementia

The cornerstone of vascular dementia management is aggressive vascular risk factor control, particularly targeting systolic blood pressure <120 mmHg in individuals over 50 with BP >130 mmHg, combined with consideration of cholinesterase inhibitors or memantine for cognitive symptoms. 1, 2

Vascular Risk Factor Management (Primary Priority)

Blood Pressure Control

• Target systolic BP <120 mmHg for individuals over 50 years old with BP >130 mmHg to reduce mortality, cardiovascular risk, and cognitive impairment. 1, 2
• Initiate antihypertensive therapy for diastolic BP ≥90 mmHg or systolic BP ≥140 mmHg, as there is a linear relationship between lower blood pressure and reduced vascular cognitive impairment risk (absolute risk reduction of 0.4-0.7% per year). 1, 2

Diabetes and Metabolic Control

• Manage diabetes aggressively, as it more than doubles the risk of vascular dementia. 1
• Control dyslipidemia and implement smoking cessation programs, which can reduce vascular cognitive impairment risk by 20-40%. 1

Antiplatelet Therapy

• Guide antiplatelet or antithrombotic therapy according to existing primary and secondary stroke prevention guidelines. 2
• Do not use aspirin in patients with mild cognitive impairment or dementia who have white matter lesions of presumed vascular origin but no history of stroke or cerebral infarcts. 3

Pharmacological Management for Cognitive Symptoms

Cholinesterase Inhibitors and Memantine

• Consider cholinesterase inhibitors (donepezil, rivastigmine, galantamine) or memantine in patients with vascular or mixed dementia, based on randomized trials showing small magnitude cognitive benefits. 1, 2
• Donepezil 10mg provides the greatest cognitive benefit but has the most side effects (dizziness, headache, confusion, constipation occurring in ≥5% of patients). 1, 2
• Memantine is FDA-approved for moderate to severe Alzheimer's dementia and shows small improvements in cognitive function in vascular dementia, with dosing starting at 5mg daily and titrating to 20mg daily (10mg twice daily) over at least 3 weeks. 4
• In patients with severe renal impairment (creatinine clearance 5-29 mL/min), reduce memantine target dose to 5mg twice daily. 4

Management of Neuropsychiatric Symptoms

Depression and Behavioral Symptoms

• Implement cognitive behavioral therapies to improve mood, increase depression remission rates, and enhance activities of daily living performance. 1, 2
• Use SSRIs as first-line pharmacotherapy for depression, agitation, and overall neuropsychiatric symptoms in vascular cognitive impairment. 1, 2, 3

Antipsychotic Use

• Use antipsychotics with extreme caution due to increased risk of death in elderly dementia patients, primarily from cardiac toxicities. 2, 3

Non-Pharmacological Interventions

Physical Activity

• Prescribe aerobic exercise and/or resistance training of at least moderate intensity to improve cognitive outcomes, as physical activity reduces vascular dementia risk by 41% (OR = 0.59). 1

Dietary Modifications

• Recommend adherence to a Mediterranean diet with high consumption of mono- and polyunsaturated fatty acids and low saturated fat intake to reduce cognitive decline risk. 1

Diagnostic Imaging Approach

• Use MRI over CT for investigating vascular cognitive impairment. 1, 2
• Report white matter hyperintensities using the Fazekas scale; beginning confluent or confluent subcortical white matter hyperintensities are often sufficient to cause clinical cognitive impairment. 1, 2
• Consider FDG-PET when frontotemporal dementia is in the differential, as it identifies 50% of cases that remain undetected by MRI. 3

Safety and Environmental Modifications

• Install grab rails, sensor night lights, electronic bracelets, and tele-assistance support centers to 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

Comorbidity and Specialist Management

• Evaluate and manage cerebrovascular disease and other cardiovascular diseases comprehensively, with referral to appropriate specialists for specific vascular risk factors and comorbidities such as dysphagia. 1

Advanced Care Planning

• Educate patients, families, and caregivers at multiple points about the expected clinical course and impact on cognition and function. 1
• Encourage advanced care planning early in the disease course, and discuss less aggressive or withdrawal of vascular risk reduction strategies for individuals with significant comorbidities or palliative care priorities. 1

Common Pitfalls to Avoid

• Do not discontinue vascular risk factor management in established dementia; continued control remains beneficial. 1, 2
• Avoid medications that raise urine pH (such as carbonic anhydrase inhibitors or sodium bicarbonate), as they decrease urinary elimination of memantine and increase plasma levels. 4
• Do not expect dramatic cognitive improvements with pharmacotherapy; benefits are modest but may slow decline. 1, 2