eMedicine Specialties > Psychiatry > Geriatric

Vascular Dementia: Differential Diagnoses & Workup

Author: Kannayiram Alagiakrishnan, MD, MBBS, Associate Professor, Department of Medicine, Division of Geriatric Medicine, University of Alberta
Coauthor(s): Kamal Masaki, MD, Associate Director of Geriatric Medicine Fellowship, Associate Professor, Department of Internal Medicine, Division of Geriatric Medicine, University of Hawaii, John Burns School of Medicine
Contributor Information and Disclosures

Updated: Aug 18, 2009

Differential Diagnoses

Dementia Due to Head Trauma
Dementia Due to HIV Disease
Depression
Huntington Disease Dementia
Parkinson Disease Dementia

Other Problems to Be Considered

Alzheimer disease
Brain tumor
Creutzfeldt-Jakob disease
Neurosyphilis
Normal pressure hydrocephalus
Frontotemporal dementia
Pick disease
Lewy body dementia

Patients with AD have early language and visuospatial deficits. The deficits in short-term memory are severe, and clues do not help in retrieving information. The onset of the disease is gradual, with a slow progression. Usually, no motor findings are present until the middle or late stages of the disease.

Patients with vascular dementia have patchy cognitive impairment, often with focal neurologic signs and symptoms. Onset may be abrupt, with a stepwise decline.

Patients with Parkinson dementia have cognitive slowing with extrapyramidal signs such as rigidity, bradykinesia, tremor, and gait disturbances. Usually, dementia is seen in later stages of the disease.

Patients with dementia due to head trauma have memory impairment, and other cognitive deficits associated with a history of head trauma occur. The physical findings depend on the location of injury. Usually, it is not progressive unless the person has a history of repeated head trauma (eg, dementia pugilistica).

Patients with HIV dementia have a positive result from an HIV test and cognitive changes with neurological signs.

Frontotemporal dementia is a type of cortical dementia characterized by behavioral and personality disorders more than cognitive issues. Three distinct types are seen: frontotemporal dementia, semantic dementia, and progressive nonfluent aphasia.

Patients with Pick disease have memory problems, personality changes, and deterioration of social skills. Onset is usually between the fifth and sixth decades of life. Upon physical examination, the patient has frontal release signs such as snout and grasp reflex.

Huntington disease is an autosomal dominant disease with an onset of cognitive changes as early as the third decade of life, with physical signs of choreoathetosis.

In Creutzfeldt-Jakob disease, onset is usually seen between the fourth and sixth decades of life, even though it can occur at any, and is associated with signs such as myoclonus, seizures, and ataxia. A rapid progression is typical.

Patients with Lewy body dementia have recurrent visual hallucinations, fluctuating cognitive impairment, and parkinsonism features. Also, the frequency of adverse reactions to antipsychotic medications is high.

In the case of cognitive symptoms secondary to depression, the onset is acute compared with the insidious onset in most types of dementia. The term pseudodementia has been used to describe the condition when cognitive symptoms are prominent. The current and more accurate name for this state is dementia of depression. Patients with depression usually report their cognitive difficulties, which is unusual for patients with dementia. Patients with depression tend to state that they do not know the answers to questions, and they appear to not try very hard during neuropsychological evaluations. Mood symptoms are prominent in patients with dementia of depression.

Workup

Laboratory Studies

  • Laboratory tests should be performed to rule out other causes of dementia. These tests should routinely include a CBC count, erythrocyte sedimentation rate, glucose level, renal and liver function tests, serologic tests for syphilis, vitamin B-12 and red blood cell folate levels, and thyroid function tests.
  • In selected patients, optional tests include HIV serology testing, lupus anticoagulant testing, antiphospholipid antibody testing, antinuclear antibody testing, and antineutrophil cytoplasmic antibody testing.

Imaging Studies

  • Neuroimaging studies may include CT brain scanning and MRI of the brain.
    • The absence of cerebrovascular lesions on CT scanning or MRI is evidence against vascular etiology.
    • The features on CT scanning or MRI that are suggestive of vascular dementia are bilateral multiple infarcts located in the dominant hemisphere and limbic structures, multiple lacunar strokes, or periventricular white matter lesions extending into the deep white matter.
    • Patients with vascular mild cognitive impairment (MCI), which is a prodromal stage for subcortical vascular dementia, have MRI features that differ from patients with amnestic MCI, which is the prodromal stage for AD. Vascular MCI shows more extensive white matter lacunar infarcts and leukoaraiosis and minimal hippocampal and entorhinal cortical atrophies, whereas the opposite is true for amnestic MCI.
  • Functional imaging studies include the following:
    • According to a 2000 study by Nagata et al,16 positron emission tomography may be useful for differentiating vascular dementia from AD. Hypoperfusion and hypometabolism can be observed in the frontal lobe, including the cingulate and superior frontal gyri, in patients with vascular dementia; a parietotemporal pattern is observed in patients with AD.
    • Starkstein et al in 199617 and other authors have demonstrated that single-photon emission CT scanning produce similar findings.
  • Cerebral angiography is not performed routinely during the evaluation of vascular dementia, but it is performed before carotid artery surgery. It also is useful in cases of possible cerebral vasculitis; cerebral vessels can demonstrate beading.

Other Tests

  • Tests that may be useful for evaluation of stroke and in certain cases of vascular dementia include the following:
    • Echocardiography
    • Holter monitoring
    • Carotid duplex Doppler scanning

More on Vascular Dementia

Overview: Vascular Dementia
Differential Diagnoses & Workup: Vascular Dementia
Treatment & Medication: Vascular Dementia
Follow-up: Vascular Dementia
References
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References

  1. Zhang-Nunes SX, Maat-Schieman ML, van Duinen SG, Roos RA, Frosch MP, Greenberg SM. The cerebral beta-amyloid angiopathies: hereditary and sporadic. Brain Pathol. Jan 2006;16(1):30-9. [Medline].

  2. Schmidtke K, Hull M. Cerebral small vessel disease: how does it progress?. J Neurol Sci. Mar 15 2005;229-230:13-20. [Medline].

  3. Jellinger KA. The enigma of vascular cognitive disorder and vascular dementia. Acta Neuropathol (Berl). Apr 2007;113(4):349-88. [Medline].

  4. Delano-Wood L, Abeles N, Sacco JM, Wierenga CE, Horne NR, Bozoki A. Regional white matter pathology in mild cognitive impairment: differential influence of lesion type on neuropsychological functioning. Stroke. Mar 2008;39(3):794-9. [Medline].

  5. Jurasic MJ, Popovic IM, Morovic S, Trkanjec Z, Seric V, Demarin V. Can beta stiffness index be proposed as risk factor for dementia?. Journal of Neurological Sciences. In press.

  6. Snowdon DA, Greiner LH, Mortimer JA, Riley KP, Greiner PA, Markesbery WR. Brain infarction and the clinical expression of Alzheimer disease. The Nun Study. JAMA. Mar 12 1997;277(10):813-7. [Medline].

  7. Roman GC, Kalaria RN. Vascular determinants of cholinergic deficits in Alzheimer disease and vascular dementia. Neurobiol Aging. Dec 2006;27(12):1769-85. [Medline].

  8. Brodaty H, McGilchrist C, Harris L, Peters KE. Time until institutionalization and death in patients with dementia. Role of caregiver training and risk factors. Arch Neurol. Jun 1993;50(6):643-50. [Medline].

  9. Brunnstrom HR, Englund EM. Cause of death in patients with dementia disorders. Eur J Neurol. Apr 2009;16(4):488-92. [Medline].

  10. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. Nov 1975;12(3):189-98. [Medline].

  11. American Psychiatric Association. Diagnosis and Statistical Manual of Mental Disorders. Fourth Edition. Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Press; 2000.

  12. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res. Apr 1983;17:37-49.

  13. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biol Psychiatry. Feb 1 1988;23(3):271-84. [Medline].

  14. Schneider B, Maurer K, Frolich L. [Dementia and suicide]. Fortschr Neurol Psychiatr. Apr 2001;69(4):164-9. [Medline].

  15. Price CC, Jefferson AL, Merino JG, Heilman KM, Libon DJ. Subcortical vascular dementia: integrating neuropsychological and neuroradiologic data. Neurology. Aug 9 2005;65(3):376-82. [Medline].

  16. Nagata K, Maruya H, Yuya H, et al. Can PET data differentiate Alzheimer's disease from vascular dementia?. Ann N Y Acad Sci. Apr 2000;903:252-61. [Medline].

  17. Starkstein SE, Sabe L, Vazquez S, et al. Neuropsychological, psychiatric, and cerebral blood flow findings in vascular dementia and Alzheimer's disease. Stroke. Mar 1996;27(3):408-14. [Medline].

  18. Amenta F, Lanari A, Mignini F, Silvestrelli G, Traini E, Tomassoni D. Nicardipine use in cerebrovascular disease: A review of controlled clinical studies. Journal of the Neurological Sciences. In press.

  19. American Psychiatric Association. Practice guideline for the treatment of patients with Alzheimer's disease and other dementias of late life. American Psychiatric Association. Am J Psychiatry. May 1997;154(5 Suppl):1-39. [Medline].

  20. Ballard C, McKeith I, O'Brien J, et al. Neuropathological substrates of dementia and depression in vascular dementia, with a particular focus on cases with small infarct volumes. Dement Geriatr Cogn Disord. Mar-Apr 2000;11(2):59-65. [Medline].

  21. Caplan LR. Binswanger's disease--revisited. Neurology. Apr 1995;45(4):626-33. [Medline].

  22. Chabriat H, Vahedi K, Iba-Zizen MT, et al. Clinical spectrum of CADASIL: a study of 7 families. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy. Lancet. Oct 7 1995;346(8980):934-9. [Medline].

  23. Chui HC. Vascular dementia, a new beginning: shifting focus from clinical phenotype to ischemic brain injury. Neurol Clin. 2001;18:951-77.

  24. Cummings JL. Vascular subcortical dementias: clinical aspects. Dementia. May-Aug 1994;5(3-4):177-80. [Medline].

  25. Erkinjuntti T, Kurz A, Gauthier S, Bullock R, Lilienfeld S, Damaraju CV. Efficacy of galantamine in probable vascular dementia and Alzheimer's disease combined with cerebrovascular disease: a randomised trial. Lancet. Apr 13 2002;359(9314):1283-90. [Medline].

  26. European Dementia Study. European Pentoxifylline Multi-Infarct Dementia Study. Eur Neurol. 1996;36(5):315-21. [Medline].

  27. Fagerstrom KO. Reducing the weight gain after stopping smoking. Addict Behav. 1987;12(1):91-3. [Medline].

  28. Grilli M, Pizzi M, Memo M, Spano P. Neuroprotection by aspirin and sodium salicylate through blockade of NF-kappaB activation. Science. Nov 22 1996;274(5291):1383-5. [Medline].

  29. Hachinski VC, Bowler JV. Vascular dementia. Neurology. Oct 1993;43(10):2159-60; discussion 2160-1. [Medline].

  30. Hebert R, Brayne C. Epidemiology of vascular dementia. Neuroepidemiology. 1995;14(5):240-57. [Medline].

  31. in't Veld BA, Ruitenberg A, Hofman A, Stricker BH, Breteler MM. Antihypertensive drugs and incidence of dementia: the Rotterdam Study. Neurobiol Aging. May-Jun 2001;22(3):407-12. [Medline].

  32. Kalaria RN. The role of cerebral ischemia in Alzheimer's disease. Neurobiol Aging. Mar-Apr 2000;21(2):321-30. [Medline].

  33. Kalmijn S, Launer LJ, Ott A, et al. Dietary fat intake and the risk of incident dementia in the Rotterdam Study. Ann Neurol. Nov 1997;42(5):776-82. [Medline].

  34. Meyer JS, Huang J, Chowdhury MH. MRI confirms mild cognitive impairments prodromal for Alzheimer's, vascular and Parkinson-Lewy body dementias. J Neurol Sci. Jun 15 2007;257(1-2):97-104. [Medline].

  35. Meyer JS, Rogers RL, McClintic K, et al. Randomized clinical trial of daily aspirin therapy in multi-infarct dementia. A pilot study. J Am Geriatr Soc. Jun 1989;37(6):549-55. [Medline].

  36. Moretti R, Torre P, Antonello RM. Rivastigmine in subcortical vascular dementia: a randomized, controlled, open 12-month study in 208 patients. Am J Alzheimers Dis Other Demen. Sep-Oct 2003;18(5):265-72. [Medline].

  37. Moretti R, Torre P, Antonello RM, et al. Rivastigmine in vascular dementia. Expert Opin Pharmacother. Jun 2004;5(6):1399-410. [Medline].

  38. Nelson NW. Differential diagnosis of Alzheimer's dementia and vascular dementia. Dis Mon. Mar 2007;53(3):148-51. [Medline].

  39. Premkumar DR, Cohen DL, Hedera P, Friedland RP, Kalaria RN. Apolipoprotein E-epsilon4 alleles in cerebral amyloid angiopathy and cerebrovascular pathology associated with Alzheimer's disease. Am J Pathol. Jun 1996;148(6):2083-95. [Medline].

  40. Sadowski M, Pankiewicz J, Scholtzova H, Li YS, Quartermain D, Duff K, et al. Links between the pathology of Alzheimer's disease and vascular dementia. Neurochem Res. Jun 2004;29(6):1257-66. [Medline].

  41. Skoog I. Status of risk factors for vascular dementia. Neuroepidemiology. 1998;17(1):2-9. [Medline].

  42. Vascular Dementia Conference. Summary of the 1st International Conference on the Development of Drug Treatment for Vascular Dementia. Alzheimer Dis Assoc Disorders. Dec 1999;13, Supplement 3:S1-S206.

  43. Wetterling T, Kanitz RD, Borgis KJ. Comparison of different diagnostic criteria for vascular dementia (ADDTC, DSM-IV, ICD-10, NINDS-AIREN). Stroke. Jan 1996;27(1):30-6. [Medline].

  44. Wilkinson D, Doody R, Helme R. Donepezil in vascular dementia: a randomized, placebo-controlled study. Neurology. Aug 26 2003;61(4):479-86. [Medline].

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Further Reading

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Keywords

arteriosclerotic dementia, atherosclerotic disease, dementia due to vascular disease, multiinfarct dementia, multi-infarct dementia, vascular cognitive impairment, Alzheimer disease, AD, Alzheimer's disease, cognitive dementia, senility, stroke, old age dementia, senile dementia, Binswanger disease, Binswanger's disease, mixed dementia, lacunar lesions, cortical dementia, subcortical dementia, cognitive decline, subcortical leukoencephalopathy, Binswanger dementia, Alzheimer dementia, cerebrovascular disease, thrombotic vascular occlusions, embolic vascular occlusions, hypertension

multiple cortical infarct, strategic single infarct, small vessel disease, single-infarct dementia, anterior cerebral artery infarct, parietal lobe infarcts, thalamic infarction, singular gyrus infarction, subcortical leukoencephalopathy, cerebral amyloid angiopathy–associated vasculopathy, hereditary cystatin-C amyloid angiopathy, recurrent cerebral hemorrhages, inflammatory arteriopathy, polyarteritis nodosa, temporal arteritis, noninflammatory arteriopathy, moyamoya disease, fibromuscular dysplasia, apolipoprotein E, apolipoprotein E-IV, cognitive impairment, urinary incontinence, gait disturbances, cerebral autosomal dominant arteriopathy, subcortical infarcts, depression, delusions, Folstein Mini-Mental State Examination, aphasia, apraxia, agnosia, smoking, hypercholesterolemia, diabetes, cardiovascular disease, vascular cognitive disorder

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Contributor Information and Disclosures

Author

Kannayiram Alagiakrishnan, MD, MBBS, Associate Professor, Department of Medicine, Division of Geriatric Medicine, University of Alberta
Kannayiram Alagiakrishnan, MD, MBBS is a member of the following medical societies: American College of Physicians, American Geriatrics Society, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Kamal Masaki, MD, Associate Director of Geriatric Medicine Fellowship, Associate Professor, Department of Internal Medicine, Division of Geriatric Medicine, University of Hawaii, John Burns School of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Mohammed A Memon, MD, Medical Director of Geriatric Psychiatry, Department of Psychiatry, Spartanburg Regional Hospital System
Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Iqbal Ahmed, MBBS, Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Iqbal Ahmed, MBBS is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, and American Psychiatric Association
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Speaking and teaching; Northstar Grant/research funds Research; Novartis Grant/research funds research; Pfizer  Speaking and teaching; Sanofi-avetis Grant/research funds research; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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