Vascular Dementia Follow-up

  • Author: Kannayiram Alagiakrishnan, MD, MBBS, MHA, MPH; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK)   more...
 
Updated: Jan 23, 2012
 

Further Inpatient Care

  • If depressed patients do not respond to medical management or if the depression is severe (ie, with life-threatening behavior such as suicide attempts), electroconvulsive therapy is indicated and patients should be hospitalized.
  • As dementia progresses, more troubling behaviors such as agitation, aggression, wandering, sleep disorders, and inappropriate sexual behavior are observed. The decision for placement in institutions is usually made when problem behaviors become unmanageable, when more assistance is necessary in performing activities of daily living, when caring duties exceed the capacity of the caregiver, or when a breakdown in the family caregiver's health occurs.
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Further Outpatient Care

  • Regular follow-up every 4-6 months is recommended to assess the patient's general condition and cognitive and noncognitive symptoms.
  • Frequent visits may be needed for patients with behavioral problems and patients who are on specific therapies such as neuroprotective agents.
  • Treatment of risk factors such as hypertension, hypercholesterolemia, and diabetes mellitus require special attention.
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Deterrence/Prevention

  • Vascular cognitive impairment is modifiable and preventable.
    • Modifying vascular risk factors (eg, hypertension, diabetes mellitus, smoking, hyperhomocystinemia) and dietary factors (eg, hypercholesterolemia) in midlife may help to prevent stroke and vascular dementia. The single most important risk factor is hypertension. Epidemiologic cohort studies and intervention trials with antihypertensive medications demonstrated the usefulness of antihypertensive drugs in the prevention of vascular dementia.
    • Appropriate treatment for atrial fibrillation, coronary artery disease, congestive heart failure, and stroke is also recommended.
    • Adequate management of vascular risk factors, stroke, and heart disease in middle age may be the most effective way to prevent vascular dementia later in life. The distinction between vascular dementia and Alzheimer dementia is becoming increasingly blurred because vascular risk factors play a role in both diseases.
  • In patients with early cognitive impairment or with neuroimaging findings that demonstrate leukoaraiosis or stroke, secondary prevention can be facilitated by applying standard stroke-preventive therapies such as antiplatelet agents, warfarin, or carotid endarterectomy according to accepted guidelines.
  • A study by Vercambre et al examined data from participants in the Women's Antioxidant Cardiovascular Study; the findings revealed a significant difference in the rate of cognitive decline over 5 years (p< .003) among elderly women who had physical activity equivalent to daily 30 minutes walk at a brisk pace. Exercise may improve brain vascular health and strengthen the mechanisms underlying brain plasticity.[23]
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Complications

  • Behavioral problems, including wandering, delusions, hallucinations, and poor judgment
  • Depression
  • Falls and gait abnormality
  • Aspiration pneumonia
  • Decubitus ulcers
  • Caregiver burden and stress: This should be considered a complication of any dementia, including vascular dementia. This can lead to increased psychiatric and medical morbidity in the caregiver.
  • Syndrome of delayed posthypoxic leukoencephalopathy (DPHL): Patients who had a period of prolonged hypoxia secondary to cardiac arrest can develop neuropsychiatric complications. It is a demyelinating syndrome and a slow gradual recovery can happen over a 3- to 12-month period. Neuroimaging can show diffuse demyelination sparing cerebellum and brain stem. In some patients, cognitive impairment, especially with domains of attention and executive function, can be permanent.[24]
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Prognosis

  • According to some studies, vascular dementia shortens life expectancy by approximately 50% in men, in persons with lower education, and in persons who perform worse on neuropsychological tests.
  • The causes of death are due to complications of dementia, cardiovascular disease, and miscellaneous factors, including malignancy.
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Patient Education

Patient and family education

  • Caregiver education is important to dementia management.
    • Structured, respectful, and friendly caregiving is best, and it forms the most important aspect of behavioral care for patients with vascular dementia.
    • Educating the caregiver on how to take care of these patients, how to react to certain behaviors and agitation, and how to reorient the patient improves the quality of care and treatment in these patients.
    • Well-informed caregivers are best equipped to address the problems that vascular dementia presents.
  • Guidelines for caregiver education are as follows:
    • Use short simple sentences when communicating with patients with dementia.
    • Simplify and create a routine for all self-care tasks such as bathing and dressing.
    • Establish a daily routine for all activities such as meals, medication administration, recreation, exercise, and sleep.
    • To reorient the patient, use signs and pictures, clocks and calendars, family photos, and a list of daily activities.
    • Use distraction, not confrontation, to control irritable or socially inappropriate behaviors.
  • Initiate discussion about long-term care planning, including nursing home placement and issues regarding caregiver stress and respite care. Respite care is a community resource that gives the caregiver relief for a short period.
  • Day programs can also provide relief for families, particularly working families, and can provide structure and activities for patients with dementia.
  • Additional patient and family education can be accessed at the following sites:
  • For excellent patient education resources, visit eMedicine's Dementia Center and Stroke Center. Also, see eMedicine's patient education articles Dementia in Head Injury, Dementia Overview, Possible Early Dementia, Dementia Medication Overview, Stroke, and Stroke-Related Dementia.
  • See other resources for caregivers at The National Institute on Aging and Family Caregiver Alliance.
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Contributor Information and Disclosures
Author

Kannayiram Alagiakrishnan, MD, MBBS, MHA, MPH  Associate Professor, Department of Medicine, Division of Geriatric Medicine, University of Alberta Faculty of Medicine and Dentistry, Canada

Kannayiram Alagiakrishnan, MD, MBBS, MHA, MPH is a member of the following medical societies: American College of Physicians and American Geriatrics Society

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.

Specialty Editor Board

Mohammed A Memon, MD  Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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 None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych (UK)  Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of Health Sciences: Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych (UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, American Neuropsychiatric Association, American Psychiatric Association, American Society of Clinical Psychopharmacology, and Royal College of Psychiatrists

Disclosure: Nothing to disclose.

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. Phelan EA, Borson S, Grothaus L, Balch S, Larson EB. Association of incident dementia with hospitalizations. JAMA. Jan 11 2012;307(2):165-72. [Medline].

  11. 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].

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

  13. 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.

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

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

  16. 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].

  17. Rusanen M, Kivipelto M, Quesenberry CP Jr, Zhou J, Whitmer RA. Heavy Smoking in Midlife and Long-term Risk of Alzheimer Disease and Vascular Dementia. Arch Intern Med. Oct 25 2010;[Medline].

  18. Roman GC. The epidemiology of vascular dementia. Handbook of Clinical Neurology. 2008;vol. 89(3rd series):639-658.

  19. 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].

  20. 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].

  21. 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.

  22. Seitz DP, Adunuri N, Gill SS, et al. Antidepressants for agitation and psychosis in dementia. Cochrane Database Syst Rev. Feb 16 2011;2:CD008191. [Medline].

  23. Vercambre MN, Grodstein F, Manson JE, Stampfer MJ, Kang JH. Physical activity and cognition in women with vascular conditions. Arch Intern Med. Jul 25 2011;171(14):1244-50. [Medline]. [Full Text].

  24. Shprecher D and Mehta L. The syndrome of delayed post- hypoxic leukoencephalopathy. Neurorehabilitation. 2010;26:65-72.

  25. 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].

  26. 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].

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

  28. 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].

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

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

  31. 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].

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

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

  34. 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].

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

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

  37. 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].

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

  39. 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].

  40. 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].

  41. 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].

  42. 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].

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

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

  45. 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].

  46. 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].

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

  48. 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.

  49. 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].

  50. 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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