eMedicine Specialties > Psychiatry > Geriatric

Vascular Dementia: Follow-up

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

Follow-up

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.

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.

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.

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.

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.

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.

Miscellaneous

Medicolegal Pitfalls

  • Dementia is a condition of impaired memory and cognition. Early in the course of vascular dementia, competence and capacity may be relatively intact. Patients may be able to manage their own affairs, provide consent for medical treatments, execute living wills, or nominate a durable power of attorney for health care and finances.
  • As the dementia progresses, competency and capacity are impaired. Sometimes, severe incapacitating dementia can occur before protective legal decisions are made. In such instances, the court may need to appoint a guardian, conservator, or trustee. The term trustee applies to a person appointed by law to execute a trust for the benefit of the beneficiary. A guardian or conservator is a person who has the legal power to take care of and/or manage the property of an incompetent person.

Special Concerns

  • Ethical issues must be considered on an individual basis, with consideration of clinical judgment and general ethical principles.
  • Frequently arising ethical issues and dilemmas in the care of individuals with vascular dementia are as follows:
    • Dementia and driving
    • Consent for treatment and care
    • Physical and chemical restraints
    • Issues of end-of-life care, including artificial nutrition and hydration
 


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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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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