eMedicine Specialties > Psychiatry > Geriatric

Vascular Dementia

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 27, 2007

Introduction

Background

Vascular dementia is the second most common form of dementia after Alzheimer disease (AD). The condition is not a single disease; it is a group of syndromes relating to different vascular mechanisms. Vascular dementia is preventable; therefore, early detection and an accurate diagnosis are important.

Patients who have had a stroke are at increased risk for vascular dementia. Recently, vascular lesions have been thought to play a role in AD.

As early as 1899, arteriosclerosis and senile dementia were described as different syndromes. In 1969, Mayer-Gross et al described this syndrome and reported that hypertension is the cause in approximately 50% of patients. In 1974, Hachinski et al coined the term multi-infarct dementia. In 1985, Loeb used the broader term vascular dementia. Recently, Bowler and Hachinski introduced a new term, vascular cognitive impairment.

Pathophysiology

Many subtypes of vascular dementia have been described to date. The spectrum includes (1) mild vascular cognitive impairment, (2) multi-infarct dementia, (3) vascular dementia due to a strategic single infarct, (4) vascular dementia due to lacunar lesions, (5) vascular dementia due to hemorrhagic lesions, (6) Binswanger disease, (7) subcortical vascular dementia, and (8) mixed dementia (combination of AD and vascular dementia).

Vascular dementia is sometimes further classified as cortical or subcortical dementia.

Vascular disease produces either focal or diffuse effects on the brain and causes cognitive decline. Focal cerebrovascular disease occurs secondary to thrombotic or embolic vascular occlusions. Common areas of the brain associated with cognitive decline are the white matter of the cerebral hemispheres and the deep gray nuclei, especially the striatum and the thalamus. Hypertension is the major cause of diffuse disease, and in many patients, both focal and diffuse disease are observed together. The 3 most common mechanisms of vascular dementia are multiple cortical infarcts, a strategic single infarct, and small vessel disease.

Mild vascular cognitive impairment can occur in elderly persons. It is associated with cognitive decline that is worse than expected for age and educational level, but the effects do not meet the criteria for dementia and are not associated with vascular risk factors or evidence of silent strokes or extensive white matter infarcts on CT scanning. These people have subjective and objective evidence of memory problems, but their daily functional living skills are within normal limits.

In multi-infarct dementia, the combined effects of different infarcts produce cognitive decline by affecting the neural nets.

In single-infarct dementia, different areas in the brain can be affected, which may result in significant impairment in cognition. This may be observed in cases of anterior cerebral artery infarct, parietal lobe infarcts, thalamic infarction, and singular gyrus infarction.

Small vessel disease affects all the small vessels of the brain and produces 2 major syndromes, Binswanger disease and lacunar state. Small vessel disease results in arterial wall changes, expansion of the Virchow-Robin spaces, and perivascular parenchymal rarefaction and gliosis.

Lacunar disease is due to small vessel occlusions and produces small cavitary lesions within the brain parenchyma secondary to occlusion of small penetrating arterial branches. These lacunae are found more typically in the internal capsule, deep gray nuclei, and white matter. Lacunar state is a condition in which numerous lacunae, which indicate widespread severe small vessel disease, are present.

Binswanger disease (also known as subcortical leukoencephalopathy) is due to diffuse white matter disease. In Binswanger disease, vascular changes observed are fibrohyalinosis of the small arteries and fibrinoid necrosis of the larger vessels inside the brain.

In cerebral amyloid angiopathy–associated vasculopathy, aneurysm formation and stenosis in the leptomeningeal and cortical vessels cause damage to the subcortical white matter. In hereditary cystatin-C amyloid angiopathy, patients have recurrent cerebral hemorrhages before age 40 years that can lead to dementia.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy is a rare autosomal dominant condition localized to chromosome arm 19q12 that affects small vessels supplying the deep white matter. Pathologically, multiple small infarcts are observed in the white matter, thalamus, basal ganglia, and pons.

Other less common syndromes may lead to vascular dementia. Rare arteriopathies such as inflammatory arteriopathy (eg, polyarteritis nodosa, temporal arteritis) and noninflammatory arteriopathy (eg, moyamoya disease, fibromuscular dysplasia) can cause multiple infarcts and can lead to vascular dementia. Hypoperfusion due to large vessel or cardiac disease can affect the watershed areas of the brain and lead to vascular dementia.

Leukoaraiosis greater than 25% is considered to be pathological. Subcortical vascular dementia is a diffuse small vessel disease with minimal or absent infarction with homogenous pathological and clinical features.^1,2

Mixed dementia is diagnosed when patients have evidence of Alzheimer dementia and cerebrovascular disease, either clinically or based on neuroimaging evidence of ischemic lesions. Growing evidence indicates that vascular dementia and Alzheimer dementia often coexist, especially in older patients with dementia.

Autopsy studies have shown the association between AD and vascular lesions.³ Several recent studies also suggest that the risk of developing AD is increased when a patient is exposed to vascular risk factors such as hypertension, diabetes mellitus, peripheral arterial disease, and smoking, which usually are associated with cerebrovascular disease and vascular dementia. Recent evidence suggests that the vascular processes in both disorders may mutually induce each other. Apolipoprotein E may play a role in AD and vascular dementia. Apolipoprotein E-IV also increases the risk of dementia in stroke survivors and is a strong risk factor for the development of cerebral amyloid angiopathy in patients with AD. In elderly individuals, many cases of dementia may be caused by the cumulative effect of cerebrovascular and Alzheimer pathology.

One-third of patients with vascular dementia are found to have significant Alzheimer disease pathology with cholinergic deficits in the nucleus basalis of Meynert.⁴

Vascular cognitive disorder (VCD) is a new term used to describe a particular constellation of cognitive and functional impairment spectrum that ranges from vascular cognitive impairment (VCI) to subcortical vascular dementia, poststroke dementia, and mixed dementia.²

Frequency

International

• Vascular dementia is the second most common cause of dementia in the United States and Europe, but it is the most common form in some parts of Asia.
• The prevalence rate of vascular dementia is 1.5% in Western countries and approximately 2.2% in Japan.
• In Japan, vascular dementia accounts for 50% of all dementias that occur in individuals older than 65 years.
• In Europe, vascular dementia and mixed dementia account for approximately 20% and 40% of cases, respectively.
• In Latin America, 15% of all dementias are vascular.
• In community-based studies in Australia, the prevalence rate for vascular and mixed dementia is 13% and 28%, respectively.
• The prevalence rate of dementia is 9 times higher in patients who have had a stroke than in controls. One year after a stroke, 25% of patients develop new-onset dementia. Within 4 years following a stroke, the relative risk of incident dementia is 5.5%.

Mortality/Morbidity

• In patients with dementia who have had a stroke, the increase in mortality is significant. The 5-year survival rate is 39% for patients with vascular dementia compared with 75% for age-matched controls.⁵
• Vascular dementia is associated with a higher mortality rate than AD, presumably because of the coexistence of other atherosclerotic diseases.

Sex

• The prevalence of vascular dementia is higher in men than in women.

Age

• Incidence increases with age.

Clinical

History

Cognitive impairment, acutely or subacutely, after an acute neurologic event with a stepwise progression is a typical history suggestive of vascular dementia. However, this classic history is usually observed with multi-infarct dementia and may not be observed with lacunar state.  

• Binswanger disease
  • The average age of onset is between the fourth and seventh decades of life, and 80% of patients have a history of hypertension.
  • Patients also show progressive motor, cognitive, mood, and behavioral changes over a period of 5-10 years. Mood and behavioral changes are observed early and, in some patients, may be the presenting feature.
  • Patients may be apathetic or abulic.
  • Intellectual deficits are also observed early in the disease, and patients are frequently described as disoriented, having memory deficits, inattentive, and vague.
  • Patients with Binswanger dementia often have early-onset urinary incontinence and gait disturbances.
• Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy
  • The onset of the disease occurs between the third and fourth decades of life.
  • The clinical picture is similar to Binswanger disease but without a history of hypertension and risk factors for cerebrovascular disease.
•  Vascular dementia in general
  • Health professionals can perform a Mini-Mental Status Exam (MMSE)⁶ , depression assessment screen using DSM-IV-TR criteria⁷ , the Geriatric Depression Scale (GDS)⁸ , or the Cornell Scale for depression in dementia⁹ . They should also assess for suicidal and homicidal risk, if necessary. Health professionals can directly ask patients about suicidal or homicidal ideation (thoughts), intent, and plan. 
  • Major depression is widely observed mood disorder in vascular dementia. Elderly demented patients may not endorse depressed mood and may be socially withdrawn with decreased psychomotor activity. Suicidal thoughts, intent, passive wishes to die and feeling that life is not worthy is seen in these patients and they should be followed closely. Suicide attempts were observed in fewer than 1% of patients with dementia, and depression is an important reason for that.¹⁰
  • Demented patients will develop psychosis, delusions, hallucinations and paranoia at some point in their disease and sometimes agitation can be dangerous when it manifests into abnormal behavior and in rare circumstances can lead to attempts of homicide.
  • The mental status is a bedside or interview assessment and includes the patient's appearance, affect (mood), thoughts (especially the presence of hallucinations and delusions), inquiry into self-destructive behavior, homicidal behavior, judgment, and, in this diagnosis, orientation, immediate, recent, and long-term memory. 
  • Patients with vascular dementia commonly have mood and behavioral changes.
  • Severe depression is more common in persons with vascular dementia than in those with AD.
  • In some patients with lacunar state and Binswanger disease, such problems may be more prominent than intellectual deficits.
  • Even psychotic symptoms, particularly delusions, have been described in patients with vascular dementia.
  • Emotional lability may be a prominent symptom in some patients.

Physical

A commonly used cognitive screening tool is the Folstein Mini-Mental State Examination. Patchy defects are present in persons with vascular dementia. The deficits are global in persons with Alzheimer dementia.

• The Folstein Mini-Mental State Examination is as follows:
  • Orientation: First, ask the patient the date, day, month, year, and season. The maximum score is 5. Second, ask the patient their current location, ie, facility, floor, town, state, and country. The maximum score is 5.
  • Registration: Name 3 objects (eg, ball, flag, door), and ask the patient to repeat them. The maximum score is 5.
  • Attention: Ask the patient to spell the word "world" backwards or to subtract 7 from 100 serially backwards (stop after 5 answers). The maximum score is 5.
  • Recall: Ask the patient to remember the 3 objects from the Registration portion of the test. The maximum score is 3.
  • Language
    • Ask the patient to identify a pencil and a watch. The maximum score is 2.
    • Ask the patient to repeat the phrase "no ifs, ands, or buts." The maximum score is 1.
    • Ask the patient to follow a 3-step command. The maximum score is 3.
    • Ask the patient to read and obey the phrase "close your eyes." The maximum score is 1.
    • Ask the patient to write a sentence. The maximum score is 1.
    • Ask the patient to copy a set of interlocking pentagons. The maximum score is 1.
  • Scoring: The maximum score possible is 30. Generally, any score less than 24 is considered abnormal, but the cutoff varies with the patient's level of education. Because the results for this test can vary over time, and for some people results can vary during the day, record when (ie, the time and date) this test was performed.
• Several specific diagnostic criteria can be used to diagnose vascular dementia, including the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria, the International Classification of Diseases, Tenth Edition criteria, the National Institute of Neurological Disorders and Stroke-Association International pour la Recherché at L'Enseignement en Neurosciences (NINDS-AIREN) criteria, the Alzheimer's Disease Diagnostic and Treatment Center criteria, and the Hachinski ischemic score.
• The DSM-IV-TR criteria have good sensitivity but low specificity. A summary of the DSM-IV-TR diagnostic criteria is as follows:
  • The patient has developed multiple cognitive deficits manifesting as both (1) memory impairment and (2) one or more of the following cognitive disturbances: aphasia, apraxia, agnosia, and disturbance in executive functioning.
  • The cognitive deficits in the above criteria cause significant impairment in social or occupational functioning and represent a significant decline from the previous level of functioning.
  • Focal neurologic signs and symptoms or radiologic evidence indicative of cerebrovascular disease are present that are judged to be etiologically related to the dementia.
  • The deficits do not occur exclusively during the course of delirium.
• The NINDS-AIREN criteria are the most specific of all available criteria and are used most commonly in research. They provide 3 levels of certainty: definite, probable, and possible.
• Lateralizing signs such as hemiparesis, bradykinesia, hyperreflexia, extensor plantar reflexes, ataxia, pseudobulbar palsy, and gait and swallowing difficulties may be observed.
• Subcortical vascular dementia signs include balance problems, gait disorder, and urinary incontinence; focal lesions may be subtle.
• Neuropsychological testing is as follows:
  • Patients with vascular dementia have patchy neuropsychological deficits. With vascular dementia, patients have better free recall and fewer recall intrusions compared with patients with AD. Apathy early in the disease is more suggestive of vascular dementia because it usually occurs in the later stages of AD.
  • Patients with vascular dementia have poor verbal fluency and more perseverative behavior compared with patients with AD. They may even have other signs of executive dysfunction such as cognitive slowing, difficulty in shifting sets, and problems with abstraction. Commonly used mental status tests include the Folstein Mini-Mental State Examination and the Cognitive Abilities Screening Instrument.
  • Some cognitive patterns may help to differentiate vascular dementia clinically from AD. Patients with vascular dementia tend to show greater deficits on measures of frontal executive functioning than patients with AD, whereas patients with AD show greater long-term memory deficits than patients with vascular dementia. 
    
  • Neuropsychological findings vary with the site and severity of cerebrovascular disease.
  • For patients with single or multiple large infarcts, deficits correlate with the site and extent of the infarct.
  • In patients with extensive deep white matter disease, impairments may be observed in tests of psychomotor speed, dexterity, executive function, and motor aspects of speech (eg, dysarthria, reduced verbal output). Patients with subcortical vascular dementia show reduced ability to set and reach goals with mental slowing and gradual executive dysfunction.

Causes

• Risk factors for vascular dementia include hypertension, smoking, hypercholesterolemia, diabetes mellitus, and cardiovascular and cerebrovascular disease.

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