eMedicine Specialties > Psychiatry > Geriatric
Vascular Dementia: Treatment & Medication
Updated: Aug 18, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
The mainstay of management of vascular dementia is the prevention of new strokes. This includes administering antiplatelet drugs and controlling major vascular risk factors. Aspirin has also been found to slow the progression of vascular dementia.
- Recent guidelines from the American Psychiatric Association provide both treatment principles and possible specific therapies.
- Drug treatment is primarily used to prevent further worsening of vascular dementia by treating the underlying disease such as hypertension, hyperlipidemia, and diabetes mellitus. Antiplatelet agents are indicated.
- Pentoxifylline and, to a more limited extent, ergoloid mesylates (Hydergine), may be useful for increasing cerebral blood flow. In the European Pentoxifylline Multi-Infarct Dementia Study, which is a double-blinded, placebo-controlled, multicenter study, treatment with pentoxifylline was found to be beneficial for patients with multi-infarct dementia. Significant improvement was observed in the scales used for assessing intellectual and cognitive function.
- Neuroprotective drugs such as nimodipine, propentofylline, and posatirelin are currently under study and may be useful for vascular dementia. Nicardipine is a dihydropyridine calcium channel blocker that was studied on the treatment of cognitive deterioration of vascular origin. Preliminary studies showed decrease in cognitive deterioration in patients with cerebrovascular disease.18
- Increasing evidence supports the involvement of the cholinergic system in vascular dementia, similar to that seen in Alzheimer dementia. However, no cholinesterase inhibitors have been approved to date for the treatment of vascular dementia, despite positive results in clinical trials with this medication.
- The general management of dementia includes appropriate referral to community services, judgment and decision-making regarding legal and ethical issues (eg, driving, competency, advance directives), and consideration of caregiver stress.
Diet
- In the Rotterdam study, an increased risk of vascular dementia was associated with total fat intake, whereas fish consumption was inversely related to dementia.
- Low levels of folate, vitamin B-6, and vitamin B-12 are associated with increased homocysteine levels, a risk factor for stroke.
Medication
Medical therapy options include antiplatelet and hemorheologic agents.
Antiplatelet agents
Studies have shown antiplatelet agents are useful for preventing recurrent stroke. In vascular dementia, a pilot study showed that aspirin has positive effects on cognitive deficits. Recent studies have shown it may have some neuroprotective effects. Other antiplatelet agents are ticlopidine and clopidogrel.
Aspirin (Anacin, Ascriptin, Bayer aspirin)
Prevents platelet-aggregating thromboxane A2 by blocking prostaglandin synthetase action and thereby preventing prostaglandin synthesis.
Adult
325 mg PO qd
Pediatric
Not established
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses > 2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; use in children ( <16 y) with flu (associated with Reye syndrome)
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants
Ticlopidine (Ticlid)
Used in patients who cannot tolerate aspirin therapy or in whom aspirin therapy fails.
Adult
250 mg PO bid
Pediatric
Not established
Effects may decrease with coadministration of corticosteroids and antacids; toxicity increases when taken concurrently with theophylline, cimetidine, aspirin, and NSAIDs
Documented hypersensitivity; neutropenia or thrombocytopenia; liver damage; active bleeding disorders
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Discontinue if absolute neutrophil count decreases to <1200/µL or if platelet count falls to <80,000/µL
Clopidogrel bisulfate (Plavix)
Antiplatelet drug that acts by direct inhibition of ADP binding to the platelet receptor and of subsequent ADP-mediated activation of the glycoprotein IIb/IIIa complex.
Adult
75 mg PO qd
Pediatric
Not established
Coadministration with naproxen associated with increased occult GI blood loss; prolongs bleeding time; safety of coadministration with warfarin not established
Documented hypersensitivity; active pathological bleeding (eg, peptic ulcer); intracranial hemorrhage
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use caution in patients at increased risk of bleeding from trauma, surgery, or other pathological conditions; caution in patients with lesions with propensity to bleed (eg, ulcers)
Hemorheologic agents
Improve flow properties of blood by lowering viscosity, improving erythrocyte flexibility, inhibiting platelet aggregation and thrombus formation, and suppressing leukocyte adhesion.
Pentoxifylline (Trental)
In a multicenter, double-blinded, placebo-controlled trial involving 29 European centers, improvement in cognitive function at 9 mo was noted.
Adult
400 mg PO tid
Pediatric
Not established
Coadministration with cimetidine or theophylline increases effects and toxic potential; increases effect of antihypertensives
Documented hypersensitivity; cerebral or retinal hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment
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
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
