Neurological Manifestations of Vascular Dementia Clinical Presentation

Updated: Nov 07, 2019
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM  more...
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Presentation

History

Criteria for the diagnosis of dementia require impairment in memory and at least 1 other cognitive domain (eg, orientation, language, praxis, executive functions, visuospatial abilities). These should be serious enough to affect activities of daily living and be consistently present to distinguish dementia from episodic impairments of consciousness such as delirium.

Currently, several sets of diagnostic criteria for vascular dementia exist. This list summarizes the main common criteria.

  • Vascular risk factors such as hypertension, coronary disease, and diabetes mellitus [17]

  • Specific evidence of cerebrovascular disease, eg, strokes and transient ischemic attacks: The cerebrovascular insult should precede (by no more than 3 months) or coincide with the onset or worsening of cognitive abnormalities.

  • Neuroimaging evidence of strokes

  • Lateralizing neurologic signs

  • Psychiatric disturbances (eg, emotional lability, depression, apathy)

Depression is a common comorbidity in patients with cerebrovascular disease and vascular dementia.

Medications should be reviewed because of the potential of drugs to interfere with alertness and cognition.

Differences between the cognitive disturbances in vascular dementia and Alzheimer disease are of limited value in discriminating vascular dementia from Alzheimer disease in a clinical setting.

  • Vascular dementia is thought to be associated with less significant memory dysfunction than Alzheimer disease. [3]

  • Frontal dysfunction due to widespread involvement of subcortical structures in vascular dementia is thought to lead to a dysexecutive syndrome with abulia and apathy.

A cognitively impaired patient with vascular risks factors but no history of cerebrovascular disease is most likely to have Alzheimer disease. Patients with dementia and vascular disease frequently have mixed pathology (ie, both Alzheimer disease and vascular dementia).

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Physical

The physical examination should be focused on the cardiovascular system and neurologic localizing signs.

  • The temporal arteries may show decreased pulsatility, local tenderness, and thickening associated with giant cell arteritis. [5]

  • Funduscopic examination provides important information regarding end-organ effects of hypertension and diabetes mellitus.

  • Cardiac auscultation may detect rhythmic and valvular abnormalities.

  • Low scores on a standardized instrument (eg, Mini Mental Status Examination, Short Blessed questionnaire) can provide corroborating evidence of a cognitive disturbance.

  • Spasticity, hemiparesis, visual field defects, pseudobulbar palsy, and extrapyramidal signs confirm focal pathology.

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Causes

Vascular dementia and cerebrovascular disease share risk factors, including age, male sex, diabetes mellitus, hypertension, cardiomyopathy, and possibly homocysteine levels.

  • So far, no relationship between cholesterol, serum lipoproteins, and the risk of vascular dementia is clearly indicated.

  • Evidence for tobacco consumption as a risk factor for vascular dementia is conflicting. However, a multiethnic, population-based study published in 2010 suggested that the brain is not immune to long-term consequences of heavy smoking. In fact, 21,123 heavy midlife smokers were followed for a mean of 23 years and were found more than 2 decades later to have a greater than 100% increased risk of dementia, Alzheimer disease, and vascular dementia. [18]

  • Limited alcohol consumption may be protective. [19]

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