Medical Care
The treatment of vascular dementia is symptomatic. Behavioral and psychiatric disturbances such as agitation, depression, and psychosis are common. Cerebrovascular disease should be treated by an internist and/or a neurologist familiar with the management of cerebrovascular disease.
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Established protocols for the evaluation and treatment of stroke are available. The individual approach combines a vascular risk factor modification and various treatments addressing the specific subtypes of stroke, such as antiplatelet drugs for the prevention of cerebral infarction in large and small artery diseases of the brain, carotid endarterectomy or stenting for tight carotid artery stenosis, and oral anticoagulants for the prevention of cardiac emboli. [8]
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The presence of a rapidly progressive dementia and multiple strokes in a young patient may indicate uncommon causes of stroke such as CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) or angiitis. If suspected on clinical grounds, these conditions should be excluded with the appropriate testing procedures (ie, skin biopsy, cerebral angiography). The decision to use anticoagulation in patients with vascular disease and dementia is particularly challenging because of the increased risk of falls and potential noncompliance in this group.
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Patients with vascular dementia are prominently affected by depression and emotional incontinence. Both conditions respond well to treatment with serotonin reuptake inhibitors.
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Patients with agitation may respond to environmental modification. Pharmacologic treatment can be useful in controlling agitation through sedation.
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In a prospective study done by Ancelin et al (2012), no evidence was found that lipid-lowering agents given in late life reduced the risk of cognitive decline and dementia. However, it did raise the possibility that women with treatment-resistant high low-density lipoprotein (LDL) cholesterol may be at increased risk of decline in visual memory. [9] . Vascular cognitive impairment seems to be a treatable common cause of memory impairment and its progression can be slowed by secondary prevention of vascular disease. [20]
Behavioral Therapy
Researchers at Johns Hopkins University have developed a new 6-step nonpharmacologic approach for identifying and managing behavioral problems in patients with dementia, as follows [6, 7] :
Screen annually with validated behavioral assessment tools (eg, Neuropsychiatric Inventory) and implement preventive measures (eg, caregiver counseling regarding patient self-care, adequate stimulation, nutrition, sleep, and detection of early symptoms)
Describe presenting behaviors by interviewing the patient and caregiver
Identify potential underlying causes (eg, medical illness, pain, medications; caregiver behaviors; home environment)
Devise a treatment plan that targets behaviors (eg, exercise, structured routines, meaningful activities) and eliminates modifiable triggers (eg, caffeinated beverages, afternoon napping, stimulating distractions such as nighttime TV)
Determine the effectiveness of the nonpharmacologic strategies (eg, Has there been any behavioral improvement? Have there been any changes in the patient’s behavioral characteristics, environment, or health status that might have affected or been affected by the treatments?)
Perform ongoing monitoring to determine whether new behavioral symptoms are emerging and whether nonpharmacologic therapies need to be adjusted or changed
