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.
In a randomized controlled trial, no significant differences were found in the follow-up coordination of care either in the memory clinics or with general practitioners in patients diagnosed to have mild to moderate dementia with regards to quality of life, mood and behavioral problems [28] .
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.
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.
A study by Vercambre et al examined data from participants in the Women's Antioxidant Cardiovascular Study; the findings revealed a significant difference in the rate of cognitive decline over 5 years (p< .003) among elderly women who had physical activity equivalent to daily 30 minutes walk at a brisk pace. Exercise may improve brain vascular health and strengthen the mechanisms underlying brain plasticity. [29]
Complications
See the list below:
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Behavioral problems, including wandering, delusions, hallucinations, and poor judgment
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Depression
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Falls and gait abnormality
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Aspiration pneumonia
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Decubitus ulcers
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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.
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Syndrome of delayed posthypoxic leukoencephalopathy (DPHL): Patients who had a period of prolonged hypoxia secondary to cardiac arrest can develop neuropsychiatric complications. It is a demyelinating syndrome and a slow gradual recovery can happen over a 3- to 12-month period. Neuroimaging can show diffuse demyelination sparing cerebellum and brain stem. In some patients, cognitive impairment, especially with domains of attention and executive function, can be permanent. [30]
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
In addition to patient 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:
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Use short simple sentences when communicating with patients with dementia.
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Simplify and create a routine for all self-care tasks such as bathing and dressing.
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Establish a daily routine for all activities such as meals, medication administration, recreation, exercise, and sleep.
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To reorient the patient, use signs and pictures, clocks and calendars, family photos, and a list of daily activities.
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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.
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Additional patient and family education can be accessed at the following sites:
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Alzheimer's Association: Vascular Dementia
National Institute of Neurological Disorders and Stroke: NINDS Multi-Infarct Dementia Information Page
For excellent patient education resources, visit eMedicineHealth's Brain and Nervous System Center. Also, see eMedicineHealth'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.
