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.^[23]

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.

Agitation and psychosis are common in older adults with dementia and are challenging to manage. Relatively few studies have examined the use of antidepressants for the treatment of agitation and psychosis in dementia; however, the selective serotonin reuptake inhibitors (SSRIs) sertraline and citalopram appear to be associated with a reduction in symptoms of agitation when compared with placebo.^[24]Both appear to be reasonably well tolerated when compared with placebo, typical antipsychotics, and atypical antipsychotics. However, more studies are needed to determine if SSRIs, trazodone, or other antidepressants are safe and effective treatments for agitation and psychosis in dementia.

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.

Prevention

In a 44-year longitudinal population study of Swedish women, researchers found that a high cardiovascular fitness in midlife was associated with a decreased risk of subsequent dementia. Data show women with high fitness levels had an 88% lower risk of developing dementia compared with women who were moderately fit in midlife. Additionally, when the highly fit women did develop dementia, they developed the disease an average of 11 years later than women who were moderately fit.^{[25, 26]}

Heavy drinking is the strongest potentially modifiable risk factor for dementia, according to a retrospective analysis involving 30 million people in France. Data from the study show that those with a history of alcohol use disorders had a threefold increased risk for dementia and that over half those with early-onset dementia had a history of alcohol problems. Of 57,000 patients who had developed dementia under the age of 65 years, 57% had a history of alcohol use disorders (66% of men and 37% of women).^[27]

Medication

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