Vascular Dementia

About

Dementia often called a 'major neurocognitive disorder,' is a chronic progressive cognitive deterioration illness that results in functional impairment. Vascular dementia is the most common type of dementia next to Alzheimer's disease(1^✔).

Vascular dementia refers to a decline in memory, thinking, behavior, and cognitive functions caused due to blockage in the blood supply to the brain. It is also called Vascular Cognitive Impairment (VCI). The etiology of vascular dementia is caused by brain tissue ischemia, which results in gliosis and demyelination. Although vascular dementia is not a genetic illness in most circumstances, the contributing health issues can be passed down from generation to generation(2^✔).

Stages of Vascular Dementia

The seven stages of vascular dementia are defined as follows(3^✔):

Stage 1: No Cognitive Decline

The first stage of dementia is also known as the normal functioning period. At this stage of dementia development, a patient usually does not have any severe memory issues or cognitive impairment. Stages 1-3 of dementia progression are commonly referred to as "pre-dementia" stages.

Stage 2: Age-Associated Memory Impairment

This stage is characterized by intermittent memory lapses, the most common of which are:

• Forgetting where one has placed an object
• Forgetting names that were formerly well-known

This slight impairment in memory is often mistaken for typical age-related cognitive decline, but it can also be one of the first indicators of degenerative dementia. Clinical testing is currently unable to detect indications at this level. Concerns about the start of dementia at a young age should be raised in light of other symptoms.

Stage 3: Mild Cognitive Impairment

In stage 3, distinct cognitive impairments emerge. Among the symptoms of stage 3 dementia are:

• Easily getting lost
• Noticeably bad work performance Forgetting the names of family members and close acquaintances
• Difficulty remembering material read in a book or chapter
• Loss or misplacement of crucial items Difficulty concentrating

As these symptoms become more disruptive to daily life, patients frequently suffer mild to moderate anxiety. Patients who may be at this stage of dementia are recommended to have a clinical interview with a doctor in order to receive an accurate diagnosis.

Stage 4: Mild Dementia

Individuals may begin to retreat socially and exhibit changes in personality and mood during this period. In stage 4, denial of symptoms is a common defense technique. Look for the following behaviour: decreased understanding of current and/or recent events.

Difficulty recalling details from one's past; decreased capacity to manage funds, plan travel, and so on.

Disorientation Difficulty identifying individuals and faces

Individuals with stage 4 dementia have no difficulty recognizing known faces or traveling to familiar settings. However, individuals in this stage will frequently avoid difficult situations in an attempt to conceal symptoms or minimize stress or anxiety.

Stage 5: Moderate Dementia

Patients in stage 5 require support to go about their daily lives. The inability to remember significant facts such as the name of a close family member or a home address is the primary symptom of stage 5 dementia. Patients may lose track of time and place, struggle to make judgement, and forget fundamental facts about themselves, such as a phone number or address.

While mild dementia can impair basic functioning, people at this stage do not require assistance with basic duties such as using the restroom or eating. Patients can also remember their names as well as the names of their spouses and children.

Stage 6: Moderately Severe Dementia

When a patient forgets the names of their children, spouse, or primary carers, they are most certainly in stage 6 of dementia and will require full-time care. Patients in the sixth stage are often ignorant of their surroundings, unable to recollect recent events, and have distorted memories of their past. Caregivers and loved ones should keep an eye out for:

• Behavior that is delusory
• Obsessive signs and behavior
• Anxiety, aggressiveness, agitation Willpower loss
• Patients may begin to wander, have trouble sleeping, and, in some situations, develop hallucinations.

Stage 7: Severe Dementia

During the course of stage 7 dementia, patients will gradually lose their ability to communicate in addition to their motor skills. The brain appears to lose contact with the body in the final stage. Severe dementia typically results in the loss of all linguistic and communication abilities. Loved ones and carers will need to assist the individual with walking, eating, and toileting.

What are the Causes of Vascular Dementia?

The main cause of vascular dementia is reduced blood supply to a part of the brain. This results in the death of the brain cells in a particular part of the brain and leads to impairment of cognitive functions such as memory, thinking, or reasoning in individuals. This loss of cognitive functions due to reduced blood supply in the brain is called vascular dementia.

Factors that increase the risk of a person developing vascular dementia include the following(4^✔):

• Older age, since the chances of stroke are higher at an older age
• Prior history of Stroke, diabetes, heart disease, high blood pressure, high cholesterol, obesity
• Atrial fibrillation, which is a disorder of cardiac rhythm. Clots are formed in the heart, which spread to other organs through the blood
• Lifestyle factors like physical inactivity, unhealthy diet,and smoking
• Genetic factors

What are the Types of Vascular Dementia?

Depending on the cause of the damage and the part of the brain affected, features of vascular dementia in the particular patient can vary. Types of vascular dementia are:

• Stroke-related dementia
• Subcortical dementia
• Mixed dementia

Stroke-Related Dementia: A Stroke occurs when the blood supply to a part of the brain gets cut off suddenly. It is often caused by a clot but may occur due to a bleed in the brain as well. Dementia that occurs following a stroke is referred to as post-stroke dementia. Post-stroke dementia occurs in about 20% of individuals who have suffered from a stroke. The part of the brain where the death of cells occurs due to reduced blood supply is called an infarct. If dementia is due to a single infarct that affects an important part of the brain, it is referred to as single-infarct dementia. If it occurs due to multiple small infarcts, it is called multi-infarct dementia(5^✔).

Subcortical Dementia: Subcortical dementia is caused due to the stiffening of very small blood vessels deep inside the brain. The damage occurs to the nerve fibers known as white matter. This is the most common form of vascular dementia(6^✔).

Mixed Dementia: It is a combination of both vascular dementia and Alzheimer's disease. At least 10% of people with dementia suffer from mixed dementia(7^✔).

Multi-infarct Dementia (MID): MID is a prevalent cause of memory loss in the elderly. Multiple strokes induce MID (disruption of blood flow to the brain). Blood flow disruption causes brain tissue injury. Some of these strokes may occur in the absence of obvious clinical symptoms. These are known as 'silent strokes' by doctors(8^✔).

What are the Symptoms and Signs of Vascular Dementia?

A patient with vascular dementia often exhibits physical symptoms of the stroke like paralysis or loss of bladder control. Dementia symptoms usually worsen in a stepwise manner in stroke-related dementia, making the patient completely dependent on the caregiver in the later stages. The most common symptoms of vascular dementia include(9^✔):

• Memory loss
• Communication difficulties:
• Difficulty in following instructions
• Difficulty in planning or organizing
• Concentration problems
• Impaired decision-making abilities
• Less problem-solving capacity
• Loss of social skills
• Unusual changes in mood. Aggression may be present in later stages
• Hallucinations
• Depression

How to Diagnose Vascular Dementia?

It is very difficult to diagnose vascular cognitive impairment. But people who are at high risk for developing dementia must undergo certain tests to access their cognitive functioning. Diagnosis of vascular dementia involves the following tests(10^✔):

• History from the patient or relatives
• Complete general and neurological examination. Memory, reasoning,and thinking abilities should also be assessed.
• Blood tests to check thyroid or vitamin deficiencies, cholesterol,and blood sugar levels.
• ECG to check heart function
• Brain imaging techniques like CT scans, andMRI imaging for identifying any infarcts, strokes, or abnormalities in the brain.

How do you Treat Vascular Dementia?

Treatment cannot cure the person affected with vascular dementia completely. But still, certain measures and drugs can help alleviate the symptoms of the disease. As an important cause of vascular dementia is a stroke, medications to prevent the occurrence of strokes can be given to high-risk individuals(11^✔).

Diseases such as hypertension, diabetes, and obesity that occur due to lifestyle changes can lead to strokes. Therefore drugs to control blood sugar levels, cholesterol, and blood pressure can be given to reduce the risk. A healthy diet and regular exercise can also reduce the risk of the disease. One must abstain from alcohol and smoking to lessen the risk of strokes.

Medication

Medications used to treat vascular dementia are anti-platelets (aspirin) can be prescribed to prevent the formation of clots in the blood vessels. Anticoagulants (warfarin) can prevent strokes. As the person affected with dementia can feel depressed and also restless, they can be prescribed anti-depressants(12^✔). Recently cholinesterase inhibitor medications such as donepezil and galantamine that are given to people with Alzheimer's disease may provide benefit to some people with vascular dementia, though they are not approved for this purpose(13^✔).

Surgical Treatment

Carotid endarterectomy is a surgical procedure that can remove blocks in the carotid artery. This is very rarely recommended for patients with vascular dementia(14^✔).

Care and Support

People affected with dementia need constant support and help from others. Therefore,family members and friends need to take care of them during this struggle. Keeping them mentally active can help them with memory and communication. They can also be encouraged to practice diary writing. Rehabilitation can also help them to get better control of the disease. Cognitive rehabilitation (CR) is a typical non-pharmacological strategy to treating cognitive impairments in dementia patients. A physiotherapist can assist them with movement, while a speech therapist can assist them with communication. Vascular dementia and mobility symptoms differ from person to person; individuals may experience difficulty walking, balance issues, and an increased risk of falling. Standing from a seated position may be more difficult. Physical exercises such as functional mobility training, particularly walking, produce better benefits(15^✔).

How do you Prevent Vascular Dementia?

As vascular dementia pertains to heart health and healthy blood vessels, it is advisable to maintain good cardiovascular health to prevent vascular dementia.

The following can help in the prevention of vascular dementia(16^✔):

• Exercise regularly: Physical activity can play a key role in your overall well-being. Regular exercise boosts the blood supply in the body which in turn can prevent blockages in the blood vessels. Thus, it helps to reduce the risk of vascular dementia.
• Eat a Healthy Diet: Consume fresh fruits and vegetables as they are rich in antioxidants. Avoid foods that have extra salt.
• Maintain Normal Blood Pressure: As high blood pressure can lead to damage of blood vessels, it is best to maintain the blood pressure in the normal range.
• Lower Blood Cholesterol Levels: Eat a healthy and low-fat diet to keep your cholesterol levels in check. Cholesterol-lowering medications are prescribed if your cholesterol levels remain high.
• Control Blood Sugar Levels: If you have diabetes, you should control your blood sugar level with diet, physical activity, and medications.
• Stop Smoking: Smoking is the most prominent cause of stroke. Therefore, it is best to quit smoking to reduce the risk of vascular dementia.
• Relax & Manage Stress: Learn to manage stress as it turns out to be the key factor for hypertension and heart diseases. Laugh, and enjoy yourself to keep stress at bay.

Prognosis

Patients suffering from vascular dementia have a life expectancy of 3 to 5 years. Those who have previously experienced a cerebrovascular accident have the highest mortality rate, with a 5-year survival rate of only 39%. Patients with vascular dementia frequently have an atherosclerotic disease, and cardiovascular mortality is prevalent(17^✔).

References:

1. Vascular dementia - (https://medlineplus.gov/ency/article/000746.htm)
2. Vascular Dementia: Causes, Symptoms, and Treatments - (https://www.nia.nih.gov/health/vascular-dementia)
3. The seven stages of vascular dementia - (https://www.dementia.org/stages-of-dementia)
4. Vascular dementia prevention: a risk factor analysis - (https://pubmed.ncbi.nlm.nih.gov/16327258/)
5. Stroke and dementia - (https://pubmed.ncbi.nlm.nih.gov/19723451/)
6. Subcortical dementia - (https://pubmed.ncbi.nlm.nih.gov/8763104/)
7. Mixed dementia: A review of the evidence - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5769994/)
8. Multi-Infarct Dementia - (https://www.ninds.nih.gov/health-information/disorders/multi-infarct-dementia)
9. About Vascular Dementia - (https://www.ncbi.nlm.nih.gov/books/NBK430817/)
10. Introduction of Vascular Dementia - (https://pubmed.ncbi.nlm.nih.gov/28613567/)
11. Stroke and Vascular Dementia and Alzheimer�s Disease - Molecular Links - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5793908/)
12. Antidepressants for treating depression in dementia - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513376/)
13. Treatment of dementia - (https://pubmed.ncbi.nlm.nih.gov/28936936/)
14. Carotid Endarterectomy - (https://www.ncbi.nlm.nih.gov/books/NBK470582/)
15. Interventions to Improve Gait in Older Adults with Cognitive Impairment: A Systematic Review - (https://pubmed.ncbi.nlm.nih.gov/30506754/)
16. Vascular dementia: prevention and treatment - (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695177/)
17. Information About Vascular Dementia - (https://www.ncbi.nlm.nih.gov/books/NBK430817/)

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