Vascular Dementia PDF

42. Vascular dementia. Definition, prevalence, risk factors, etiopathogenesis, clinical course, complications, diagnosis, treatment, prevention (L.5.10) Definition: gradual cognitive decline caused by small or large vessel disease. Prevalence: It is the second most common cause of de...

42. Vascular dementia. Definition, prevalence, risk factors, etiopathogenesis, clinical course, complications, diagnosis, treatment, prevention (L.5.10) Definition: gradual cognitive decline caused by small or large vessel disease. Prevalence: It is the second most common cause of dementia in the elderly (10-20% of cases); prevalence increases with age ranging from 1.2 to 4.2% of people over 65 years old Risk factors: (possible etiologies) Cerebrovascular disorders: 1. Large artery disease 2. Artery-to-artery embolism 3. Occlusion of an extra- or intracranial artery 4. Cardiac embolic events 5. Small vessel disease (lacunar infarcts; ischaemic white matter lesions) 6. Haemodynamic mechanisms 7. Specific arteriopathies 8. Haemorrhages (intracranial, subarachnoid) 9. Haematological factors 10. Venous diseases 11. Hereditary entities. Pathogenesis: The 3 most common mechanisms of vascular dementia: 1. multiple cortical infarcts, 2. a strategic single infarct 3. small vessel disease. Clinical Course: abrupt onset of cognitive impairment (Days to weeks) Often stepwise deterioration (some recovery after worsening) and fluctuating course of cognitive symptoms 20-40 % is insidious progression Complications: Future strokes Heart disease Loss of function Loss of independence Infections & pneumonia Pressure sores Diagnosis: Clinical neurological findings indicating focal brain lesion early in the course: (mild motor, sensory deficits, decreased coordination, brisk tendon reflexes, Babinski’s sign Bulbar signs including dysarthria and dysphagia Gait disorder: hemiplegic, apractic-atactic, small-stepped Unsteadiness and unprovoked falls Urinary frequency and urgency Psychomotor slowing, abnormal executive functioning Depression, anxiety, emotional lability Relatively preserved personality and insight in mild and moderate cases. Comorbid findings: History of cardiovascular diseases (not always present): arterial hypertension, coronary heart disease, atrial fibrillation Radiological findings: Computed tomography or magnetic resonance imaging: focal infarcts (70-90%), diffuse or patchy white matter lesions (70- 100%), often more extensive SPECT or PET: often patchy reduction of regional blood flow. Electroencephalography: if abnormal, more focal findings; Laboratory findings: No known specific tests; findings related to concomitant diseases, e.g. hyperlipidemia, diabetes mellitus, cardiac abnormality. Assessment of cognitive function: e.g. MMSE, Blessed dementia scale, Assessment of functional ability: eg. ADL, IADL, Barthel index Prevention & treatment of Vascular Dementia: 1. Control of risk factors of cerebrovascular disease; Control of hypertension: BP 135-150 mmHg To avoid nocturnal drop in BP Prevention of embolization: Anticoagulants (warfarin, INR 2,0-4,5) or Aspirin (up to 325 mg/d) Control of hypercholesterolemia and diabetes Nonsmoking 2. Improvement of cognitive functions; Acetylcholinesterase inhibitors (AChEIs) ( only for patient with mixed dementia) No strong evidence that drugs can improve cognitive functions in vascular dementia. 3. Management of non-cognitive functions (approach is the same as in other dementias, including Alzheimer type dementia)