Vascular dementia is a heterogeneous disorder caused by the sequelae of cerebrovascular disease that manifests in cognitive impairment affecting memory, thinking, language, behavior, judgment, and executive dysfunction.
- Vascular dementia (previously known as multi-infarct dementia) was first mentioned by Thomas Willis in 1672. Later, it was further described in the late 19th century by Binswanger and Alzheimer as a separate entity from dementia paralytica caused by neurosyphilis. This concept has evolved tremendously since the advent of neuroimaging modalities.
- Synonym(s): vascular cognitive impairment (VCI); vascular cognitive disorder (VCD); poststroke dementia; Binswanger disease. Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) categorizes vascular dementia as mild or major VCD.
Common cause of dementia in the elderly and it frequently overlaps with Alzheimer dementia
About 6 to 12 cases per 1,000/person age >70 years
- ~1.2–4.2% in those age >65 years
- 14–32% prevalence of dementia after a stroke
Etiology and Pathophysiology
No set pathologic criteria exist for the diagnosis of vascular dementia such as those that exist for Alzheimer dementia. Pathology includes the following:
- Large vessel disease: cognitive impairment that follows a stroke
- Small vessel disease (subcortical) includes white matter changes (leukoaraiosis), subcortical infarcts, and incomplete infarction. This is usually the most common cause of multi-infarct dementia. Lacunar infarcts and deep white matter changes are typically included in this category.
- Transient ischemic attack (TIA)/stroke
- Vascular, demographic, genetic factors
- Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is caused by a mutation in the NOTCH3 gene on chromosome 19 that results in leukoencephalopathy and subcortical infarcts. This is clinically manifested in recurrent strokes, migraine with aura, and vascular dementia.
- Apolipoprotein E gene type: Those with ApoE4 subtypes are at higher risk of developing both vascular and Alzheimer dementia.
- Amyloid precursor protein (APP) gene: leads to a form of vascular dementia called heritable cerebral hemorrhage with amyloidosis
- Optimization and aggressive treatment of vascular risk factors, such as HTN, diabetes, and hyperlipidemia
- HTN is the single most modifiable risk factor and treatment for it must be optimized.
- Smoking is associated with white matter changes on imaging, which may be associated with small vessel disease and vascular dementia progression.
- Lifestyle modification: weight loss, physical activity, smoking cessation
- Hearing loss should be corrected.
- Depression and social isolation should be evaluated.
- Cognitively stimulating activity can be beneficial.
Commonly Associated Conditions
- Cerebral amyloid angiopathy (CAA) causes ischemic white matter damage due to amyloid deposition in penetrating cortical vessels.
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