Dementia is an umbrella term that is often used inaccurately to describe several different conditions. Dementia can often be confused with disorders such as delirium and be mistaken for Alzheimer’s disease. The confusion is understandable, as Vascular Dementia falls into a cluster of disorders which are part of the Alzheimer’s family. The Alzheimer’s Society has noted that Vascular Dementia is the second most common cause of dementia after Alzheimer’s disease. Research has raised the knowledge and understanding of the disease and supported earlier detection.
- What is Vascular Dementia?
- How Does Vascular Dememtia Differ from Alzheimer’s disease?
- Who is at Risk of Developing Vascular Dementia?
- What are the Symptoms of Vascular Dementia?
- Diagnosing Vascular Dementia
- Treatment and outcomes for Vascular Dementia
- Prevention of Vascular Dementia
- Living with Vascular Dementia
- The future of Vascular Dementia
There are 8 Subtypes of Vascular Dementia:
- Mild Vascular Cognitive Impairment
- Multi-Infract Dementia
- Vascular Dementia due to a Single Infarct
- Vascular Dementia due to Lacunar Lesions
- Vascular Dementia due to Hemorrhagic Lesions
- Binswanger Disease
- Subcortical Vascular Dementia
- Mixed Dementia (a combination of Alzheimer’s disease and Vascular Dementia)
Vascular dementia may also be classified as Cortical or Subcortical Dementia in correlation with the areas of the brain which may be impacted.
People with Vascular dementia can end up with either focal or diffused effects on the brain. This means that the damage people incur may be focused in one area, or it may spread throughout the brain. Mild Vascular Cognitive Impairment can occur in older adults as a result of multiple infarcts or tissue death due to aging. The greater the breadth of vascular damage, the larger the impact on the brain. Focal vascular diseases usually occur after another type of event in the body, such as an embolic or thrombotic clot. Hypertension or high blood pressure that is left untreated is often the cause of such vascular disease.
Small Vessel Disease occurs when all small vessels within a specific area are compromised, again mostly in the brain. Small vessel disease implies damage to arterial walls; this damage and the events that follow are what lead to vascular dementia.
Lacunar Disease is another disease of small vessels; in this instance the vessels become occluded, or clogged. In the absence of adequate treatment, blood flow is inhibited, thus resulting in tissue damage and death. With lacunar disease, the lack of blood flow causes some people to develop lesions within the brain, called lacunae.
Binswanger Disease is a disease that causes diffused, or widespread damage to the white matter in the brain. This damage impairs the blood flow within the brain, resulting in vascular dementia.
The common theme throughout the different causes of vascular dementia is an event in the body that results in decreased blood flow to the brain. This may be from hereditary conditions or other types of underlying diseases.
While many of the presenting symptoms are the same, major differences consist of onset and predisposing factors including different types of illness. Alzheimer’s disease generally has a slower onset, and patients report symptoms such as memory difficulties, particularly in regard to recent activities or conversations. Vascular dementia, on the other hand, presents more as changes in judgment or ability to make decisions.
Vascular dementia occurs most often from blockage of blood vessels or damage that leads to tissue death in the brain (for example, stroke). The location and size of this damage determines the extent of disease a person will experience, and the likely treatment.
Previous thinking was that Alzheimer’s disease and Vascular dementia were two distinct diseases; however, we now know many patients suffer from the type known as mixed dementia.
Many of the risk factors and treatments for Vascular Dementia are like those of heart disease, due to the relationship between Vascular Dementia and the occlusion of blood vessels. Those with diagnosed heart conditions may be at greater risk for VD (for example, atrial fibrillation that does not undergo treatment). People with high blood pressure and high cholesterol that is left untreated are also at greater risk. Heart conditions, high blood pressure, and high cholesterol increase damage to blood vessels, increasing the likelihood of ischemic damage. Those who have previously suffered strokes or transient ischemic attacks (TIAs) are at the greatest risk.
Vascular dementia symptoms are most obvious if they occur relatively soon after a stroke. Sudden post-stroke symptoms may include confusion, disorientation, difficulty speaking or understanding speech, or vision loss. These symptoms make diagnosis and treatment challenging as they often mimic stroke symptoms, and may also occur at the same time a stroke is occurring.
If a person has suffered multiple strokes over a period of time, the changes may be more gradual. This happens because the damage spreads more slowly across the brain. The person may begin to demonstrate impaired planning and judgment, uncontrolled laughing or crying, inability to pay attention, impaired social ability, and have difficulty finding words.
Vascular dementia may progress in an irregular pattern, where the patient appears better for a period of time, only to have their health worsen.
The most effective diagnosis and subsequent treatment involves professional screening which will include a thorough analysis of medical history, noting any family history of dementia. In addition, an evaluation of independent function and daily activities is required to identify what areas the patient has difficulty with. Family members are consulted to determine what changes they have noticed, and laboratory tests are performed to detect underlying medical issues. Brain imaging may also be necessary to see where damage has occurred.
The most useful test in determining the presence of dementia is a neurological examination or neuropsychological assessment. These tests will look at behavioral factors such as mood, temper, etc., but more importantly, they will focus on a person’s decision making abilities. Simple tests can assess a person’s executive functioning skills (i.e. their ability to solve problems and make decisions.) This test can provide the health care team and family members with an idea of how significant the disease is, and will allow for the development of treatment strategies to assist the person.
In 2011, the American Stroke Association and the American Heart Association identified the following Three Criteria that indicate the greatest likelihood that mild cognitive impairment is the result of vascular changes:
- The diagnosis of dementia or mild cognitive impairment as confirmed by neurocognitive testing, which involves several hours of written or computerized tests that provide detailed evaluation of specific thinking skills such as judgment, planning, problem solving, reasoning, and memory.
- Brain imaging, usually with magnetic resonance imaging (MRI), may show evidence of either:
- A recent stroke
- Other brain vessel changes for which the severity and pattern of affected tissue are consistent with the types of impairment documented in neurocognitive testing.
The most important treatment factor is controlling the risk factors that caused the dementia in the first place, e.g. blood pressure or cholesterol levels.
Vascular dementia does shorten lifespan; this is especially true if the dementia follows on the heels of an event such as a stroke.
- Don’t smoke – or quit if you do
- Maintain your blood pressure, cholesterol and blood sugar within recommended limits
- Sustain a healthy diet
- Limit alcohol consumption
- Manage your stress levels
Fiona is a middle-aged woman living in England who details her experience fighting for a diagnosis for her mother:
My mother, Rita, was diagnosed with vascular dementia in September 2008. It took about 15 months to get the diagnosis, mainly because the assessment team in Salford is radically understaffed. If a case worker goes off sick because of stress, as happened in our case, then there are insufficient staff to pick up the slack, and the cases get left until that staff member returns to work.
Fiona goes on to discuss challenges that have become all too familiar for the carers of those with vascular dementia:
The first sign of the dementia setting in was when my mother wouldn’t recognize where she was as she was driving; she would have to pull over to re-orientate herself, and she found this confusing and very frightening. After this, there was quite a rapid progression with her having episodes that would cause her to blank out and then sleep. She also became very argumentative and aggressive, attacking me physically by pushing, shoving, and throwing water over me. She also gave my husband a clip round the ear when she thought he’d been cheeky!
Marie is a 47-year-old woman from Ireland who shares her frustrations obtaining a diagnosis for her mother:
Seven years ago, we received the diagnosis that my mum had vascular dementia. There is still confusion over the difference between vascular dementia and Alzheimer’s: there are over 200 causes of dementia, and Alzheimer’s disease is only one of them.
Dementia itself is a collection of symptoms that can surface slowly over time, or suddenly with a health setback such as a stroke. Seven years before my mum was diagnosed, she had two heart attacks which I think attributed to her dementia.
My parents lived in London most of their adult lives but are from Ireland. When I was in my twenties, they moved back to Belfast, mother’s home town. I stayed in London and met my husband, married and had my children there.
It’s been a long journey and it’s so true, I once heard: ‘Dementia is the longest goodbye’ and that is so true. The most difficult aspect for me still is that although she is here, she is no longer the same person and has forgotten who I am.
Margaret is a middle aged woman from Canada who discusses her family’s experience when her mother began showing signs of vascular dementia:
My mother was independent, intelligent and very private. She had strict boundaries and questions about her health, and her finances were off limits. My father died after a brief illness when my mom was 52. He was 6 years away from retirement, and her world was shattered. I’m not an expert on dementia. I only know my mom’s case. We knew she’d had mini strokes over the years. In her case:
- Her short term memory was awful
- She repeated herself constantly (told the same stories and asked the same question)
- She had trouble with context and wasn’t able to string information together and come to logical conclusions
- She couldn’t remember dates and was confused by numbers
- She would acknowledge that she had challenges but believed she could live independently
- She had no ability to manage her medication or meals. She was always extremely well groomed and looked great, though
In 2001, after several odd incidentsinvolving my mother, I decided it was time to contact her doctor and express my concerns about my mother’s memory. My mother was 67. The doctor was surprised that I thought my mom had dementia. We made an appointment and the doctor asked my mom a few questions, designed for those with memory loss. The doctor agreed that there might be some sort of vascular dementia. The situation was difficult because I had young kids, and my mother lived 3 hours away. My sister and I tried hard to support her but her illness was confusing. She could seem normal and well. It became hard to know if we were overreacting.
In 2002, she blacked out outside of her condo. She fell down and was completely disoriented. A neighbor saw her and thought she was drunk. She had been on her way to a wedding with my aunt, and they ended up going to the wedding anyway. However, people kept asking my aunt what was wrong with my mother because she wasn’t able to follow conversations.
It is clear from these heart wrenching stories that caring for a person with vascular dementia takes a toll on families. It is essential caregivers seek out support to ensure they do not burn out or become ill themselves.
Other studies are addressing the lifestyle factors which cause vascular dementia, which includes quickly recognizing the signs and symptoms of stroke to prevent its development in the first place.
In overview, the best method of managing vascular dementia is to modify risk factors to prevent the disease.
- The Alzheimer’s Society www.alz.org 2016 Alzheimer’s facts and figures
- The American Heart Association www.heart.org
- The Mayo Clinic: http://www.mayoclinic.org/diseases-conditions/vascular-dementia/basics/coping-support/con-20029330
- Patients Canada www.patientscanada.ca
- Medscape: www.emedicine.medscape.com
- University of California Memory and Aging Centre www.memory.ucsf.edu