QuestionSBA
QuestionChoice
Frontotemporal dementia (FTD) typically presents with profound behavioural and personality changes, often affecting social conduct. Hallucinations are also not uncommon. These are not seen in this patient. In FTD, the cognitive decline is usually gradual and not associated with stepwise progression. This patient also has significant vascular risk factors that increase the likelihood of cerebrovascular disease, making vascular dementia more likely.
10025457
c
Frontotemporal dementia
QuestionChoice
The stepwise progression of symptoms, where there are noticeable declines in cognitive function followed by periods of stability, is more characteristic of vascular dementia. Alzheimer's disease typically exhibits a gradual, progressive decline in cognitive function without distinct, stepwise changes. Furthermore, Alzheimer's disease is primarily associated with memory, cognitive and behavioural changes and may not manifest with motor symptoms in the early stages. This patient also has significant vascular risk factors that increase the likelihood of cerebrovascular disease, making vascular dementia more likely.
10025456
b
Alzheimer's disease
QuestionChoice
This is the correct answer. The patient has diabetes and a history of hypertension and myocardial infarction, all of which are significant vascular risk factors for the development of vascular dementia. These conditions increase the risk of cerebrovascular disease and damage to the brain's blood vessels, which can lead to vascular dementia. The patient's condition deteriorating in an incremental or stepwise nature is a classic feature of vascular dementia, as vascular events such as small infarcts can lead to several small, sudden declines in cognitive function.
10025455
a
Vascular dementia
QuestionChoice
Visual hallucinations and fluctuating attention and alertness are more common in Lewy body dementia, which are not described in this vignette. A stepwise progression is less typical of dementia with Lewy bodies, which tends to have a more fluctuating course. This patient also has significant vascular risk factors that increase the likelihood of cerebrovascular disease, making vascular dementia more likely.
10025458
d
Dementia with Lewy bodies
QuestionChoice
First of all, this patient does not have an excessive alcohol intake as she drinks around 5 units every week, which is less than the recommended 14 unit limit. Although alcohol-related dementia could also present with memory problems, her moderate alcohol intake makes alcohol-related dementia highly unlikely. Given her old age, diagnosis of a form of dementia due to age-related neuropathologic changes is much more likely. The patient's vascular risk factors and step-wise progression points towards a diagnosis of vascular dementia.
10025459
e
Alcohol related dementia
Concept
Chapter
# Summary

Vascular dementia (VaD) is a cognitive impairment resulting from cerebrovascular disease, often presenting with progressive stepwise cognitive deterioration over months or years. Typical presentations are stroke-related vascular disease, subcortical vascular dementia, and mixed dementia. Diagnosis is established via comprehensive history, formal cognitive screening, medication review, exclusion of reversible organic causes, and neuroimaging, preferably MRI. Management revolves around symptomatic treatment, detection and control of cardiovascular risk factors, and advanced care planning.

# Definition

Vascular dementia is an umbrella term denoting a collection of cognitive impairment syndromes caused by cerebrovascular disease.These include stroke-related vascular disease, subcortical vascular dementia, and mixed dementia —a combination of Alzheimer's disease and vascular dementia.

# Epidemiology

Vascular dementia (VaD) is the second most common type of dementia after Alzheimer's disease, accounting for around 15-20% of all dementia cases.

Prevalence of VaD increases with age, being rare before the age of 65 but significantly rising thereafter. 

The incidence of VaD is higher in males than in females, and higher in individuals with cardiovascular risk factors.

# Aetiology

The primary cause of vascular dementia is ischemic or hemorrhagic cerebrovascular disease, which leads to brain damage. 

Various vascular events or conditions can lead to VaD, including multi-infarct dementia, single-infarct dementia, subcortical vascular dementia (also known as Binswanger's disease), and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).

Risk factors for VaD mirror those for stroke and other cardiovascular diseases: hypertension, diabetes mellitus, hyperlipidemia, smoking, and atrial fibrillation are significant risk factors. 

Less common causes include inflammatory and immunological vascular disorders, genetic conditions, and infections that affect the brain's blood vessels.

# Signs and Symptoms

The hallmark of vascular dementia is a progressive, **stepwise** deterioration in cognition. This typically occurs over a span of several months to years. Patients may present with a history of strokes, which may be accompanied by stepwise cognitive decline or sudden changes in cognitive function, as well as stroke-like symptoms:

- Visual disturbance
- Sensory or motor symptoms
- Difficulty with attention and concentration
- Seizures
- Memory disturbance
- Gait/speech/emotional disturbance

To compare with Alzheimer's dementia, there is less impairment in episodic memory and more in visual skills, semantic memory and executive functioning.

# Differential Diagnosis

The differential diagnosis for vascular dementia includes, but is not limited to:

- **Alzheimer's disease**: Predominant memory impairment, slower and continuous decline, usually lack of significant vascular risk factors or neuroimaging evidence of cerebrovascular disease.
- **Lewy body dementia**: Fluctuating cognition, visual hallucinations, Parkinsonism, and REM sleep behavior disorder are the core features.
- **Frontotemporal dementia**: Prominent changes in personality and behavior or language difficulties with relative sparing of memory.
- **Normal pressure hydrocephalus**: Gait disturbance, urinary incontinence, and cognitive impairment (triad of Hakim-Adams).

# Investigations

The investigations for vascular dementia generally include:

- Comprehensive history and examination.
- Formal cognition screening, such as MMSE (Mini-Mental State Examination) or MoCA (Montreal Cognitive Assessment).
- Medication review to exclude medication-induced cognitive impairment.
- Exclusion of reversible organic causes such as vitamin B12 or folic acid deficiency, hypothyroidism, or normal pressure hydrocephalus.
- MRI Head, to identify vascular changes, infarcts, or white matter hyperintensities indicative of cerebrovascular disease. The hallmark of vascular dementia is extensive white matter change and infarcts evident on MRI imaging.

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# Management

The management of vascular dementia involves:

- Detection of and addressing cardiovascular risk factors such as hypertension, diabetes, hyperlipidemia, and smoking to slow disease progression.
- Cognitive stimulation programmes, music and art therapy, etc. to help with cognitive impairment. 
- Symptomatic treatment, including cognitive enhancers such as cholinesterase inhibitors or memantine - if there is evidence of co-existent AD, Parkinson's dementia, or dementia with Lewy bodies. Management of neuropsychiatric symptoms.
- Advanced care planning to prepare for progressive cognitive and physical decline.

# NICE Guidelines

[NICE CKS - Dementia](https://cks.nice.org.uk/topics/dementia/)
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Brain atrophy seen in vascular dementia.
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Atrophy brain (Vascular dementia).png
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Vascular Dementia
Topic
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Psychiatry
17489
A 77 year old woman attends her GP surgery accompanied by her daughter, who is concerned about her memory. This has been getting incrementally worsening over the last 1-2 years, but around 1 month ago deteriorated again to the point that it is now difficult to complete day-to-day activities like cooking and shopping. For the last month, there have been instances of difficulty with fine motor tasks, such as buttoning shirts and tying shoelaces. She has a past medical history of diabetes and hypertension and had a myocardial infarction 15 years ago. She has stopped smoking since her myocardial infarction, and only drinks two glasses of wine every weekend.

Both the patient and her daughter deny any personality changes or hallucinations.

Which of the following is the most likely diagnosis?
a