QuestionSBA
QuestionChoice
FTD is classically characterised by behavioural and personality changes, and would be expected to have a progressive rather than step-wise decline.
61982
e
Frontotemporal dementia
QuestionChoice
Lewy Body Dementia (LBD) has a progressive onset and distinguishing features can include Parkinsonism, REM sleep disorder and visual hallucinations.
61980
c
Lewy Body Dementia
QuestionChoice
Vascular dementia tends to have a 'step-wise' decline, with multiple vascular events causing acute on chronic deficits. This patient has risk factors and evidence of vasculopathy.
61978
a
Vascular dementia
QuestionChoice
Pseudodementia is a term used to describe cognitive impairment associated with psychiatric disorders especially depression in the elderly. There is no suggestion of depression in the question; therefore, dementia is more likely.
61981
d
Pseudodementia
QuestionChoice
While there can be overlap in that vascular dementia can affect any part of the brain and therefore mimic Alzheimer's Disease, AD has a slow and progressive onset.
61979
b
Alzheimer's 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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2453
Vascular dementia
Topic
57
Geriatrics
12457
A 67 year old male is brought to GP by his family over concerns for his memory. He has type 2 diabetes, a previous CABG and COPD. He has had a sudden deterioration in his cognition three weeks ago, with persistent confusion and difficulty with word finding. He had a similar abrupt decline last year and needed additional support ever since.

Which of the following is the most likely diagnosis?
a