QuestionSBA
QuestionChoice
In FTLD, the first symptoms are often personality change or inappropriate social behaviour, prior to any significant impact in memory (cognitive decline comes later in the disease course). As the name suggests, this is due to the specific area of the brain that is affected. FTLD tends to develop in younger patients, classically <65 years of age, compared with the other forms of dementia which increase in incidence with increasing age
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c
Frontotemporal lobe dementia (FTLD)
QuestionChoice
Alzheimer's dementia follows a much more gradual course and would not cause these distinct episodes of sudden, marked deterioration in memory
33456
d
Delirium
QuestionChoice
This patient has had a previous stroke, as well as comorbidities that together indicate pre-existing vascular disease. In vascular dementia, the deterioration in memory is classically "step-wise" as mini-infarcts occur, compared to other forms of dementia where there is a very gradual and insidious decline
33453
a
Vascular dementia
QuestionChoice
In some elderly patients, depression can present by causing cognitive impairment, which can mask as a neurodegenerative disorder. Once treated, the cognitive impairment is often reversible. It is always important to consider and address mood in a patient presenting with memory loss, as **depression rates are very high in patients experiencing true forms of dementia**, and identifying and treating this appropriately can improve cognition and quality of life
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e
Pseudo-dementia
QuestionChoice
Alzheimer's dementia follows a much more gradual course and would not cause these distinct episodes of sudden, marked deterioration in memory
33454
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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Vascular Dementia
Topic
34
Neurology
Vascular dementia
6691
A 74-year-old man is brought to the GP by his wife, concerned about his deteriorating memory over the past 3 years. She reports several episodes of marked decline, with the most recent occurring when he woke up and failed to recognize his children. 

He has a past medical history of hypertension and atrial fibrillation, for which he takes amlodipine, ramipril and apixaban. He also had a stroke ten years previously and has some residual visual deficit and right arm weakness from this.


What is the most likely diagnosis?
a