QuestionSBA
QuestionChoice
Wernicke's encephalopathy is characterised by a tetrad of ataxia, ophthalmoplegia, nystagmus and an acute confusional state. It is associated with lesions in the mamillary bodies. This patient does not present with any of these symptoms, making Wernicke's encephalopathy a less likely diagnosis than vascular dementia.
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Wernicke's encephalopathy
QuestionChoice
In Lewy Body dementia, abnormal protein deposits called Lewy Bodies cause cognitive decline associated with parkinsonism (rigidity, tremor, bradykinesia). This patient does not have any parkinsonian features, making this a less likely diagnosis than vascular dementia.
10008136
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Lewy Body Dementia
QuestionChoice
Fronto-temporal dementia is characterised by atrophy of the frontal and temporal lobes. Patients therefore present with cognitive impairment, personality change and disinhibition. This patient is not suffering from any personality changes or disinhibition, making fronto-temporal dementia a less likely diagnosis than vascular dementia.
10008138
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Fronto-temporal dementia
QuestionChoice
The most common cause of dementia is Alzheimer's disease, a chronic and progressive form of dementia, characterised by neuropathological features such as amyloid plaques and tau proteins. It presents with gradual onset of memory loss, word-finding problems, and impaired motor function. The sudden onset of this patient’s cognitive deterioration makes vascular dementia a more likely diagnosis.
10008139
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Alzheimer’s disease
QuestionChoice
Vascular dementia is a type of cognitive impairment resulting from multiple infarcts in the brain. It presents with sudden onset cognitive difficulties and a stepwise deterioration that occurs with successive cerebrovascular events. It is more common in those with known cardiovascular risk factors such as diabetes, hypercholesterolaemia, or a raised BMI. This patient's sudden decline, previous stroke, and known diabetes make vascular dementia the most likely diagnosis.
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Vascular 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
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Neurology
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An 85-year-old man is brought to the GP by his wife. She reports he has been more forgetful than usual, losing things around the house and occasionally forgetting the names of close friends. This began suddenly around 6 months ago and has not improved.

He has a past diagnosis of type II diabetes and suffered from a stroke five years ago. However, he remains independent and active, playing golf twice a week.

Which of the following is the most likely diagnosis?
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