Vascular Dementia

Author: Kannayiram Alagiakrishnan, MD, MBBS, MHA, MPH; Chief Editor: Iqbal
Ahmed, MBBS, FRCPsych (UK) more...

Background
Vascular dementia is the second most common form of dementia after Alzheimer disease (AD).
The condition is not a single disease; it is a group of syndromes relating to different vascular
mechanisms. Vascular dementia is preventable; therefore, early detection and an accurate
diagnosis are important.
Patients who have had a stroke are at increased risk for vascular dementia. Recently, vascular
lesions have been thought to play a role in AD.
As early as 1899, arteriosclerosis and senile dementia were described as different syndromes. In
1969, Mayer-Gross et al described this syndrome and reported that hypertension is the cause in
approximately 50% of patients. In 1974, Hachinski et al coined the term multi-infarct dementia.
In 1985, Loeb used the broader term vascular dementia. Recently, Bowler and Hachinski
introduced a new term, vascular cognitive impairment.

Case study
A 70-year-old woman came to the clinic with her son for assessment of her cognitive decline.
The son is concerned about her short-term memory problems for the past 10 months. Patient had
a fall 10 months ago; after that fall, she started to ask the same questions over and over. Patient
had another fall 4 months ago and also an episode of dizziness 2 months ago. With these
incidents, her son noticed further decline in cognition. Recently, her son noticed that she has
become a bit more suspicious of her daughter-in-law and has been hoarding things. She has lost
interest in her day-to-day activities and forgets to include the right ingredients when cooking.
Family has to remind her to take her medications, and her son is helping with the management of
her finances.
The patient has hypertension, diabetes, coronary artery disease, osteoarthritis, and osteoporosis.
On the Mini-Mental Status Examination (MMSE), the patient scored 21/30 with abnormal clock
drawing. On the Geriatric Depression Scale (GDS), the patient scored 2/15. CT scan of the head
showed multiple lacunar infarcts in the right basal ganglia and left cerebellar region.
Next Section: Pathophysiology

Pathophysiology
Many subtypes of vascular dementia have been described to date. The spectrum includes (1) mild
vascular cognitive impairment, (2) multi-infarct dementia, (3) vascular dementia due to a
strategic single infarct, (4) vascular dementia due to lacunar lesions, (5) vascular dementia due to
hemorrhagic lesions, (6) Binswanger disease, (7) subcortical vascular dementia, and (8) mixed
dementia (combination of AD and vascular dementia).
Vascular dementia is sometimes further classified as cortical or subcortical dementia.
Vascular disease produces either focal or diffuse effects on the brain and causes cognitive
decline. Focal cerebrovascular disease occurs secondary to thrombotic or embolic vascular
occlusions. Common areas of the brain associated with cognitive decline are the white matter of
the cerebral hemispheres and the deep gray nuclei, especially the striatum and the thalamus.
Hypertension is the major cause of diffuse disease, and in many patients, both focal and diffuse
disease are observed together. The 3 most common mechanisms of vascular dementia are
multiple cortical infarcts, a strategic single infarct, and small vessel disease.
Mild vascular cognitive impairment can occur in elderly persons. It is associated with cognitive
decline that is worse than expected for age and educational level, but the effects do not meet the
criteria for dementia. These people have subjective and objective evidence of memory problems,
but their daily functional living skills are within normal limits.
In multi-infarct dementia, the combined effects of different infarcts produce cognitive decline by
affecting the neural nets.
In single-infarct dementia, different areas in the brain can be affected, which may result in
significant impairment in cognition. This may be observed in cases of anterior cerebral artery
infarct, parietal lobe infarcts, thalamic infarction, and singular gyrus infarction.
Small vessel disease affects all the small vessels of the brain and produces 2 major syndromes,
Binswanger disease and lacunar state. Small vessel disease results in arterial wall changes,
expansion of the Virchow-Robin spaces, and perivascular parenchymal rarefaction and gliosis.
Lacunar disease is due to small vessel occlusions and produces small cavitary lesions within the
brain parenchyma secondary to occlusion of small penetrating arterial branches. These lacunae
are found more typically in the internal capsule, deep gray nuclei, and white matter. Lacunar
state is a condition in which numerous lacunae, which indicate widespread severe small vessel
disease, are present.
Binswanger disease (also known as subcortical leukoencephalopathy) is due to diffuse white
matter disease. In Binswanger disease, vascular changes observed are fibrohyalinosis of the
small arteries and fibrinoid necrosis of the larger vessels inside the brain.
In cerebral amyloid angiopathyassociated vasculopathy, aneurysm formation and stenosis in the
leptomeningeal and cortical vessels cause damage to the subcortical white matter. In hereditary

cystatin-C amyloid angiopathy, patients have recurrent cerebral hemorrhages before age 40 years
that can lead to dementia. Prevalence of cerebral amyloid angiopathy is consistently higher in
patients with dementia than in patients without dementia, which indicates its significant role in
the pathogenesis of dementia.[1]
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy is a
rare autosomal dominant condition localized to chromosome arm 19q12 that affects small vessels
supplying the deep white matter. Pathologically, multiple small infarcts are observed in the white
matter, thalamus, basal ganglia, and pons.
Other less common syndromes may lead to vascular dementia. Rare arteriopathies such as
inflammatory arteriopathy (eg, polyarteritis nodosa, temporal arteritis) and noninflammatory
arteriopathy (eg, moyamoya disease, fibromuscular dysplasia) can cause multiple infarcts and
can lead to vascular dementia. Hypoperfusion due to large vessel or cardiac disease can affect the
watershed areas of the brain and lead to vascular dementia.
Leukoaraiosis greater than 25% is considered to be pathological. Subcortical vascular dementia
is a diffuse small vessel disease with minimal or absent infarction with homogenous pathological
and clinical features.[2, 3] White matter ischemic changes affect executive dysfunction and cause
slower processing speed, rather than memory and language impairment.[4]
Arterial stiffness, which reflects an alteration in arterial mechanics, can be a risk factor for
vascular dementia.[5]
Mixed dementia is diagnosed when patients have evidence of Alzheimer dementia and
cerebrovascular disease, either clinically or based on neuroimaging evidence of ischemic lesions.
Growing evidence indicates that vascular dementia and Alzheimer dementia often coexist,
especially in older patients with dementia. Autopsy studies have shown an association between
Alzheimer disease and vascular lesions.[6]
Several recent studies also suggest that the risk of developing Alzheimer disease is increased
when a patient is exposed to vascular risk factors such as hypertension, diabetes mellitus,
peripheral arterial disease, and smoking, which usually are associated with cerebrovascular
disease and vascular dementia. Recent evidence suggests that the vascular processes in both
disorders may mutually induce each other. Apolipoprotein E may play a role in Alzheimer
disease and vascular dementia. Apolipoprotein E4 also increases the risk of dementia in stroke
survivors and is a strong risk factor for the development of cerebral amyloid angiopathy in
patients with Alzheimer disease. In elderly individuals, many cases of dementia may be caused
by the cumulative effect of cerebrovascular and Alzheimer pathology.
One-third of patients with vascular dementia are found to have significant Alzheimer disease
pathology with cholinergic deficits in the nucleus basalis of Meynert.[7]
Vascular cognitive disorder (VCD) is a new term used to describe a particular constellation of
cognitive and functional impairment spectrum that ranges from vascular cognitive impairment
(VCI) to subcortical vascular dementia, poststroke dementia, and mixed dementia.[3]

Epidemiology
Frequency
International
Vascular dementia is the second most common cause of dementia in the
United States and Europe, but it is the most common form in some parts of
Asia.
The prevalence rate of vascular dementia is 1.5% in Western countries and
approximately 2.2% in Japan.

In Japan, vascular dementia accounts for 50% of all dementias that occur in
individuals older than 65 years.

In Europe, vascular dementia and mixed dementia account for approximately

20% and 40% of cases, respectively.

In Latin America, 15% of all dementias are vascular.

In community-based studies in Australia, the prevalence rate for vascular and

mixed dementia is 13% and 28%, respectively.

The prevalence rate of dementia is 9 times higher in patients who have had a
stroke than in controls. One year after a stroke, 25% of patients develop newonset dementia. Within 4 years following a stroke, the relative risk of incident
dementia is 5.5%.

Mortality/Morbidity

In patients with dementia who have had a stroke, the increase in mortality is
significant. The 5-year survival rate is 39% for patients with vascular
dementia compared with 75% for age-matched controls. [8]
Vascular dementia is associated with a higher mortality rate than AD,
presumably because of the coexistence of other atherosclerotic diseases.

Study on causes of death in patients with dementia showed that circulatory

system disorders (eg, ischemic heart disease) is the most common
immediate cause of death in vascular dementia, followed by respiratory
system diseases (eg, pneumonia). [9]

A study of hospitalization rates in patients with dementia showed that

persons who developed different types of incident dementia, including
vascular dementia, were found to have an increased risk of hospitalization,
including hospitalization for ambulatory care-sensitive conditions. [10]

Sex

The prevalence of vascular dementia is higher in men than in women.

Age

Incidence increases with age.

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