Familial Forms Of Vascular Dementia
Herein, we briefly summarise the available data in relation to clinical diagnostic criteria. The genetic underpinning of cerebrovascular changes has been less well studied compared to other dementia forms, such as AD . However, in most genetic studies in sporadic AD, the inclusion criteria are such that they may allow a variable number of cases and/or of mixed pathologies to be included. Of note, the upper age limit of most of these studies is in excess of 80 years, when mixed pathologies are common. Thus far, studies have failed to characterise the heritability of sporadic VCI but there have been several reports on rare monogenic conditions involving cerebral small vessels and predisposing to ischemic and/or haemorrhagic stroke and diffuse white matter disease. In these disorders, the primary genetic defect may alter endothelial cells of microvessels leading to impairment of deep brain vascularisation and resulting in clinical manifestations such as subcortical leucoencephalopathy and episodes of stroke.
Table 1 Characteristics of important inherited cerebral small vessel diseases
What Is Vascular Dementia
Vascular dementia is a form of dementia that develops because of problems with the bloods circulation to the brain. It causes problems with reasoning, planning, judgement, memory and other thinking.
Vascular dementia is the second most common form of dementia after Alzheimer’s disease. People with vascular dementia tend to decline more rapidly than people with Alzheimer’s disease.
Outlook For Vascular Dementia
Vascular dementia will usually get worse over time. This can happen in sudden steps, with periods in between where the symptoms do not change much, but it’s difficult to predict when this will happen.
Home-based help will usually be needed, and some people will eventually need care in a nursing home.
Although treatment can help, vascular dementia can significantly shorten life expectancy.
But this is highly variable, and many people live for several years with the condition, or die from some other cause.
If you or a loved one has been diagnosed with dementia, remember that you’re not alone. The NHS and social services, as well as voluntary organisations, can provide advice and support for you and your family.
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What Are The Different Types Of Vascular Dementia
There are several types of vascular dementia. Two of the most common are:
- Multi-infarct dementia: This is a common form of vascular dementia caused by several strokes which damage the brains cortex, the area responsible for learning, memory and language.
- Binswanger’s disease or subcortical vascular dementia: This form develops when high blood pressure, thickening of the arteries and inadequate blood flow damage the white matter in the brain.
What To Do If A Loved One Is Suspicious Of Having Dementia
- Discuss with loved one. Talk about seeing a medical provider about the observed changes soon. Talk about the issue of driving and always carrying an ID.
- Medical assessment. Be with a provider that you are comfortable with. Ask about the Medicare Annual Wellness exam.
- Family Meeting. Start planning, and gather documents like the Health Care Directive, Durable Power of Attorney for Health Care, Estate Plan.
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Stage : Mild Dementia
At this stage, individuals may start to become socially withdrawn and show changes in personality and mood. Denial of symptoms as a defense mechanism is commonly seen in stage 4. Behaviors to look for include:
- Difficulty remembering things about one’s personal history
- Disorientation
- Difficulty recognizing faces and people
In stage 4 dementia, individuals have no trouble recognizing familiar faces or traveling to familiar locations. However, patients in this stage will often avoid challenging situations in order to hide symptoms or prevent stress or anxiety.
Stage : Moderately Severe Dementia
When the patient begins to forget the names of their children, spouse, or primary caregivers, they are most likely entering stage 6 of dementia and will need full time care. In the sixth stage, patients are generally unaware of their surroundings, cannot recall recent events, and have skewed memories of their personal past. Caregivers and loved ones should watch for:
- Delusional behavior
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Is There Treatment Available
While no treatment can reverse damage that has already been done, treatment to prevent additional strokes is very important. To prevent strokes, medicines to control high blood pressure, high cholesterol, heart disease and diabetes can be prescribed. A healthy diet, exercise and avoidance of smoking and excessive alcohol also lessen the risk of further strokes. Sometimes aspirin or other drugs are prescribed to prevent clots from forming in the small blood vessels.
Drugs can also be prescribed to relieve restlessness or depression or to help the person with dementia to sleep better. In some cases surgery known as carotid endarterectomy may be recommended to remove blockage in the carotid artery, the main blood vessel to the brain. Recent research suggests that cholinesterase inhibitor medications such as Donepezil and Galantamine , which are helpful for some people with Alzheimer’s disease, may also be of some benefit to some people with Vascular dementia. However, the evidence is not yet as clear or compelling as that for the use of these medications with Alzheimer’s disease.
Support is available for the person with Vascular dementia, their families and carers. This support can make a positive difference to managing the condition. Dementia Australia provides support, information, education and counselling for people affected by dementia. Up-to-date information about drug treatments is also available from Dementia Australia.
Living With Vascular Dementia
Vascular dementia is a progressive disease that has no cure, but the rate at which the disease progresses can vary. Some people with vascular dementia may eventually need a high level of care due to the loss of mental and physical abilities. Family members may be able to care for a person with vascular dementia early on. But if the disease progresses, the person may need more specialized care.
Respite programs, adult daycare programs, and other resources can help the caregiver get some time away from the demands of caring for a loved one with vascular dementia.
Long-term care facilities that specialize in the care of people with dementias, Alzheimer’s, and other related conditions are often available if a person affected by vascular dementia can no longer be cared for at home. Your healthcare provider can recommend caregiver resources.
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Stage : Mid Stage Semi Severe Vascular Dementia
Another one on the list of the vascular dementia stages that I would like to reveal in this article today and want you and my other readers to know if you are considering whether they get this disorder or not.
Loss of mobility: Many people gradually lose the ability of walking and performing everyday tasks. One of the first signs is that they walk unsteadily. They can also seem slower, bump into things and fall objects. Some people even become confined to a chair or bed. People who are caring for people with vascular dementia should ask for an advice from a community nurse or a therapist to aid mobility.
Memory loss: This symptom is very severe in the stages of vascular dementia. Patients may not be able to recognize other people who are close to them and even their own reflection. Also, they may not be able to find their way home around familiar surroundings or identify objects they use every day. However, occasionally, they may experience sudden flashes of recognition. They may believe that they are in a time from their past and may look for something or somebody from that time. For those around them, it may be helpful to try talking with them about the past. Even when they have severe memory loss, they still can appreciate or respond to music, touch and scent. Thus, continue to talk to them, even when they cannot respond.
The Seven Stages Of Dementia
One of the most difficult things to hear about dementia is that, in most cases, dementia is irreversible and incurable. However, with an early diagnosis and proper care, the progression of some forms of dementia can be managed and slowed down. The cognitive decline that accompanies dementia conditions does not happen all at once – the progression of dementia can be divided into seven distinct, identifiable stages.
Learning about the stages of dementia can help with identifying signs and symptoms early on, as well as assisting sufferers and caretakers in knowing what to expect in further stages. The earlier dementia is diagnosed, the sooner treatment can start.
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Treatments For Vascular Dementia
There’s currently no cure for vascular dementia and there’s no way to reverse any loss of brain cells that happened before the condition was diagnosed.
But treatment can sometimes help slow down vascular dementia.
Treatment aims to tackle the underlying cause, which may reduce the speed at which brain cells are lost.
This will often involve:
- taking medicines, such as those used to treat high blood pressure, lower cholesterol or prevent blood clots
Other treatments, including physiotherapy, occupational therapy, dementia activities and psychological therapies, can help reduce the impact of any existing problems.
Lack Of Direct Clinicopathological Correlation
Dementia is a clinical syndrome. Therefore, a set of criteria for a given dementia subtype is defined based on the best knowledge about the neuropathological hallmarks underlying the clinical symptoms and intended to ensure a high clinic-pathological correlation. Rarely, a set of criteria reaches enough clinicopathological correlation on the first attempt, and modifications should be made with the passage of time, after testing and validation attempts using clinicopathological studies. For instance, the neuropathological criteria for frontotemporal lobar degeneration were subjected to at least three major modifications in the last 15 years , , -.
In the case of VaD, it has proven a very difficult task to define neuropathological thresholds for considering a lesion as causative of cognitive decline. In a classical paper published in 1970, Tomlinson and Blessed set a threshold of 60 ml of tissue loss for considering as vascular the causative factor of the cognitive decline . Since that time, the threshold has decreased. Kovari et al. in a study with 45 cases without significant AD pathology or macrovascular lesions showed that in a univariate model, cortical microinfarcts explained 36% of the variability of the last available Clinical Dementia Rating scores CDR 32. In addition to the lower threshold, it is clear that the strategic of a lesion may matter more than the amount of tissue loss.
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Pathophysiology Of Vascular Dementia
1Department of Clinical Neurological Sciences University of Western Ontario, Ontario, Canada
2Robarts Research Institute Stroke Prevention & Atherosclerosis Research Centre, London, England, UK
3U.O. di Neurologia, Ospedale di Vittoria, ASL7-Ragusa and Clinica Neurologica Università di Catania, Catania, Italia
4Istituto di Biomedicina ed Immunologia Molecolare-Consiglio Nazionale delle Ricerche , Palermo, Italy
How Does Vascular Dementia Develop
Changes in a persons condition as a result of TIAs or a larger stroke are often sudden, before their condition plateaus. But the damage caused often means the person does not function quite the same way as they did before.
The signs and symptoms of vascular dementia depend on which area of the brain has been affected. Language, reading, writing and communication can be affected in vascular dementia. Memory problems may not be an issue initially, if this area of the brain has not been damaged, although they may occur later on.
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Who Is At Risk For Vascular Dementia
Some risk factors for vascular dementia can be managed others, like age and gender, cannot. Among all factors, high blood pressure carries the greatest risk vascular dementia almost never occurs without it.
Likewise, a high risk of stroke goes hand in hand with risk for vascular dementia. One-quarter to one-third of strokes are thought to result in some degree of dementia. People who smoke, consume excessive amounts of alcohol, have diabetes, or heart disease also have a higher rate of the condition.
Vascular dementia most commonly occurs in people between the ages of 60 and 75. Men seem to be more vulnerable than women, and the condition affects African-Americans more often than other races. People whose age, sex, or race puts them at increased risk of vascular dementia have that much more reason to manage risk factors within their control.
Most Of The Dementias Are Mixed Dementias
The literature reports a 3.4 to 73% overlapping between AD and VaD , -. This overlapping makes difficult to estimate to which extent each disease contributes to the cognitive decline. In fact, the majority of the subjects older than 65 years do have some degree of AD-type changes and cerebrovascular lesions. Several studies demonstrated that cerebrovascular lesions lower the threshold of AD-type changes necessary to cause cognitive decline , -. The burden of vascular and AD-type lesions are considered to be independent of each other, and are consistent with an additive or synergistic effect, but this effect could not be measurable so far –
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Vascular Cognitive Impairment In Dsm
The fifth edition of DSM, published in 2013 by the American Psychiatric Association, introduced major changes to the chapter referred to in DSM-IV as Dementia, delirium, amnestic, and other cognitive disorders . One such change concerns the used nomenclature the chapter being referred to as Neurocognitive Disorders recommends replacing the term dementia with that of major neurocognitive disorder . Two reasons are stated for this change, firstly, dementia is wrongly attributed only to older populations, while it can appear in young adults , and, secondly, NCD is a broader definition individuals with substantial decline in a single domain can receive this diagnosis as opposed to the definition of dementia, which requires a decline in at least two cognitive domains . Another substantial change concerns the inclusion of a less severe level of cognitive impairment named mild NCD, which, in DSM-IV, was subsumed under cognitive disorder not otherwise specified. This addition is in line with the current trends in terms of the optimal therapeutic intervention in the very early or pre-symptomatic stages of at-risk individuals for dementia. However, it may also have wide economic and public health implications, adding millions of potential new drug consumers, worldwide .
Causes Of Vascular Dementia
Vascular dementia is caused by reduced blood supply to the brain due to diseased blood vessels.
To be healthy and function properly, brain cells need a constant supply of blood to bring oxygen and nutrients. Blood is delivered to the brain through a network of vessels called the vascular system. If the vascular system within the brain becomes damaged – so that the blood vessels leak or become blocked – then blood cannot reach the brain cells and they will eventually die.
This death of brain cells can cause problems with memory, thinking or reasoning. Together these three elements are known as cognition. When these cognitive problems are bad enough to have a significant impact on daily life, this is known as vascular dementia.
Dementia and the brain
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Dementia And Down Syndrome
It is also very common for people who suffer from Down syndrome to develop dementia, usually in the form of Alzheimers disease, although this is not always the case. This is because there are some similarities in the brain abnormalities among people with Down syndrome, and people who suffer from Alzheimers disease.
Studies show that around the age of 40, people who suffer from Down syndrome are very likely to also have significant levels of the beta-amyloid plaques and tau tangles in their brains the main cause of Alzheimers disease.
Despite this fact, not all patients who have the presence of these abnormal protein deposits develop the symptoms of Alzheimers disease.
How Is Dementia Diagnosed
To diagnose dementia, doctors first assess whether a person has an underlying, potentially treatable, condition that may relate to cognitive difficulties. A physical exam to measure blood pressure and other vital signs, as well as laboratory tests of blood and other fluids to check levels of various chemicals, hormones, and vitamins, can help uncover or rule out possible causes of symptoms.
A review of a persons medical and family history can provide important clues about risk for dementia. Typical questions might include asking about whether dementia runs in the family, how and when symptoms began, changes in behavior and personality, and if the person is taking certain medications that might cause or worsen symptoms.
The following procedures also may be used to diagnose dementia:
Early detection of symptoms is important, as some causes can be treated. However, in many cases, the cause of dementia is unknown and cannot be treated. Still, obtaining an early diagnosis can help with managing the condition and planning ahead.
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What Other Things Help
In addition to medications, there are various ways to help a person with vascular dementia. Research has shown that physical exercise and maintaining a healthy weight help to enhance brain health and reduce the risk of heart problems, stroke and other diseases that affect blood vessels. A balanced diet, enough sleep and limited alcohol intake are other important ways to promote good brain health and reduce the risk for heart disease. Other illnesses that affect the brain, such as diabetes, high blood pressure and high cholesterol, should also be treated if present.
Major Risk Factors For Strokes
Medical factors
- Prior stroke warning sign
- Heart disease
- A disease of other blood vessels of the body
- Diabetes
- Alcohol: more than one drink per day
Uncontrollable factors
- Old age: after age 55, the stroke risk doubles every decade
It is common to have both Alzheimers disease and small strokes in the brain after age 70. When strokes are the only cause of thinking and memory problems, there are usually clinically apparent, large-vessel strokes affecting strength, sensation, balance, walking, speech, or vision in the weeks, months, or years preceding dementia. When there is no history or suspicion of strokes, and silent strokes are found incidentally on the MRI or CT scan, the cause of the cognitive impairment is typically small-vessel strokes plus Alzheimers disease or another disorder.
Q: Youve seen your loved ones MRI report, and it says they have scattered T2 hyperintensities consistent with microvascular ischemic disease. What does that mean?
A: Thats a doctors way of saying that there is something on the MRI scan that looks like tiny, small-vessel strokes.
Q: Your loved one has never had a stroke, yet the doctor says they did, and she can see it on the MRI scan. How can that be?
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