Treatment and prevention of vascular dementia
- Clinton B Wright, MD, MS
Clinton B Wright, MD, MS
- Associate Professor of Neurology
- Scientific Director, Evelyn F. McKnight Brain Institute, Department of Neurology
- Miller School of Medicine, University of Miami
- Section Editors
- Steven T DeKosky, MD, FAAN, FACP, FANA
Steven T DeKosky, MD, FAAN, FACP, FANA
- Section Editor — Dementia
- Visiting Professor of Radiology and Neurology
- University of Pittsburgh School of Medicine
- Scott E Kasner, MD
Scott E Kasner, MD
- Section Editor — Stroke
- Professor of Neurology
- University of Pennsylvania School of Medicine
The entity of vascular dementia (VaD) is best understood as a heterogeneous syndrome rather than a distinct disorder, in which the underlying cause is cerebrovascular disease in some form, and its ultimate manifestation is dementia. There is considerable overlap between AD and VaD with regard to comorbidity as well as shared risk factors and even pathogenesis. The combination of pathologies may be more common than either in isolation, and it is not generally easy to identify the primary etiologic entity.
Preventative agents and treatments for VaD have at least potential overlap. The same agent could both prevent the development of VaD in patients at risk and prevent cognitive decline in patients with VaD or in earlier stages of cognitive impairment.
This topic will review the treatment, prevention, and prognosis of VaD. Other aspects of this disorder are discussed separately. (See "Etiology, clinical manifestations, and diagnosis of vascular dementia".)
RISK FACTOR MANAGEMENT
Patients with cognitive impairment and clinical or radiologic evidence of cerebrovascular pathology should be screened and treated for vascular risk factors, especially hypertension. Although these measures have been shown to be helpful in preventing rather than ameliorating dementia, there is a strong rationale for aggressive secondary stroke prevention measures in these patients [1,2]. As an example, a cohort study of 99 cases followed after a first stroke found that those with recurrent stroke had greater cognitive decline . In addition, other studies have shown that poststroke dementia is associated with higher mortality .
A few studies have examined the effects of programs that target all aspects of vascular risk factor reduction. One study compared a strategy of repeated systematic identification and treatment of vascular risk factors in a German population of patients >54 years in age . After five years, there was a 10 percent reduction in the rate of long-term care dependence in the treated compared with a reference population (1240 cases observed, 1375 expected). The intervention was intended to target both stroke and dementia, but the specific incidence of either diagnosis over the study time period was not measured. A randomized study of patients with AD found that after two years, progression of white matter lesions on MRI was less in those who were assigned to vascular care (which included lifestyle interventions: physical exercise, smoking cessation, weight loss; daily aspirin; antihypertensive treatment protocol, and statin treatment for hypercholesterolemia) compared to those who received standard care .
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- RISK FACTOR MANAGEMENT
- Antihypertensive drugs
- Diabetes management
- Antiplatelet agents
- Homocysteine lowering
- Healthy lifestyle
- DISEASE MODIFYING THERAPY
- Acetylcholinesterase inhibitors
- N-Methyl-D-aspartate receptor antagonists
- Calcium channel blockers
- Other agents
- Treatment duration
- TREATMENT OF BEHAVIORAL SYMPTOMS
- PALLIATIVE CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS