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Treatment and prevention of vascular dementia

Clinton B Wright, MD, MS
Section Editors
Steven T DeKosky, MD, FAAN, FACP, FANA
Scott E Kasner, MD
Deputy Editor
April F Eichler, MD, MPH


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".)


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 may be more helpful in preventing rather than ameliorating dementia, there is a strong rationale for aggressive secondary stroke prevention measures in these patients [1,2]. Recurrent stroke is associated with greater risk of cognitive decline, and poststroke dementia is associated with higher mortality [3,4].

Based on the observed prevalence of potentially modifiable risk factors (eg, hypertension, diabetes, inactivity) combined with their associated relative risk for dementia, it has been estimated that risk factor reductions of 10 to 25 percent could prevent up to half of dementia cases [5]. Although population-based data are not entirely consistent and do not establish causality, it does appear that the incidence of all-cause dementia, and especially vascular dementia, is declining in high-income countries over the past several decades [6-10].


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Literature review current through: Jul 2017. | This topic last updated: May 11, 2017.
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  1. Dichgans M, Zietemann V. Prevention of vascular cognitive impairment. Stroke 2012; 43:3137.
  2. Douiri A, McKevitt C, Emmett ES, et al. Long-term effects of secondary prevention on cognitive function in stroke patients. Circulation 2013; 128:1341.
  3. Srikanth VK, Quinn SJ, Donnan GA, et al. Long-term cognitive transitions, rates of cognitive change, and predictors of incident dementia in a population-based first-ever stroke cohort. Stroke 2006; 37:2479.
  4. Melkas S, Oksala NK, Jokinen H, et al. Poststroke dementia predicts poor survival in long-term follow-up: influence of prestroke cognitive decline and previous stroke. J Neurol Neurosurg Psychiatry 2009; 80:865.
  5. Barnes DE, Yaffe K. The projected effect of risk factor reduction on Alzheimer's disease prevalence. Lancet Neurol 2011; 10:819.
  6. Satizabal CL, Beiser AS, Chouraki V, et al. Incidence of Dementia over Three Decades in the Framingham Heart Study. N Engl J Med 2016; 374:523.
  7. Schrijvers EM, Verhaaren BF, Koudstaal PJ, et al. Is dementia incidence declining?: Trends in dementia incidence since 1990 in the Rotterdam Study. Neurology 2012; 78:1456.
  8. Rocca WA, Petersen RC, Knopman DS, et al. Trends in the incidence and prevalence of Alzheimer's disease, dementia, and cognitive impairment in the United States. Alzheimers Dement 2011; 7:80.
  9. Matthews FE, Arthur A, Barnes LE, et al. A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: results of the Cognitive Function and Ageing Study I and II. Lancet 2013; 382:1405.
  10. Qiu C, von Strauss E, Bäckman L, et al. Twenty-year changes in dementia occurrence suggest decreasing incidence in central Stockholm, Sweden. Neurology 2013; 80:1888.
  11. Rigaud AS, Seux ML, Staessen JA, et al. Cerebral complications of hypertension. J Hum Hypertens 2000; 14:605.
  12. Birkenhäger WH, Forette F, Seux ML, et al. Blood pressure, cognitive functions, and prevention of dementias in older patients with hypertension. Arch Intern Med 2001; 161:152.
  13. Forette F, Seux ML, Staessen JA, et al. The prevention of dementia with antihypertensive treatment: new evidence from the Systolic Hypertension in Europe (Syst-Eur) study. Arch Intern Med 2002; 162:2046.
  14. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). SHEP Cooperative Research Group. JAMA 1991; 265:3255.
  15. Prince MJ, Bird AS, Blizard RA, Mann AH. Is the cognitive function of older patients affected by antihypertensive treatment? Results from 54 months of the Medical Research Council's trial of hypertension in older adults. BMJ 1996; 312:801.
  16. Tzourio C, Anderson C, Chapman N, et al. Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease. Arch Intern Med 2003; 163:1069.
  17. Saxby BK, Harrington F, Wesnes KA, et al. Candesartan and cognitive decline in older patients with hypertension: a substudy of the SCOPE trial. Neurology 2008; 70:1858.
  18. Peters R, Beckett N, Forette F, et al. Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial. Lancet Neurol 2008; 7:683.
  19. Anderson C, Teo K, Gao P, et al. Renin-angiotensin system blockade and cognitive function in patients at high risk of cardiovascular disease: analysis of data from the ONTARGET and TRANSCEND studies. Lancet Neurol 2011; 10:43.
  20. McGuinness B, Todd S, Passmore P, Bullock R. Blood pressure lowering in patients without prior cerebrovascular disease for prevention of cognitive impairment and dementia. Cochrane Database Syst Rev 2009; :CD004034.
  21. Rose KM, Eigenbrodt ML, Biga RL, et al. Orthostatic hypotension predicts mortality in middle-aged adults: the Atherosclerosis Risk In Communities (ARIC) Study. Circulation 2006; 114:630.
  22. Kähönen-Väre M, Brunni-Hakala S, Lindroos M, et al. Left ventricular hypertrophy and blood pressure as predictors of cognitive decline in old age. Aging Clin Exp Res 2004; 16:147.
  23. Qiu C, von Strauss E, Fastbom J, et al. Low blood pressure and risk of dementia in the Kungsholmen project: a 6-year follow-up study. Arch Neurol 2003; 60:223.
  24. Verghese J, Lipton RB, Hall CB, et al. Low blood pressure and the risk of dementia in very old individuals. Neurology 2003; 61:1667.
  25. SPRINT Research Group, Wright JT Jr, Williamson JD, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med 2015; 373:2103.
  26. Gorelick PB, Scuteri A, Black SE, et al. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association. Stroke 2011; 42:2672.
  27. Hébert R, Brayne C. Epidemiology of vascular dementia. Neuroepidemiology 1995; 14:240.
  28. Ott A, Stolk RP, Hofman A, et al. Association of diabetes mellitus and dementia: the Rotterdam Study. Diabetologia 1996; 39:1392.
  29. Rockwood K, Ebly E, Hachinski V, Hogan D. Presence and treatment of vascular risk factors in patients with vascular cognitive impairment. Arch Neurol 1997; 54:33.
  30. MacKnight C, Rockwood K, Awalt E, McDowell I. Diabetes mellitus and the risk of dementia, Alzheimer's disease and vascular cognitive impairment in the Canadian Study of Health and Aging. Dement Geriatr Cogn Disord 2002; 14:77.
  31. Areosa SA, Grimley EV. Effect of the treatment of Type II diabetes mellitus on the development of cognitive impairment and dementia. Cochrane Database Syst Rev 2002; :CD003804.
  32. Abbatecola AM, Rizzo MR, Barbieri M, et al. Postprandial plasma glucose excursions and cognitive functioning in aged type 2 diabetics. Neurology 2006; 67:235.
  33. Cukierman-Yaffe T, Gerstein HC, Williamson JD, et al. Relationship between baseline glycemic control and cognitive function in individuals with type 2 diabetes and other cardiovascular risk factors: the action to control cardiovascular risk in diabetes-memory in diabetes (ACCORD-MIND) trial. Diabetes Care 2009; 32:221.
  34. Jick H, Zornberg GL, Jick SS, et al. Statins and the risk of dementia. Lancet 2000; 356:1627.
  35. Reitz C, Tang MX, Luchsinger J, Mayeux R. Relation of plasma lipids to Alzheimer disease and vascular dementia. Arch Neurol 2004; 61:705.
  36. Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. Lancet 2002; 360:1623.
  37. Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360:7.
  38. Collins R, Armitage J, Parish S, et al. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet 2004; 363:757.
  39. Williams PS, Rands G, Orrel M, Spector A. Aspirin for vascular dementia. Cochrane Database Syst Rev 2000; :CD001296.
  40. Price JF, Stewart MC, Deary IJ, et al. Low dose aspirin and cognitive function in middle aged to elderly adults: randomised controlled trial. BMJ 2008; 337:a1198.
  41. Diener HC, Sacco RL, Yusuf S, et al. Effects of aspirin plus extended-release dipyridamole versus clopidogrel and telmisartan on disability and cognitive function after recurrent stroke in patients with ischaemic stroke in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial: a double-blind, active and placebo-controlled study. Lancet Neurol 2008; 7:875.
  42. Pearce LA, McClure LA, Anderson DC, et al. Effects of long-term blood pressure lowering and dual antiplatelet treatment on cognitive function in patients with recent lacunar stroke: a secondary analysis from the SPS3 randomised trial. Lancet Neurol 2014; 13:1177.
  43. Stott DJ, MacIntosh G, Lowe GD, et al. Randomized controlled trial of homocysteine-lowering vitamin treatment in elderly patients with vascular disease. Am J Clin Nutr 2005; 82:1320.
  44. Sabia S, Nabi H, Kivimaki M, et al. Health behaviors from early to late midlife as predictors of cognitive function: The Whitehall II study. Am J Epidemiol 2009; 170:428.
  45. Verghese J, Cuiling Wang, Katz MJ, et al. Leisure activities and risk of vascular cognitive impairment in older adults. J Geriatr Psychiatry Neurol 2009; 22:110.
  46. Coyle JT. Use it or lose it--do effortful mental activities protect against dementia? N Engl J Med 2003; 348:2489.
  47. Verdelho A, Madureira S, Ferro JM, et al. Physical activity prevents progression for cognitive impairment and vascular dementia: results from the LADIS (Leukoaraiosis and Disability) study. Stroke 2012; 43:3331.
  48. Liu-Ambrose T, Best JR, Davis JC, et al. Aerobic exercise and vascular cognitive impairment: A randomized controlled trial. Neurology 2016; 87:2082.
  49. Bickel H, Ander KH, Brönner M, et al. Reduction of Long-Term Care Dependence After an 8-Year Primary Care Prevention Program for Stroke and Dementia: The INVADE Trial. J Am Heart Assoc 2012; 1:e000786.
  50. Richard E, Gouw AA, Scheltens P, van Gool WA. Vascular care in patients with Alzheimer disease with cerebrovascular lesions slows progression of white matter lesions on MRI: the evaluation of vascular care in Alzheimer's disease (EVA) study. Stroke 2010; 41:554.
  51. Moll van Charante EP, Richard E, Eurelings LS, et al. Effectiveness of a 6-year multidomain vascular care intervention to prevent dementia (preDIVA): a cluster-randomised controlled trial. Lancet 2016; 388:797.
  52. Kalaria RN, Ballard C. Overlap between pathology of Alzheimer disease and vascular dementia. Alzheimer Dis Assoc Disord 1999; 13 Suppl 3:S115.
  53. Bär KJ, Boettger MK, Seidler N, et al. Influence of galantamine on vasomotor reactivity in Alzheimer's disease and vascular dementia due to cerebral microangiopathy. Stroke 2007; 38:3186.
  54. Malouf R, Birks J. Donepezil for vascular cognitive impairment. Cochrane Database Syst Rev 2004; :CD004395.
  55. Erkinjuntti T, Kurz A, Gauthier S, et al. Efficacy of galantamine in probable vascular dementia and Alzheimer's disease combined with cerebrovascular disease: a randomised trial. Lancet 2002; 359:1283.
  56. Auchus AP, Brashear HR, Salloway S, et al. Galantamine treatment of vascular dementia: a randomized trial. Neurology 2007; 69:448.
  57. Birks J, McGuinness B, Craig D. Rivastigmine for vascular cognitive impairment. Cochrane Database Syst Rev 2013; :CD004744.
  58. Ballard C, Sauter M, Scheltens P, et al. Efficacy, safety and tolerability of rivastigmine capsules in patients with probable vascular dementia: the VantagE study. Curr Med Res Opin 2008; 24:2561.
  59. Mok V, Wong A, Ho S, et al. Rivastigmine in Chinese patients with subcortical vascular dementia. Neuropsychiatr Dis Treat 2007; 3:943.
  60. Narasimhalu K, Effendy S, Sim CH, et al. A randomized controlled trial of rivastigmine in patients with cognitive impairment no dementia because of cerebrovascular disease. Acta Neurol Scand 2010; 121:217.
  61. Kavirajan H, Schneider LS. Efficacy and adverse effects of cholinesterase inhibitors and memantine in vascular dementia: a meta-analysis of randomised controlled trials. Lancet Neurol 2007; 6:782.
  62. Bonelli RM. Editorial comment--How to treat vascular dementia? Stroke 2003; 34:2331.
  63. Kester MI, Scheltens P. Dementia: the bare essentials. Pract Neurol 2009; 9:241.
  64. Orgogozo JM, Rigaud AS, Stöffler A, et al. Efficacy and safety of memantine in patients with mild to moderate vascular dementia: a randomized, placebo-controlled trial (MMM 300). Stroke 2002; 33:1834.
  65. Wilcock G, Möbius HJ, Stöffler A, MMM 500 group. A double-blind, placebo-controlled multicentre study of memantine in mild to moderate vascular dementia (MMM500). Int Clin Psychopharmacol 2002; 17:297.
  66. McShane R, Areosa Sastre A, Minakaran N. Memantine for dementia. Cochrane Database Syst Rev 2006; :CD003154.
  67. Rainer M, Mucke HA, Krüger-Rainer C, et al. Cognitive relapse after discontinuation of drug therapy in Alzheimer's disease: cholinesterase inhibitors versus nootropics. J Neural Transm (Vienna) 2001; 108:1327.
  68. Howard R, McShane R, Lindesay J, et al. Donepezil and memantine for moderate-to-severe Alzheimer's disease. N Engl J Med 2012; 366:893.
  69. Olin J, Schneider L, Novit A, Luczak S. Hydergine for dementia. Cochrane Database Syst Rev 2001; :CD000359.
  70. Bès A, Orgogozo JM, Poncet M, et al. A 24-month, double-blind, placebo-controlled multicentre pilot study of the efficacy and safety of nicergoline 60 mg per day in elderly hypertensive patients with leukoaraiosis. Eur J Neurol 1999; 6:313.
  71. Herrmann WM, Stephan K, Gaede K, Apeceche M. A multicenter randomized double-blind study on the efficacy and safety of nicergoline in patients with multi-infarct dementia. Dement Geriatr Cogn Disord 1997; 8:9.
  72. Birks J, Grimley EV, Van Dongen M. Ginkgo biloba for cognitive impairment and dementia. Cochrane Database Syst Rev 2002; :CD003120.
  73. Frampton M, Harvey RJ, Kirchner V. Propentofylline for dementia. Cochrane Database Syst Rev 2003; :CD002853.
  74. European Pentoxifylline Multi-Infarct Dementia Study. Eur Neurol 1996; 36:315.
  75. Treves TA, Korczyn AD. Denbufylline in dementia: a double-blind controlled study. Dement Geriatr Cogn Disord 1999; 10:505.
  76. Fioravanti M, Yanagi M. Cytidinediphosphocholine (CDP-choline) for cognitive and behavioural disturbances associated with chronic cerebral disorders in the elderly. Cochrane Database Syst Rev 2005; :CD000269.
  77. Flicker L, Grimley Evans G. Piracetam for dementia or cognitive impairment. Cochrane Database Syst Rev 2001; :CD001011.
  78. López-Arrieta JM, Birks J. Nimodipine for primary degenerative, mixed and vascular dementia. Cochrane Database Syst Rev 2002; :CD000147.
  79. Pantoni L, del Ser T, Soglian AG, et al. Efficacy and safety of nimodipine in subcortical vascular dementia: a randomized placebo-controlled trial. Stroke 2005; 36:619.
  80. [An experimental, randomized, double-blind, placebo-controlled clinical trial to infestigate the effect of nicardipine on cognitive function in patients with vascular dementia. Spanish group of nicardipine study in vascular dementia]. Rev Neurol 1999; 28:835.
  81. Weyer G, Eul A, Milde K, et al. Cyclandelate in the treatment of patients with mild to moderate primary degenerative dementia of the Alzheimer type or vascular dementia: experience from a placebo controlled multi-center study. Pharmacopsychiatry 2000; 33:89.
  82. Guekht A, Skoog I, Edmundson S, et al. ARTEMIDA Trial (A Randomized Trial of Efficacy, 12 Months International Double-Blind Actovegin): A Randomized Controlled Trial to Assess the Efficacy of Actovegin in Poststroke Cognitive Impairment. Stroke 2017; 48:1262.
  83. Román GC, Salloway S, Black SE, et al. Randomized, placebo-controlled, clinical trial of donepezil in vascular dementia: differential effects by hippocampal size. Stroke 2010; 41:1213.
  84. Chui, H, Mack, W, Varpetian, A, Mungas, D. Evidence-based prognosis of vascular dementia: Survival and rate of cognitive decline. In: Vascular cognitive impairment, Hachinski, V (Ed), Oxford University Press, Oxford 2003. p.33.
  85. Rockwood K, Wentzel C, Hachinski V, et al. Prevalence and outcomes of vascular cognitive impairment. Vascular Cognitive Impairment Investigators of the Canadian Study of Health and Aging. Neurology 2000; 54:447.
  86. Mölsä PK, Marttila RJ, Rinne UK. Long-term survival and predictors of mortality in Alzheimer's disease and multi-infarct dementia. Acta Neurol Scand 1995; 91:159.
  87. Wentzel C, Rockwood K, MacKnight C, et al. Progression of impairment in patients with vascular cognitive impairment without dementia. Neurology 2001; 57:714.