Summary

Vascular Dementia (VaD) is the second most common form of dementia, caused by cerebrovascular disease reducing blood flow to the brain. It encompasses a spectrum from "Multi-infarct dementia" (post-stroke) to "Subcortical ischaemic vascular dementia" (small vessel disease). Unlike Alzheimer's, VaD classically presents with a stepwise deterioration and prominent executive dysfunction (slowing of thought, planning difficulties) often preceding memory loss. Management focuses strictly on secondary prevention of cerebrovascular events to halt progression, as standard dementia drugs (cholinesterase inhibitors) have limited benefit unless mixed pathology exists. [1,2]

Key Facts

• Prevalence: Accounts for ~15-20% of all dementia cases.
• Pathology: Ischaemic or haemorrhagic brain damage. "Mixed Dementia" (Alzheimer's + Vascular) is extremely common in the elderly (>30%).
• Presentation: "Subcortical" pattern: Slow processing speed (Bradyphrenia), Gait disturbance ("Marche à petits pas"), Mood changes/Lability, Early urinary urgency.
• Imaging: MRI shows White Matter Hyperintensities (Leukoaraiosis) and lacunar infarcts.
• Treatment Limitations: Donepezil/Memantine are NOT first-line for pure vascular dementia (NICE), unlike Alzheimer's.

Clinical Pearls

The "Stepwise" Course: The classic textbook description is a patient who is stable, has a "mini-stroke" or event, drops a level in function, stabilises, then drops again. (Reality: Small vessel disease can present as a smoother, gradual decline mimicking Alzheimer's).

Emotional Incontinence: Also known as Pseudobulbar Affect. The patient laughs or cries disproportionately to the stimulus (e.g., crying when asking for tea). It is a sign of bilateral upper motor neurone damage.

Gait is the clue: Alzheimer's patients often walk normally until late stages. Vascular patients often have an early "magnetic" or "shuffling" gait and falls.

Executive vs Memory: If a patient can't draw a clock (Executive/Visuospatial) but remembers three words (Memory), think Vascular or Lewy Body rather than early Alzheimer's.

Cognitive Testing

• MoCA / ACE-III: Preferred over MMSE. MMSE focuses on memory/language (Alzheimer's) and misses executive dysfunction. MoCA includes trails, abstraction, clock draw.

Cardiovascular

• BP: Check for hypertension.
• Pulse: Irregular (AF).
• Carotid: Bruits.

Neurological

• Focal weakness (previous stroke).
• Parkinsonism (Lower body parkinsonism common in vascular).

Survival

• Median survival: 3-5 years from diagnosis.
• Prognosis is generally worse than Alzheimer's Disease (due to high cardiovascular mortality burden).

Progression

• Variable. Can be stable for years if no further strokes occur.
• Acute deteriorations usually signal new vascular events or infection (delirium).

Key Guidelines

Landmark Studies

1. PROSPER Study (2002)

• Result: Pravastatin reduced risk of TIA/Stroke in elderly.
• Impact: Statins prevent the cause of VaD.

2. HYVET-COG (2008)

• Question: Does treating HTN in over-80s reduce dementia?
• Result: Trend towards reduction (reached significance when combined with other trials).
• Impact: Treat BP even in the very elderly.

3. GAL-INT-6 (Galantamine in VaD)

• Result: Small cognitive benefit but NO functional benefit.
• Impact: Led to recommendation against routine use of AChE inhibitors.

What is Vascular Dementia?

It is a decline in memory and thinking skills caused by reduced blood flow to the brain. This can be caused by a series of small strokes, one large stroke, or narrowing of the tiny blood vessels deep in the brain.

How is it different from Alzheimer's?

• Alzheimer's: A build-up of proteins damages brain cells directly. Memory loss is usually the first sign.
• Vascular: Lack of blood supply damages brain cells. Slow thinking/walking and mood changes often happen before memory loss. It can get worse in "steps" (sudden drops) rather than a smooth slide.

Can we treat it?

We cannot reverse the damage already done (dead brain cells won't grow back). However, we can stop it getting worse.

• The Strategy: Protect the remaining brain tissue by stopping new strokes.
• Medications: Blood Pressure tablets, Blood thinners, and Cholesterol tablets are the most important treatments.
• Dementia pills: The pills used for Alzheimer's don't tend to work well for pure vascular dementia.

Common Exam Questions

1. Geriatrics: "Patient with step-wise decline, early incontinence, and broad-based gait. Diagnosis?"
   • Answer: Vascular Dementia (Subcortical type).
2. Psychiatry: "Use of Donepezil in pure Vascular Dementia?"
   • Answer: Not recommended/Not effective. Only if mixed pathology.
3. Neurology: "MRI shows extensive periventricular hyperintensities. Term for this?"
   • Answer: Leukoaraiosis (Small vessel disease).
4. Pharmacology: "Best prevention for VaD?"
   • Answer: Antihypertensives.

Viva Points

• Binswanger's Disease: Eponym for subcortical vascular dementia (white matter disease).
• Hachinski Ischaemia Score: Old clinical tool to distinguish VaD from AD based on history (stepwise, somatic complaints, focal signs).
• Pseudobulbar Affect: Mechanism? Disconnection of cortical inhibition of the brainstem emotional centres.

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.