Vascular Dementia (formerly Multi-Infarct Dementia) (see this page)
What is vascular dementia?
What is Multi-Infarct Dementia?
Multi-infarct dementia (MID) is a common cause of memory loss in the elderly. MID is caused by multiple strokes (disruption of blood flow to the brain). Disruption of blood flow leads to damaged brain tissue. Some of these strokes may occur without noticeable clinical symptoms. Doctors refer to these as “silent strokes.” An individual having a silent stroke may not even know it is happening, but over time, as more areas of the brain are damaged and more small blood vessels are blocked, the symptoms of MID begin to appear. MID can be diagnosed by an MRI or CT of the brain, along with a neurological examination. Symptoms include confusion or problems with short-term memory; wandering, or getting lost in familiar places; walking with rapid, shuffling steps; losing bladder or bowel control; laughing or crying inappropriately; having difficulty following instructions; and having problems counting money and making monetary transactions. MID, which typically begins between the ages of 60 and 75, affects men more often than women. Because the symptoms of MID are so similar to Alzheimer’s disease, it can be difficult for a doctor to make a firm diagnosis. Since the diseases often occur together, making a single diagnosis of one or the other is even more problematic.
Is there any treatment?
There is no treatment available to reverse brain damage that has been caused by a stroke. Treatment focuses on preventing future strokes by controlling or avoiding the diseases and medical conditions that put people at high risk for stroke: high blood pressure, diabetes, high cholesterol, and cardiovascular disease. The best treatment for MID is prevention early in life – eating a healthy diet, exercising, not smoking, moderately using alcohol, and maintaining a healthy weight.
What is the prognosis?
The prognosis for individuals with MID is generally poor. The symptoms of the disorder may begin suddenly, often in a step-wise pattern after each small stroke. Some people with MID may even appear to improve for short periods of time, then decline after having more silent strokes. The disorder generally takes a downward course with intermittent periods of rapid deterioration. Death may occur from stroke, heart disease, pneumonia, or other infection
— NINDS page
Vascular dementia refers to a subtle, progressive decline in memory and cognitive functioning. It occurs when the blood supply carrying oxygen and nutrients to the brain is interrupted by a blocked or diseased vascular system. If blood supply is blocked for longer than a few seconds, brain cells can die, causing damage to the cortex of the brain—the area associated with learning, memory, and language.
Depending on the person, and the severity of the stroke or strokes, vascular dementia may come on gradually or suddenly. Currently, there is no known cure, but the good news is that making certain lifestyle changes and using practical strategies may help prevent strokes, compensate for cognitive loses, and slow its development.
Multi-infarct dementia: The most common type of vascular dementia
The most common type of vascular dementia is multi-infarct dementia (MID), which is caused by a series of small strokes, or “mini-strokes,” that often go unnoticed. These mini-strokes, also referred to as transient ischemic attacks (TIAs), result in only temporary, partial blockages of blood supply and brief impairments in consciousness or sight. Over time, however, as more areas of the brain become damaged, the symptoms of vascular dementia begin to appear.
Signs and symptoms of vascular dementia
Vascular dementia affects different people in different ways and the speed of the progression varies from person to person. Some symptoms may be similar to those of other types of dementia and usually reflect increasing difficulty to perform everyday activities like eating, dressing, or shopping.
Behavioral and physical symptoms can come on dramatically or very gradually, although it appears that a prolonged period of TIAs—the mini-strokes discussed above—leads to a gradual decline in memory, whereas a bigger stroke can produce profound symptoms immediately. Regardless of the rate of appearance, vascular dementia typically progresses in a stepwise fashion, where lapses in memory and reasoning abilities are followed by periods of stability, only to give way to further decline.
Common mental and emotional signs and symptoms of vascular dementia
Memory problems; general forgetfulness
Unusual mood changes (e.g. depression, irritability)
Hallucinations and delusions
Confusion, which may get worse at night
Personality changes and loss of social skills
Common physical signs and symptoms of vascular dementia
Leg or arm weakness
Moving with rapid, shuffling steps
Loss of bladder or bowel control
Common behavioral signs and symptoms of vascular dementia
Language problems, such as difficulty finding the right words for things
Getting lost in familiar surroundings
Laughing or crying inappropriately
Difficulty planning, organizing, or following instructions
Difficulty doing things that used to come easily (e.g. paying bills or playing a favorite card game)
Reduced ability to function in daily life
Causes of vascular dementia
Stroke, small vessel disease, or a mixture of the two can cause vascular dementia. Most commonly there is a blockage of small blood vessels somewhere in the vast system of arteries that feeds the brain and enters through the base of the skull. Blockages may be caused by plaque build-up on the inside of the artery wall, or by blood clots which have broken loose and clogged a tributary further downstream. Clots can form as a result of abnormal heart rhythms, or other heart abnormalities. Also, a weak patch on an artery wall can balloon outward and form an aneurysm, which can burst and deprive the brain cells of oxygen.
It is estimated that about 50 percent of the cases of vascular dementia result from hypertension, or high blood pressure. Less common causes of vascular dementia are associated with autoimmune inflammatory diseases of the arteries such as lupus and temporal arteritis, which are treatable with drugs that suppress the immune system.
Know the symptoms of stroke
Call your country’s emergency number (911 in the United States) immediately if you experience any of the following symptoms, which may indicate you’ve had a stroke or a transient ischemic attack (TIA), or mini-stroke.
Numbness, paralysis, or weakness on one side of your body or face.
Trouble speaking (e.g. slurring your words, inability to repeat a simple sentence).
Loss of vision or seeing double.
Loss of balance and coordination (e.g. dizziness, trouble walking).
Sudden, severe headache (may include a stiff neck, vomiting, or pain between your eyes).
Vascular dementia prevention and treatment
There is not yet a known cure for vascular dementia, so prevention is important. The best way to prevent vascular dementia is to lower your risk of stroke. This means getting high blood pressure under control, avoiding cigarettes, and controlling cholesterol levels and diabetes.
But even if you or a loved one have already been diagnosed with vascular dementia, it’s not too late to do anything about it. If you treat the risk factors that led to vascular dementia, you may be able to slow the progression of the disease and possibly reverse some of the symptoms. The most important thing is minimize your risk of having another stroke and making the dementia worse.
While there are not yet any approved medications for the treatment of vascular dementia, a number of medications used to treat the cognitive symptoms of Alzheimer’s disease appear to work for vascular dementia, too.
Prevent and treat vascular dementia by reducing your risk for stroke
Know your blood pressure. If high, work with your doctor to lower it.
Find out from your doctor if you have atrial fibrillation.
If you smoke, stop.
If you drink alcohol, do so in moderation.
Find out if you have high cholesterol. If so, work with your doctor to control it.
If you are diabetic, follow your doctor’s recommendations carefully to control your diabetes.
Include exercise in the activities you enjoy in your daily routine.
Enjoy a lower sodium (salt), lower fat diet.
Source: National Stroke Association
Living with vascular dementia
A diagnosis of dementia is scary. But it’s important to remember that many people with dementia lead healthy, fulfilling lives for years after the diagnosis. Don’t give up on life! As much as possible, continue to look after your physical and emotional health, do the things you love to do, and spend time with family and friends.
Stay active as much as possible. Research suggests that even a leisurely 30-minute walk a day may reduce the risk of vascular dementia and help slow its progression. It will also boost your overall health and happiness.
Create a network of support. Seeking help and encouragement from friends, family, health care experts, and support groups can improve your outlook and your health.
Eat for heart health. Heart disease and stroke share many of the same risk factors, such as high LDL cholesterol (bad cholesterol), low HDL cholesterol (good cholesterol), and high blood pressure. Adopting a more heart-healthy diet may improve or slow down your dementia symptoms.
Make it a point to have more fun. Laughing, playing and enjoying yourself are great ways to reduce stress and worry. Joy energizes and inspires lifestyle changes that prevent further strokes and blockages and compensate for memory and cognitive losses.
Learn how to relax and manage stress. Stress is a major contributor to high blood pressure and heart disease, so it’s helpful to practice relaxation techniques, such as yoga, meditation, deep breathing, or rhythmic exercise, and know how to quickly reduce stress in the moment by employing one or more of your senses.
Challenge your brain. Your brain remains capable of change throughout your life, so you may be able to improve your ability to retain and retrieve memories. Set aside some time in the evening to recall the day’s events, which can build memory capacity. Learning new skills, such as a foreign language or how to paint, can also help build brain capacity if done consistently.
Managing symptoms of vascular dementia
Managing the symptoms of vascular dementia means learning practical ways to manage memory loss, while staying as optimistic and realistic as possible. Although you may not be able to bring back what’s lost, you can still find ways to make a challenging situation easier.
Follow a routine. A regular, daily routine can stimulate your memory and help you feel more balanced and in control. Keep important items in the same place so they’re easier to find.
Carry a notepad. Take some pressure off your memory by writing down names, dates, appointment times, and a to-do list of errands. You can also post important phone numbers and reminders in a prominent place.
Be upfront about your condition. Tell the people you’re around that you’ve had a stroke. This way, they know what to expect and you can alleviate or prevent misunderstandings.
Communicate your needs. Ask people to speak slowly or repeat things when necessary. Ask for a message broken into smaller parts, and repeat what you heard back to them.
Remove distractions. When attempting to understand long messages or instructions, take away distractions such as TV or radio so that you can better concentrate and take notes.
Avoid rushing into new tasks. Be deliberate and stop to think and plan before beginning a task, whether it’s taking out the garbage or conducting a meeting.
Be patient with yourself. Getting angry only makes it more difficult to remember. Learning relaxation techniques can help you cope with changes.
Allow those close to you to help you. It’s not easy to admit you need help, but letting those who care about you lend support is important to your independence.
Recent guidelines from the American Psychiatric Association provide both treatment principles and possible specific therapies.
Drug treatment is primarily used to prevent further worsening of vascular dementia by treating the underlying disease such as hypertension, hyperlipidemia, and diabetes mellitus. Antiplatelet agents are indicated.
Pentoxifylline and, to a more limited extent, ergoloid mesylates (Hydergine), may be useful for increasing cerebral blood flow. In the European Pentoxifylline Multi-Infarct Dementia Study, which is a double-blinded, placebo-controlled, multicenter study, treatment with pentoxifylline was found to be beneficial for patients with multi-infarct dementia. Significant improvement was observed in the scales used for assessing intellectual and cognitive function.
Neuroprotective drugs such as nimodipine, propentofylline, and posatirelin are currently under study and may be useful for vascular dementia. Nicardipine is a dihydropyridine calcium channel blocker that was studied on the treatment of cognitive deterioration of vascular origin. Preliminary studies showed decrease in cognitive deterioration in patients with cerebrovascular disease.
Increasing evidence supports the involvement of the cholinergic system in vascular dementia, similar to that seen in Alzheimer dementia. However, no cholinesterase inhibitors have been approved to date for the treatment of vascular dementia, despite positive results in clinical trials with this medication.
The general management of dementia includes appropriate referral to community services, judgment and decision-making regarding legal and ethical issues (eg, driving, competency, advance directives), and consideration of caregiver stress.
Agitation and psychosis are common in older adults with dementia and are challenging to manage. Relatively few studies have examined the use of antidepressants for the treatment of agitation and psychosis in dementia; however, the selective serotonin reuptake inhibitors (SSRIs) sertraline and citalopram appear to be associated with a reduction in symptoms of agitation when compared with placebo. Both appear to be reasonably well tolerated when compared with placebo, typical antipsychotics, and atypical antipsychotics. However, more studies are needed to determine if SSRIs, trazodone, or other antidepressants are safe and effective treatments for agitation and psychosis in dementia.
In the Rotterdam study, an increased risk of vascular dementia was associated with total fat intake, whereas fish consumption was inversely related to dementia.
Low levels of folate, vitamin B-6, and vitamin B-12 are associated with increased homocysteine levels, a risk factor for stroke.