- 1. Vascular Dementia biopsychosocial aspects! Dr Maryam Hussain
Dr Cornelia van Ineveld March 11 th , 2008
2. Clinical Vignette
- 82 year old female, widowed, referred because of rapid decline
in cognition
- 2 year history of gradual decline in cognition and
function
-
- Initially difficulty with memory and higher order tasks
-
- 1 year ago episode of sudden confusion with slurred speech,
resolved but cognition worse
-
- 6months ago developed mild paranoia, mixing up pills, fire on
stove
-
- 6 weeks ago worsened confusion with slurred speech, drooped
face, signs resolved but cognition worse
3.
-
- Diabetes Mellitus Type II
-
- Enalapril (high blood pressure)
-
- Hydrochlorthiazide (high blood pressure)
4. Cognitive testing:
- MMSE 18/30 (normal 24), 0/3 recall
- Clock: All numbers spaced on right
- Verbal fluency 4 (normal 10)
- Difficulty following complex commands
- Anxious, repetitive, notable word finding problems
5. Physical Examination:
- Strength equal throughout
- Reflexes equal throughout
- Increased motor tone bilaterally, no tremor
- Difficulty with rapid alternating movements
- Positive palmo-mental frontal release sign bilaterally
- Gait: slowed, decreased step height, cautious, Romberg
negative
6.
-
- Two very small strokes deep inside the brain
-
- Brain is smaller than it should be given her age
-
- Other changes deep inside the brain that tell us it is not
getting enough oxygen (white matter ischemic changes)
7. Diagnosis
-
- Clinical features of Alzhiemers Disease: prominent memory loss,
language changes, behavior problems
-
- Risk factors for stroke, two suspicious events with possible
step-wise decline, CT evidence of strokes
- Rapidity of decline consistent with mixed disease
-
- Presence of cerebrovascular (stroke) lesions with AD pathology
= more severe disease presentation
8. 9. Objectives
- What is Vascular Dementia (VaD)?
- Neuropsychiatric manifestations
- Risk factors & common presentations
10. Dementia
- Common condition , especiallyin the oldest old groups
-
- impairment in other cognitive domains
-
- impairment in functional status
- Associated with considerable morbidity and mortality
11. Types of dementia
- Alzheimer's dementia (AD): 60%
- Vascular dementia (VaD): 15-20%
- Others including frontal lobe dementia, alcohol, CBG 10%
- Japan/China VaD is the commonest
- Expected that VaD will become commonest form of dementia
throughout the world
12. History. (just for fun!)
- 17 thcentury Thomas Willis described post-apoplectic
dementia
- 1894 Otto Binswanger and Alois Alzheimer differentiated between
VaD and neurosyphilis (and sub-categorized VaD into 4
subtypes)
- 1910 Kraeplin concluded that arteriosclerotic insanity was the
most frequent form of senile dementia
- 1970s AD identified as the most common cause of dementia
- At the same time Tomlinson, Blessed and Roth showed that loss
of more than 50-100mL of brain tissue from strokes caused cognitive
impairment and the term multi-infarct dementia was coined
13. Language, language, language
-
- Cognitive deficits meet clinical criteria for dementia
-
- Also has been called: multi-infarct dementia, ischemic vascular
dementia, arteriosclerotic dementia, cerebrovascular dementia,
ischemic-vascular dementia
-
- 4 sets of diagnostic criteria: all give you slightly different
results
- You can see why this is a difficult area!
14. Vascular Dementia
- Generally clinicians look for
-
- Stepwise progression, prolonged plateaus or fluctuating
course
-
- Focal cognitive deficitsbut not necessarily memory
impairment
-
- Impaired executive function (difficulty problem solving,
difficulty with judgement)
- Diagnosis strengthened by
-
- Focal neurological signs (weakness on one side, difficulty with
speech)
-
- Neuroimaging (CT or MRI) consistent with ischemia
-
- CV risk factors, concurrent peripheral vascular disease,
coronary artery disease etc
15. 16. Objectives
- What is Vascular Dementia (VaD)?
- Neuropsychiatric manifestations
- Risk factors & common presentations
17. Clinical Categories
- Large Vessel Vascular Dementia
- Small Vessel Vascular Dementia
- Ischemic-Hypoxic Vascular Dementia
18. Large Vessel
- Post-stroke dementia/ Multi-infarct dementia
-
- Dementia developing after multiple completed infarcts
-
- Significant proportion of post-stroke dementia remains
undiagnosed
-
- Dementia developing after occlusion of a single large - sized
vessel in a functionally critical area
- Easiest to recognize, temporal relationship of event and
cognitive loss usually evident
19. 20. 21. 22.
- Incidence estimates (3 monthspost CVA) vary: 25-41%
- Clinical features will depend largely on what part of the brain
was damaged
- Location of vascular lesion is likelymore important than how
much tissuedied
23. 24. Why do some patients with stroke have cognitive
impairment and others dont?
- Risk factors for post-stroke VaD:
- Trouble swallowing, gait changes and urinary incontinence
- Acute complications of stroke (seizures, cardiac arrhythmias,
aspiration pneumonia etc)
25. Small Vessel Disease
- Memory impairment is less pronounced
26. 27.
- Magnetic resonance image of the brain, T2 axial view without
contrast enhancement. Note the areas of increased signal
bilaterally, known as periventricular hyperintensity (arrows).
28. Mixed dementia
- Vascular lesions may have synergistic effect with AD
pathology
- If evidence of cerebrovascular disease present, the density of
plaques and tangles needed to cause dementia is lower than that
needed for pure AD
29. AD combined with lacunes Data from Nun Study 30.
Objectives
- What is Vascular Dementia (VaD)?
- Neuropsychiatric manifestations
- Risk factors & common presentations
31. Neuropsychiatric Symptoms
- The neuropsychiatric symptoms of VaD can be very different
qualitatively, as those in AD
- Patients with VaD have a higher risk for institutionalization
than those with AD, partly because of the BPSD
32. Frontal Sub-cortical symptoms
- Area of the brain responsible for making us human
33.
- Executive dysfunction poor planning and judgement, no
anticipation of the consequences of actions
-
- Not thinking things through!
-
- Difficulties with finances, financial vulnerability
-
- Increasingly simple and automatic behaviour as disease
progresses (switching lights on and off just because they
can!)
- Abulia pervasive lack of initiative or drive
- AD doesnt normally have above features until late in the
course
34. What is executive function?
- those processes that orchestrate relatively simple ideas,
movements, actions into complex goal oriented behavior (Royall
D)
- frontal executive cognitive functions control volition,
planning, programming, anticipation, inhibition of inappropriate
behaviors and monitoring of goal-directed, purposeful activities
(Roman G)
35. Depression & VaD
- Common, especially with large vessel disease
- In up to 40% of VaD patients
- Associated with a higher incidence of functional impairment,
failure of rehabilitation, admission to PCH and death
- More common in left hemisphere strokes; however can be hard to
diagnose in patients with right hemisphere strokes because they
have difficulty with emotional tone of speech and awareness of
symptoms!
- Most cases are undiagnosed!
36.
- Often tearfulness and sadness are absent
- Will have neurovegetative symptoms (sleep disturbances, changes
in appetite, loss of energy)
- Guilt, pessimism, anhedonia are more sensitive
- Atypical presentations like somatic complaints, irritability,
unexplained screaming and pathologic laughing and crying can be
seen
- Responds well to pharmacotherapy
- Cognitive Behavioural Therapy (CBT) less likely to work
secondary to cognitive impairment
37. 38. Objectives
- What is Vascular Dementia (VaD)?
- Neuropsychiatric manifestations
- Risk factors & common presentations
39. Risk factors
40. 41. Clinical examination
-
- Demographics, family history, cardiac risk factors, medical
history, medications
-
- Height/weight/waist circumference/ BP/timed up and go
-
- Exact circumstances surrounding the cognitive and functional
impairment
-
- Textbook abrupt onset/stepwise decline often not found
42.
-
- Looking for signs of neurological deficits, parkinsonism,
asymmetry, gait changes
-
- Bloodwork: C-reactive protein, lipids, homocysteine, glucose,
HbA1C, insulin, clotting factors
43. Objectives
- What is Vascular Dementia (VaD)?
- Neuropsychiatric manifestations
- Risk factors & common presentations
44.
- MMSE not adequate because of lack sensitivity in VCI, as it
isnt a sensitive test for executive function, inattention, mood or
personality changes
- Montreal Cognitive Assessment (MoCA)
-
- Designed for vascular dementia
Cognitive Tests 45.
46. Objectives
- What is Vascular Dementia (VaD)?
- Neuropsychiatric manifestations
- Risk factors & common presentations
47.
- Enduring POA, health care proxy, will etc.
-
- Providing jobs e.g.: folding towels, wiping off dishes
- Caregiver education patients with abulia are not lazy, need to
limit expectations
-
- If resistive to personal care, limit the amount and frequency;
establish a routine
- Rule out depression and treat if needed (most commonly use
serotonin selective reuptake inhibitors)
Treatment 48.
- Disinhibition lose manners, become vulgar, are socially
inappropriate, sexually inappropriate, shop lifting, vagrancy,
irritability, combativeness
-
- Educate caregivers: not doing things on purpose, remove the
stimulus or take the patient out of the situation
-
- If one has to use medication for aggression; use one medication
at a time, lowest possible dose, monitor closely for side
effects
-
-
- Atypical antipsychotics [risperidone, olanzapine, seroquel],
anticonvulsants [valproic acid and carbamezipine] and nonselective
Beta Blockers [propranalol or pindolol])
-
- In men, may consider hormonal agents that decrease testosterone
levels (medroxyprogesterone and leuprolide)
49.
- THE BEST NUMBER OF MEDICATIONS TO USE IS ZERO (or sometimes
one)
- WHEN IN DOUBT, GET RID OF MEDICATIONS!
50. Pharmacologic and medical treatment of VaD
-
- Treatment of HTN, DM, hypercholestrolemia
-
- More aggressive control of HTN, DM and hypercholestrolemia
-
- Anti-platelet agents like Aspirin and Plavix
-
- Warfarin in patients with Atrial fibrillation
-
- Possible surgery in patients with documented carotid artery
stenosis
51.
- Avoid orthostatic hypotension
- Good control of congestive heart failure and obstructive sleep
apnea
52. 53. Once VaD is present,
- Acetyl cholinesterase inhibitors (AChEI) may have mild -
moderate benefit, patients with VaD are more likely to experience
side effects with AChEI than AD patients and so may be more likely
to discontinue the drug
- Memantine may be useful as an adjunct to AChEI in patients with
moderate to severe dementia, not covered by Pharmacare
- Anti depressants (specifically SSRIs)
54. Take Home Messages
- VaD is a common cause of dementia
- Look for risk factors of VaD and focal neurological signs
- Significant memory impairment is not always present
- Classic step wise progression not always present
- BPSD more common and can occur at earlier stage than AD
behavioral strategies are helpful
55. 56. References
- Roma, Erkinjutti et al, Lancet Neurology 2002;1: 426-36
- Stewart JT, The American Journal of Geriatric Cardiology
2007;16(3):165-70
- Roman GC,Med Clin N Am 86 (2002) 477499
- The frontal/subcortical dementias: Common dementing illnesses
associated with prominent and disturbing behavioral changes.
Geriatrics August 2006